Framework for Remote and Rural Readiness in Telehealth

Final Report
March 2003

Table of Contents

• Executive Summary
• Volume I: Project Report
  • 1.1 Introduction
  • 1.2 Approach of Research
  • 1.3 Body
  • 1.4 Conclusion
  • 1.5 How Work Will Be Used
• Volume II: Evaluation of Project
  • 2.1 Evaluation Activity Summary
  • 2.2 Program Evaluation - Team Feedback
• Volume III: Dissemination Plan
  • 3.1 Deliverables
  • 3.2 Questionnaire on Knowledge Dissemination / Transfer

Executive Summary

Objective of Project

Telehealth is defined as the use of advanced telecommunications technologies to exchange health information and to provide health care services across geographic, time, social, and cultural barriers (Reid, 1996). Understanding telehealth 'readiness', i.e., the degree to which public users, health care organizations, and the health system itself are prepared to participate and succeed in telehealth implementation (Harvard, 2002) is essential for the successful adoption of new, innovative technologies in the health care field (Dowling, 1980; Lyytien & Hirschheim, 1987; More, 1990; Edwards et al., 2000). Adopting such innovations can address a number of pressing problems facing the Canadian health care system, such as inequities in health status and quality of care and access faced in rural and remote areas (Health Canada, 1999). There is a definite need for all community groups (patients, providers, organizations, and the public) to have a clear understanding of readiness.

Questions Being Addressed

The following questions were addressed in this study in an effort to gain a better understanding of readiness and its factors in rural and remote communities: 1) What are the elements within the concept of readiness? 2) Is there more than one type of readiness? and 3) What are the factors within those types of readiness?

Policy Priority

Large-scale Information Technology (IT) projects are associated with failure rates of 30% and greater (Dowling, 1980; Lyytien & Hirschheim, 1987; More, 1990). Telehealth represents a substantial IT investment, and as such, failure of telehealth systems can result in huge losses in time, money, and effort (Southon, Sauer & Dampney, 1997; Doolittle, 2001). It is necessary that all telehealth stakeholders have the tools and mechanisms to understand the readiness concept, and to determine the readiness status of communities before implementing costly telehealth innovations.

In order to overcome a sense of risk that telehealth poses as a relatively unknown or untested solution, planners might listen closely to the concerns of various communities and respond to them by building strong, flexible, and responsive telehealth structures into existing systems of health care. In working to reduce the sense of risk, planners may enhance the sense of curiosity and willingness of various communities, in order to improve their health care system through the use of telehealth.

Specifically from a policy perspective, the study provides a 'eadiness assessment framework which, when applied, can provide data and information that can facilitate the successful implementation of telehealth applications in rural / remote areas. This is accomplished by the assessment framework, which can highlight enablers and barriers that can be addressed during the implementation / diffusion process. In particular, five policy-related recommendations are:

1. Understanding readiness is a critical first step towards the successful adoption of telehealth.
2. A readiness assessment should be conducted prior to telehealth or e-health applications being implemented in rural / remote settings. This is important, as the application of the framework highlights enablers and barriers not otherwise apparent.
3. As telehealth continues to evolve, input from all key stakeholders (including patients, health care providers, and the public) into policy development is required. Consideration of needs and practical experience are essential for a meaningful exchange of information and views.
4. Telehealth programs should be implemented and evaluated in a culturally aware and sensitive manner.
5. Increased awareness and understanding of telehealth opportunities among rural / remote community stakeholders are essential steps to readiness and successful implementation.

Key Target Group(s)

This study had one major target group - rural / remote Canadian communities. Four additional groups, i.e., patients, practitioners, health organizations, and the public were targeted.

Specifically, the Alliance for Building Capacity Project aimed to identify core factors of readiness in rural and remote communities in Canada. Statistics Canada defines a rural community as one having a population of fewer than 10,000, outside of the Census Metropolitan Area and census agglomerations. A Canadian town which met this definition was chosen as an exemplar community in this study. Four specific target groups (patient, practitioner, organization, and public) considered to be core to the rural / remote community context were examined.

Main Components of Methodology

Using a qualitative approach, this study aimed to construct the concept of telehealth readiness in one community. Sixteen key-informant, semi-structured, audio-taped telephone interviews (3-5 in each group); two community awareness sessions followed by five audio-taped focus groups (5-8 per focus group) in the groups of patient, practitioner, and public; and two in-depth interviews with community physicians were conducted.

These approaches together assured data collection on telehealth readiness from the expert key-informant level, the grassroots clinical level, and the lay community level. Participants were selected as part of convenience samples. Key informants were experts in their field and active in the use of telehealth applications. Interviewers were experts in their specified groups and had extensive interviewing experience. All ethical requirements were met, including gaining approval from the appropriate ethics committees and consent from the participants.

Data were organized using program and implementation theory (Weiss, 1998), then coded and analyzed using a multi-step approach. Theory and data were treated as dialectic, in that the program's theories of change were kept in mind while reading and organizing the data, but the analysis remained open to other processes, patterns, and ideas. As new themes arose, transcripts were read and coded by one analyst multiple times, in order to determine answers to four questions that guided the analysis process: What factors do key informants believe contribute to a successful service? How do these relate to readiness? How do various community groups react to the prospect of telehealth? What does this tell us about readiness from the perspective of various communities? This approach generated an understanding of the types of telehealth readiness and identified prominent themes and relationships across all target groups.

Findings

In reviewing the data gathered for this project it became evident that there was more than one type of readiness. Indeed, the data suggest that there are four types, with some conditions being more central to readiness than others.

Types of Readiness

1. Core Readiness: the identification of need and dissatisfaction with the status quo;
2. Engagement: a state of questioning and risk assessment;
3. Structural Readiness: the building of efficient structures and supports; and
4. Non-Readiness: a lack of need or failure to recognize need.

Readiness was explored across all target groups (patient, practitioner, organizational, and public) in order to examine group-specific factors of readiness. Factors of readiness were evident in each target group within each type of readiness (see Table 1.1). Further, a number of prominent themes were also identified in the data, such as projection of benefits, assessment of risk, awareness and education, and intra- / inter-group dynamics.

The four types of readiness, along with the factors within types of readiness and the themes across types of readiness over the four target groups, assist in creating a framework. This framework can be used to study readiness in a much more informed way. Such an understanding can assist in the successful adoption of telehealth, as well as help stakeholders avoid failure rates associated with such investments.

Volume I: Project Report

1.1 Introduction

1.1.1 Impetus for Project

Telehealth has been defined as the use of advanced telecommunications technologies to exchange health information and provide health care services across geographic, time, social, and cultural barriers (Reid, 1996). The successful introduction of telehealth into health care has great potential to address a number of pressing problems facing the Canadian health care system, including clear inequities in health status, quality of care, and access, challenges often faced by rural and remote Canadians (Health Canada, 1999). A key justification for telehealth implementation is the Canada Health Act - the cornerstone of the publicly funded Canadian health system that promises comprehensive, universal, and accessible care for all citizens regardless of gender, race, place or residence.

Understanding readiness is a critical first step towards the successful adoption of telehealth. Administrators, policy planners, and governmental agencies require clear mechanisms to determine the readiness status of communities before investments are made to help avoid failure rates associated with information technology (IT) projects. Large-scale IT projects are associated with failure rates of 30% or more (Dowling, 1980; Lyytien & Hirschheim, 1987; More, 1990). Indeed, the failure of telehealth systems can result in substantial losses in time, money, and effort (Southon et al., 1997; Doolittle, 2001).

1.1.2 Objective

This study was designed to construct the types and factors of telehealth readiness through an in-depth, qualitative examination of the concept in one community. The project set the following objectives at the beginning of the study:

• Discuss the concepts of readiness and community, and invite community input into these concepts and activities.
• With community participation, identify the factors that determine community-based readiness.
• Develop framework, models or approaches for assessing community readiness for telehealth.

Meeting these objectives is the first step in understanding the factors of influence, and in creating a readiness framework or taxonomy that can be used in assessing the degree of readiness for rural / remote communities to roll out, implement or integrate telehealth into usual health care.

1.1.3 Research Topic / Questions Being Addressed

The successful introduction of telehealth requires the examination of complex social, political, organizational, and infrastructure factors. Established innovation adoption and change theories suggest that multiple factors are at play when an innovation is successful or failing, although the interactions and relationships among these factors and innovation adoption are unclear. One such factor is 'readiness', a preliminary requirement for success in telehealth adoption (Harvard, 2002). An abbreviated literature review around the topic of innovation adoption, change, and readiness can be found in Volume II, Appendix A.

This research aimed to identify the core factors of telehealth readiness in rural and remote communities; i.e., the factors that either promote or impede the successful implementation of and participation in telehealth by rural community members. Readiness can be defined as the degree to which a community is prepared to participate and succeed in telehealth (Harvard, 2002) and is the cognitive precursor to the behaviours of either resistance to or support for a change effort (Armenakis et al., 1993).

The following questions were addressed in this study in an effort to gain a better understanding of readiness and its factors in rural and remote communities: 1) What are the elements within the concept of readiness? 2) Is there more than one type of readiness? 3) What are the factors within those types of readiness?

1.1.4 Names of Researchers and Team Members

Dr. Penny Jennett, Head of the Health Telematics Unit, University of Calgary, was the Project Lead.

Researchers: Andora Jackson, Health Telematics Unit, University of Calgary; Susan Haydt, Health Telematics Unit, University of Calgary; Dr. Theresa Healy, School of Environmental Planning, University of Northern British Columbia; Dr. Joanna Bates, Faculty of Medicine, University of British Columbia; Dr. Kendall Ho, Continuing Medical Education, University of British Columbia; Dr. Arminee Kazanjian, Centre for Health Sciences & Policy Research, University of British Columbia; and Dr. Robert Woollard, Faculty of Medicine, University of British Columbia.

Other Team Members: Gilat Linn, Christina McLennan, Monica Pauls.

1.1.5 Partners / Funders

Primary locations for this project were the University of Calgary, the University of Northern British Columbia, the University of British Columbia, and a representative rural / remote geographical community ('TOWN') in Canada. Project support was provided by CANARIE Inc., Health Canada, the Office of Health and the Information Highway (OHIH), and the University of Calgary, Health Telematics Unit.

1.2 Approach of Research

1.2.1 Scope of Research

Community is a common and at the same time complex concept; it may be delimited according to spatial and social boundaries. For the purposes of this study we examined aspects of the community from both perspectives; those of 'communities of interest' as well as of 'place-based community' (Taggart, 1997). Our definition was broad, in that it included rural geographical communities; communities of 'like' health providers (e.g., physicians, nurses, rehabilitation therapists); communities of patients who share a common problem (e.g., cardiac, cancer); and communities of multidisciplinary health team providers caring together for either patient or public health promotion (e.g., eating disorder support / women's health). All communities or target groups share the common base of receiving or providing health services in a rural and remote region of Canada.

A rural community is defined by Statistics Canada as one having a population of fewer than 10,000, outside of the Census Metropolitan Area (CMA) and census agglomerations (CA). A CMA is delineated around an urban core with a population of at least 100,000. CA are smaller urban areas centered on urbanized cores of a population of 10,000 to 99,999. For this project, a Canadian town which met this definition was selected to act as an exemplar community ('TOWN'). Like many rural towns of its size, TOWN contains a small hospital which supports acute care patients and ambulatory emergency. Like many rural hospitals, TOWN hospital has seen a reduction in beds over the recent years. In addition to the medical support of the hospital, there is also a health unit that supports general health prevention and promotion programming; a continuing care facility; a medical clinic; and a few allied health services (e.g., massage therapy, dentistry). However, patients requiring intermediate or extended care and / or psychiatric in-patient care must be referred to the facilities in the regional medical centre (approximately a two-hour drive). Patients requiring advanced specialist care must travel to a tertiary site for treatment (approximately a twelve-hour drive or a two-hour flight).

Some early discussions on the use of telehealth in TOWN started around the same time as this project, which provided an interesting field to examine the responses, beliefs, and concerns of the community to telehealth. Four community target groups allowed for the acknowledgement of the personal, professional, and organizational influences on telehealth readiness. TOWN was large enough to provide focus group samples for the examination of sociological groups of Patient, Practitioner, and Public.

1.2.2 Target Audience

Based on the literature, a qualitative approach was used to explore the meaning of telehealth readiness within four target groups (patient, practitioner, organization, and public). These groups are considered as core to a rural / remote community context. Telehealth, as an element of clinical health care, involves Patient and Practitioner groups, as well as elements of the Organization. Further, telehealth, for health promotion and prevention programming at the level of the community, involves a Public group. Applying both a top-down expert review and a bottom-up community input approach assured the collection of data as perceived from the expert key-informant level, as well as from the grass roots provider and lay community levels.

1.3 Body

1.3.1 Methodology

Sixteen key-informant, semi-structured, audio-taped telephone interviews (3-5 in each group); two community awareness sessions followed by five audio-taped focus groups (5-8 per focus group) in the target groups of practitioner, patient, and public; and two in-depth interviews with community physicians were conducted. Participants were selected as part of convenience samples. Interviewers were experts within their specified groups, with extensive experience in conducting interviews and focus groups. Data reflected both retrospective (key-informant) and prospective (community-participant) views of readiness. All ethical requirements, including approval from the appropriate ethics committees and consent from the participants were met.

Key Informants

Key informants were defined as known experts with experience in rural-based telehealth programs. Key informants within each of the community groups (public, patient, practitioner, and organizational) were recruited to participate in semi-structured telephone interviews. This approach allowed for the collection of different perspectives on telehealth readiness. Three to five interviews were conducted in each group. The key-informant interview guides are located in Volume II, Appendix B.

Awareness Sessions

Awareness sessions were held in TOWN, in order to allow the public to explore what telehealth was about, to see the types of health services and technologies involved in telehealth, and to build awareness about telehealth. The goal was to collect, through voluntary participation in focus groups, opinions of the target groups (within the rural community) regarding telehealth readiness. However, in order to talk about the topic, the community needed to be aware of what 'telehealth' entails. The materials for the awareness sessions, including the media announcement package are located in Volume II, Appendix C.

Focus Groups

Focus groups were held following the awareness sessions. They consisted of 5-8 participants and allowed individuals who were part of the population of interest (i.e., rural communities) to reflect on readiness. Focus groups were held in the groups of practitioner, patient, and public. Due to the unavailability of community physician participants for focus group participation, in-depth interviews were used to collect physician perceptions and beliefs about readiness. The focus group frameworks are located in Volume II, Appendix D.

Data Analysis

Data were organized using program and implementation theory (Weiss, 1998). Program theory is abstract in its focus. It addresses the effect of intangible factors such as people's reactions to program activities, cultural factors, and interactions between or within communities. Implementation theory focuses on identifying the concrete steps that program designers take to implement a program successfully. Together, program and implementation theory make up the program's theory of change.

Once organized, data were coded and analyzed using a multi-step approach. Theory and data were treated as dialectic, in that the program's theory of change was kept in mind while reading and organizing the data, but analysis remained open to other processes, patterns, and ideas. As new themes arose, transcripts were read and coded by one analyst multiple times, in order to determine answers to four questions that guided the analysis process: 1) Which factors do key informants believe contribute to a successful service? 2) How do these relate to readiness? 3) How do various communities react to the prospect of telehealth? 4) What does this tell us about readiness from the perspective of various communities? This approach generated an understanding of the types of telehealth readiness and identified prominent themes and relationships across all the community groups.

1.3.2 Results / Findings

Identifying Readiness

The data suggest that there are varying types of readiness, with some conditions being more central to the concept than others. These include core readiness, engagement, structural readiness, and non-readiness. Across each of the groups of patient, practitioner, public, and organizational, specific indicators of these levels of readiness were found. However, common to all groups was an assessment of 'risk' as a part of adopting telehealth, and this study identified a number of proposed solutions to these perceived risks to readiness, as provided by key experts in Canadian rural telehealth.

There is no discernible, clear link between core readiness and engagement. The data do not suggest that a relationship or time order can be imposed. However, a clearer relationship can be seen between engagement and structural readiness. Often, people's perceptions of the structure of telehealth and how it could potentially work (or not work) are related to their willingness to adopt it. All four types of readiness, along with the factors within and the themes across types of readiness over the four communities of interest assist in creating a framework that can be used to study readiness in a much more informed way.

Types of Readiness

i) Core Readiness

Seemingly the strongest form of readiness for key informants was a combination of 'real need' (usually based on conditions caused by isolation) and a felt or expressed dissatisfaction with current conditions, so strong that members of the community in question were willing to adopt new practices to create change. Core readiness was identified in each of the communities.

Needs Based on Isolation

A good portion of respondents from each type of community suggested that a successful telehealth service is based on the genuine need of a community. Most acknowledged that it was the isolation of rural and remote communities that produced a genuine need for telehealth. One respondent described need based on isolation as the true foundation of a successful telehealth service:

"...one of the most important factors is that ...if telehealth is put into those regions, into the rural and remote communities first, it's the most difficult to serve or serve first, then there will be a foundation for telehealth...Otherwise, what we end up with is a bunch of institutions with all these toys to play with as alternative delivery methods. There's no foundation. There's no real need."

This is an extreme view; more commonly, respondents suggested that a community lacking services or information was more likely to adopt telehealth successfully than communities where there was access to adequate services or ways of obtaining information. Overall, need was perceived as a fundamental part of the readiness of a community to adopt and successfully use telehealth: "The more need, the more ready they are to participate."

Isolation produces some unique problems for rural and remote areas, particularly in creating conditions that limit access to health care. For example, isolation creates the need for patients to travel long distances for specialized services such as specialists or rehabilitation services, which are unavailable in small centres. Isolation also creates a need for practitioners to travel to upgrade their skills. Typically, conditions like these are believed by key informants to be a source of frustration which in turn builds readiness for telehealth.

Dissatisfaction with the Status Quo and a Willingness to Change

There is some evidence that needs created by isolation are by themselves not sufficient to create readiness for implementation of telehealth services. Key informants from various perspectives also spoke of the importance of community members viewing the current conditions as unacceptable and in need of change. Dissatisfaction with the status quo and the willingness to try telehealth, along with the conditions of isolation were seen as fundamental to a successful telehealth service. Here, an organizational key informant notes that the need for telehealth was only noticed by a few in her organization, and telehealth may never have been implemented in her area without the efforts of the practitioner community in the region, who recognized the needs and wanted to change:

"Well, the only fellow that really wanted to move forward with telehealth was [name1] and myself, and [name2] when she came on board. We could have gone on forever without telehealth, and I don't think anyone would have noticed. But where some of the dissatisfaction was expressing itself was in transportation costs, and the rise in transportation costs which is exponential. And I think some frustration, you know, in recognized lack of access. And this was not seen as much in [place] but was certainly coming up from the region where they couldn't access the specialists that they needed, the physician because of weather couldn't get into a community for months on end, they needed rehabilitation and there was no way of meeting -- I mean the applications really did respond to unmet needs. The wish for change was actually being driven by the front line, people that were really experiencing the problem."

In this case, it appears that the organization in question was at the level of non-readiness, as it did not recognize a problem or see a need to change, while the practitioners and public (it is not exactly clear who the front line is in this case) were experiencing a state of core readiness.

ii) Engagement

Less obvious in the data was a process in which people were actively engaged with the idea of telehealth, weighing its perceived advantages and disadvantages. This process was most obvious in the focus group data, where people were aware of their needs as members of rural and remote communities, but were unaware of the potential of telehealth applications. These people did not immediately and unquestioningly accept telehealth as a solution. Rather, they asked questions of what telehealth could do and expressed their hopes, fears, and concerns about adopting such a system. This process of actively questioning telehealth also appeared in the key-informant interviews, in the form of resistance or hesitation to use telehealth. The following excerpt provides an example of this questioning process:

"Let's see the cost benefit analysis of implementing 'telehealth' - the unanswerable question... You may be able to save in the longer term by, you know, earlier intervention, better education and prevention, lower staff turnover, better retention of staff, better education staff that don't make mistakes, the rest of it. But those are long term benefits and you're asked to show immediately - you know, they almost want a cost neutral proposition, and it's usually stated show me the business case or the cost benefit analysis."

The process of engagement gives insight into the factors that potentially encourage or impede further readiness for telehealth adoption.

An important concept that emerged was the idea of innovators or champions; i.e., people who are enthusiastic promoters of an innovation. Readiness among individuals varies from absolute refusal to cautionary interest, and innovators were often thought to be essential to the successful implementation of projects. The following excerpt addresses the opposing responses of people confronted with organizational change and the role of innovators in this process:

"Basically, when there's a change within an organization, there's different ways that people respond. There's a couple of innovators who really push for the change, there's sort of early adopters who are willing to try it out, and there's the late majority who come on later. Then there's always a few people screaming no, no, no, never, at the other end... There's different kinds of percentages of people in different organizations so, you know, if they have a lot of no, no, no-ers in an organization, it makes it a lot tougher and they're not ready."

Instead of structural changes, key informants suggested attitudinal changes to increase readiness for successful telehealth implementation. This involves a shift from expecting short-term results to viewing telehealth as a long-term project, with utilization itself indicating success:

"...I don't want to take a position that we should have a year-long project or two-year project or three-year project to determine... if it is a success or not a success... those are pilot projects and I want to get out of this pilot project mentality, but that it's just become an integrated service within everything out that's being done, it's another tool."

iii) Structural Readiness

A considerable amount of data focused on building efficient structures to support successful implementation of telehealth, implying that a certain level of structural readiness is also needed to participate and succeed in telehealth.

Technical Readiness in the Rural / Remote Area: Bandwidth and Network Connection

Bandwidth access (also referred to as network connections) was identified by a majority of key informants and by some participants in the focus groups as being a fundamental, structural-level requirement for the introduction of telehealth into a rural and remote area. A certain level of technical readiness, in terms of bandwidth access, is needed for effective participation in a telehealth program: "Infrastructure is a big issue, both facility-wise but also telecom-wise, making sure that you have the bandwidth and stuff like that."

"So, for example, they [the government] made a commitment to improve the telecom infrastructure, which is absolutely vital in providing the telehealth applications or you being able to use telehealth applications in rural communities."

The high cost of obtaining adequate bandwidth access in remote areas was often discussed as a barrier to readiness in the implementation and use of telehealth. Due to low volume, the cost of establishing bandwidth access is compounded in northern areas. One key informant pointed out the dilemma facing the highest-need communities in the north, with regard to connections:

"I guess one of the biggest barriers is the network cost. It's huge. I mean both for accessing, you know, if you're using videoconferencing and you're required to use a bridge and a gateway so you can join multiple sites but then these multiple sites if they talked to one another properly, you know, ...if you're using ISDN or what, you know, so that those things are also very expensive... I think that's particularly true in the north where the telecom companies, you know, they don't have the volume so that they're not really making huge dollars so then they're going to tack things on to be pretty expensive. But the irony of it is that those people who are living in the northern rural communities are really remote and they ought to be afforded the opportunity to be able to access services that they can't access because it's too expensive. So it's a real Catch 22."

In this case, those who were the most ready, in terms of need created by isolation, were also those least able to participate. These concerns were echoed in one of the public focus groups, where it was noted that establishing even basic phone lines had been a challenge and was a potential barrier to implementing telehealth applications in the area.

A key informant from the organizational group noted that a potential solution to the high cost of obtaining appropriate bandwidth in small communities is sharing network connections between organizations using distance technology in some capacity:

"Well, I think communities are so small that it has to fit in with what else is going on. I think in their case the key is sharing of resources among multiple applications, not just health but justice and education, because the communities are so small they really can't afford to maintain separate networks for each application."

Thus, inter-group cooperation can potentially contribute to basic technical readiness within the geographical area. Key informants and focus group participants also noted that sustained funding (through the public sector) would ensure that bandwidth access and network connections could be established and maintained.

iv) Non-Readiness

Instances of non-readiness are evident throughout the data. Non-readiness for telehealth may occur in a number of ways. Key informants gave several examples where telehealth implementation had failed due to a lack of need to use the service in that geographical area. A key informant stated that she knew of a telehealth service that failed as a result of a lack of a genuine need to use it: "The...community was too close to the larger centre so that, you know, it was just as easy to send a person in. So, you know, again, that didn't work that well."

Another key informant explained the potential for indifference toward telehealth applications in larger communities, where adequate resources already exist:

"Other communities that are larger - these are communities that might have 5,000 - 15 or 20,000 people, they have face to face CME going on in their communities anyway. So if they don't have the video conferencing CME it is not a big loss to them."

Non-readiness may be characterized by a lack of awareness of the benefits that technology can offer to health care delivery, and by avoidance of addressing the topic with any real consideration. This key informant outlined an instance of non-readiness at the organizational level:

"From my organization being at a headquarters' level, we're dealing with people that are designing, planning or supporting regional implementation of programs. We found that the programs are established. There's a certain way of delivering the programs. Why should they change? It may not be perfect but - one example was with the delivery of the home and community care program. We have done a lot of talking to try to get people interested in trying to incorporate some telehealth applications into the implementation of the homecare strategy. And it's basically a new way of working. They don't understand well or see the benefit of using a technology as opposed doing things the way they used to be done. So you can get caught into, you know, almost a 1950's model of service delivery because that's, you know, how we do things. You just see it with passive resistance. It's not overt because everybody says, "oh, yeah, it sounds like a really good idea and I'll catch you later because now I've got to go back to my job"."

Factors within Types of Readiness by Community Target Groups

Readiness was explored across community target groups (i.e., public, patient, practitioner, and organizational), in order to examine specific factors of telehealth readiness within each type (see Table 1.1). It is interesting to note that some characteristics are shared between groups but not necessarily at the same level. For example, local champions, identified as vital to the structural readiness of the public community, act as educators who facilitate the movement from engagement to structural readiness. For the practitioner community, champions are characteristic of engagement. They promote curiosity about telehealth and exert a power of peer influence in encouraging practitioners to engage in questions about telehealth and to consider its utility.

Table 1.1 Factors within Types of Readiness Affecting Target Groups' Telehealth Readiness

Public	Patient	Practitioner	Organization
Core Readiness dissatis-faction with the current state of health care dissatis-faction with typical doctor-patient interaction; desire for a more comfortable setting for obtaining health information desire for change isolation /poor access Engagement wanting to know what telehealth is; having a clear definition of telehealth recognizing (or estimating) the benefits of telehealth having a sensitive health condition; desire for privacy regarding health practice Structural Readiness education availability of formal and informal information networks availability of testimonials from people awareness campaigns champions, especially local ones community consultation sessions; sense of ownership healthy inter-organi-zational dynamics in promotion activity	Core Readiness sense of isolation /lack of access recognition of unmet need desire for change; willingness to actively help themselves /their condition Engagement knowledge about what exactly telehealth is knowledge about the benefits (or anticipated benefits) fear of damaging equipment gender privacy concerns availability /reliability of content that fits rural /remote culture address concerns about telehealth as a replacement for already available services sense of ownership Structural Readiness education about telehealth awareness about telehealth; over-coming sense of vulnerability in video-conference ability /training to use equipment practitioner mediated liaison for telehealth programs	Core Readiness extreme dissatisfaction with the status quo first-hand understanding /experience of negative effects of isolation driving need to address a public or patient problem (as opposed to practitioner -specific one) Engagement innovators; champions sense of curiosity peer influence evidence of utility inter-group cooperation (between practitioners and the other domains) intra-group cooperation (between working practitioners) commu-nication openness; respect for others willingness to make initial extra investment in time Structural Readiness addressing scheduling concerns; overextended workloads 24 hour access to equipment established reimbur-sement plans reliability in equipment functioning; good technical support; backup plans confirmation of reliable and available clinical consultants reliable content-clinical and CME liability	Core Readiness recognition of unaddressed needs dissatis-faction with the organizational status quo Engagement champions availability of risk-takers, pioneers education /awareness process for innovators reduction of nay-sayers /resisters ability /willingness of senior admini-stration to consider benefits outside standard business case /cost effectiveness schemes willingness to consider long timelines for implem-entation movement from short-term funding; short-term accountability deadlines cost-benefit analysis established mechanisms of knowledge transfer between staff Structural Readiness identification of equipment difficulties; 'bugs' well-conducted needs assessment community consultation process; ownership allowance for creative use of equipment by practitioners and patients accessible, compre-hensive technical support: locally available and on-call effective scheduling; integration into the routine proper facilities: lighting, size, hvac-heating, adequate equipment accessible, sustained staff training (including training at medical school to encourage routine perception) provision of a telehealth coordinator written policy on reimbur-sement, liability, cross-jurisdiction use, privacy sufficient ongoing funding: local, provincial, federal buy-in

Themes

Six prominent themes were also identified in the data:

1. Core Readiness: Seemed relatively stable and consistent across all the community groups. A recognized need for service and an expressed dissatisfaction with the existing circumstances were always present where telehealth implementation was successful.
2. Structural Readiness: Solid infrastructure, including adequate human resources, training, policies, and funding, and having appropriate equipment that functioned properly or was easily repaired were shown to lead to successful telehealth services. Levels of readiness were higher if group members perceived the structures surrounding telehealth to be adequate.
3. Projection of Benefits: Respondents from all groups were able to project the ways in which telehealth would relieve some of the strains that isolation places on their health care system. All hoped that telehealth would reduce the need to travel, improve access to services / information, support the quality of services, and enhance the professional education of practitioners in rural / remote areas.
4. Assessment of Risk: Was common to all community groups. Risk included liability issues; compromising privacy; inability to obtain reliable information; loss of face-to-face contact; exclusion of poorer or less educated segments of the population; and financial risk. Key informants suggested a number of solutions to these perceived risks (see Table 1.2).
5. Awareness and Education: Will help to promote readiness of a community to use telehealth, and will potentially represent a broader structural-level solution to some of the perceived problems raised in the engagement process. Education and awareness may be spread via information campaigns or through example, with 'champions' or innovators playing a major role in the latter. A genuine understanding of telehealth was linked to readiness to adopt.
6. Intra- / Inter-Group Dynamics: Were found to play a role in readiness. Communication across the community groups and co-operation between these groups were emphasized as factors contributing to readiness to adopt telehealth.

The complete Qualitative Analysis Report is available in Volume II, Appendix E.

1.4 Conclusion

1.4.1 Discussion

A number of themes regarding readiness are repeated across data sets and are worth revisiting. Core readiness seemed relatively stable and consistent across all target groups. In locations where telehealth services had been successful, a recognized need for the service, as well as an expressed or felt dissatisfaction with existing services or circumstances were always present (this was, of course, based on retrospective data, but evidence of these characteristics was also present in the focus group data, indicating a predisposition to readiness to adopt telehealth). The isolation of rural and remote areas repeatedly emerged as a factor in creating needs.

Structural readiness and responsiveness were other prominent themes in the data. A solid infrastructure, including having appropriate equipment that functioned properly or was very easily repaired, as well as adequate human resources, training, policies, and funding, was shown to lead to successful telehealth services. Further, levels of readiness among the practitioner, patient, and public groups may be raised if members perceive the structures surrounding telehealth to be adequate, given that fears and reservations are often linked to telehealth structures. Finally, it was suggested that allowing flexible use of telehealth equipment would allow for greater responsiveness in meeting community needs and would increase the chances of successful uses of telehealth services.

Present in all target groups was an assessment of 'risk' when adopting telehealth. For practitioners, telehealth presented a number of risks. These range from adding more working time to the practitioner's day to liability in using the equipment during delivery of care, as well as to deciding whether or not to trust the information available to them through web-based applications. For patients, telehealth presented a risk in terms of obtaining reliable information and compromising their privacy and, more broadly, it presented a possible threat to receiving face-to-face care. The data from the public perspective also reflected a fear that such services would replace the existing health care system (including face-to-face contact with practitioners), and a concern with the reliability of information. A perceived risk of excluding poorer or less educated segments of the population from health services was also present. For organizations telehealth presented a financial risk, especially since results are not easily tabulated in short time periods. Given these uncertainties, it is easy to see how the investment of extra time, effort, and money required for the implementation or use of telehealth poses a risk for various communities.

Juxtaposed to the sense of risk is the sense of the benefits that telehealth may bring to rural and remote areas. Respondents from all target groups were able to project the ways in which telehealth would relieve some of the strains that isolation places on their health care system. All respondents hoped that telehealth would reduce the need to travel, improve access to services and information, improve the quality of services, and enhance the professional education of practitioners in rural and remote communities. These reflect areas which promoters of telehealth can build upon in order to increase readiness for telehealth, especially if these benefits have been demonstrated in other areas.

Education and awareness are significant themes in the data, and potentially represent a broader, structural-level solution to some of the perceived problems raised in the engagement process. Overall, a genuine understanding of telehealth (the various applications, their potential benefits and limitations) is believed to be linked to readiness to adopt. A lack of this understanding makes people wary about adopting telehealth. Education and awareness may be spread via information campaigns or through example, with champions or innovators playing a major role in the latter. The public and patient data sets referred mainly to the role that would be played by information campaigns, while the practitioner and organizational data sets referred mainly to the role of champions in diffusing information through example to all the types of target groups. Learning through example was believed to be far more potent in its effect of producing readiness than provision of information only, and planners of future information campaigns might consider demonstrations as part of the campaign. Overall, awareness of the potential of telehealth and education as part of promoting awareness will help to promote readiness of a population to use telehealth.

Finally, target group interaction was a repeated theme throughout the data. Both intra- and inter-group dynamics were found to play a role in readiness. Intra-group dynamics were examined in detail in the organizational and practitioner data sets, where innovators were shown to play an important role in diffusing innovations such as telehealth. In the practitioner group, a healthy respect for the various levels of readiness to use telehealth was believed to be of key importance in allowing the gradual spread of telehealth with the least amount of resistance. Inter-group dynamics were examined to some extent in all target groups, but they were most obvious in the public and organizational data sets. Communication (in the form of consultation and effective listening) and cooperation between target groups were emphasized as factors that contribute to readiness to adopt telehealth.

1.4.2 Implications

Readiness is a necessary requirement for successful implementation of an innovation. Lack of readiness can result in the inability to adopt telehealth projects or to maintain successful services. This study aimed to identify core factors of telehealth readiness in rural or remote Canadian communities. Readiness in these areas is particularly important, considering the isolation and the lack of accessible services that these communities often experience. Ensuring an acceptable level of readiness can prevent losses of time, money, and effort, and can increase the chances of successful implementation and maintenance of telehealth services.

This project addressed the gaps or barriers to the implementation of telehealth applications in rural and remote communities. This is the first known research which identifies an initial typology for telehealth readiness for rural environments using a qualitative approach and theoretical framework. The complete and sophisticated analysis provided exact details on perceived risks to readiness, as well as the proposed solutions to these risks as outlined by expert respondents. The results of this study have strong implications for future telehealth implementation in rural areas; they help communities identify the factors required for readiness to support success in telehealth as well as encourage innovation adoption in rural communities.

The data revealed a number of solutions to readiness challenges. As can be seen in Table 1.2, most of these challenges were related to structural readiness and responsiveness. This table offers a guide for decision-makers and communities considering integration of telehealth. The list of potential impediments to telehealth readiness and the proposed solutions can be used as a foundation for dialogue or thought exercises to assess the telehealth readiness of specific groups, and to set direction for action steps to improve the readiness of a community for telehealth.

Specifically, from a policy perspective, the study provides a readiness assessment framework which, when applied, can provide data and information that can facilitate the successful implementation of telehealth applications in rural / remote areas. This is accomplished by the assessment framework which can highlight enablers and barriers that can be addressed during the implementation / diffusion process. In particular, five policy-related recommendations are:

1. Understanding readiness is a critical first step towards the successful adoption of telehealth.
2. A readiness assessment should be conducted prior to telehealth or e-health applications being implemented in rural / remote settings. This is important, as the application of the framework highlights enablers and barriers not otherwise apparent.
3. As telehealth continues to evolve, input from all key stakeholders (including patients, health care providers, and the public) into policy development is required. Consideration of needs as well as practical experience is essential for a meaningful exchange of information and views.
4. Telehealth programs should be implemented and evaluated in a culturally aware and culturally sensitive manner.
5. Increased awareness and understanding of telehealth opportunities among rural / remote community stakeholders is an essential step to readiness and successful implementation.

In summary, readiness, defined as the degree to which a community is ready to participate and succeed in telehealth, is believed by key informants to be related to needs and to a willingness to try telehealth as a solution. In order to overcome the sense of risk that telehealth poses as a relatively unknown or untested solution, planners might listen closely to the concerns of various communities and respond to them by building strong, flexible, and responsive telehealth structures into existing systems of health care. Education, awareness campaigns, and demonstrations will also promote readiness by spreading understanding about the benefits and limitations of telehealth. In working to reduce the sense of risk, planners may enhance the sense of curiosity and willingness of various communities to improve their health care system through the use of telehealth.

Table 1.2 Perceived Risks and Proposed Solutions for Telehealth Readiness

Community	Perceived Risk	Proposed Solution(s)
Practitioner	telehealth will add more work to practitioners' schedules	ensure that scheduling around use of telehealth is smooth (this may include ensuring that patients come to their appointments by providing transportation for them) providing practitioners with access to computers and the internet
Practitioner	physicians will not be reimbursed/paid when using telehealth applications as part of delivery of care	reimburse physicians the same amount of money as for face-to-face consultations provide funding, so that urban end consultants may be paid a sessional fee for their time ensure that reimbursement policies are in place
Practitioner	telehealth equipment will fail (especially salient in emergency situations)	provide reliable and easily accessible technical support management should allow reliable back-up systems in case of irreparable technical failure
Practitioner	content/information provided via telehealth applications will be unreliable or irrelevant to practice	consult with practitioners about the content of websites or CME sessions to increase confidence in reliability & relevance of data beyond consultation, allow active participation of practitioners in the design or execution of applications (e.g., physician panel on content of websites or 'reversed' CME, where rural physicians set the topic)
Practitioner	physicians will not have legal protection when using telehealth applications	introduce policies that clearly outline the legal implications for physicians and other professionals using telehealth applications
Patient	the definition, benefits, and limitations of telehealth are unknown	provide education and awareness about the definition, benefits, and limitations of telehealth through awareness campaigns
Patient	patients will be unable to use applications, due to lack of technical skills	provide one-on-one training for the patient in home-based applications provide easy-to-use applications, such as one-touch operations/touch screens in lieu of mouse/keyboard operations lower the level of technology required, e.g., using the telephone rather than computers the supplying organization should provide technical support and assume responsibility for any technical failure
Patient	patients will feel vulnerable using videoconferencing applications	use videoconferencing applications after an initial face-to-face consult, or ensure that the patient knows the people on the other end via some other method of consultation first
Patient	patients using web-based applications of telehealth will overwhelm themselves with too much information about their conditions, or will not be able to judge the reliability of websites	provide an official liaison site, where patients know they may access reliable information or ask experts questions allow active patient participation in the design of telehealth applications, to avoid the problems of reliability and being overwhelmed with too much information
Patient	telehealth will replace existing health care services and will eventually eliminate face-to-face contact with practitioners	supplying organizations should listen to patient concerns about this matter and take measures to show that telehealth will enhance rather than replace services
Public	the definition, benefits, and limitations of telehealth are unknown	provide education and awareness about the definition, benefits, and limitations of telehealth through awareness campaigns spread awareness through media (TV/radio/press); use flyers or door-to-door campaigns where media are lacking or as supplement to media campaign allow awareness of telehealth to spread through informal networks, or allow experienced public/champions to speak about telehealth
Public	small communities will not be able to afford the necessary bandwidth or network connections	sharing of costs and equipment among various public service providers
Public	telehealth applications will only be accessible to the wealthier or more educated segments of the population	provide an appropriate number of computer terminals in public locations to increase access for all members of the public. provide these in a context where people may talk to a person, ask questions (perhaps a drop-in center) lower the level of technology required, e.g., using the phone rather than a computer
Public	telehealth applications will replace existing health services and eventually eliminate face-to-face contact with practitioners	supplying organizations should listen to patient concerns about this matter, and take measures to show that telehealth will enhance rather than replace services
Public	people will use telehealth applications to self-diagnose, leading to either complacency or hypochondria	allow local telehealth coordinators to act as liaisons between the public and the information available, to maximize user safety (mechanism for doing so not supplied)
Organization	telehealth will be a risky investment	lengthen timelines to reflect a long-term investment rather than a pilot project allow sufficient time for results to appear (may take years) place less emphasis on cost-benefit analyses or business case analyses, be satisfied with any utilization as worth the effort

1.5 How Work will be Used

1. The Alliance for Building Capacity Readiness (ABC) Project was involved in a number of awareness events. These activities helped to initiate discussion, at particular locations, about the benefits which rural communities may receive from the use of advanced networks in health care. On a broader and probably much more important level, the dissemination of the final report has the potential to help other rural communities consider what they may require to be 'ready' for e-health, and how these leading-edge technologies might support or improve their access to and the quality of health care.
2. As the results of this Project are disseminated, it is anticipated that there will be increased innovative activity and capability in telehealth in Canada. In particular, awareness of the findings and lessons learned from this study can prevent errors and delays in implementing successful and sustainable telehealth solutions.
3. The ABC Project has expanded the Research & Development program within the Health Telematics Unit; it has partially supported e-health activities over three sites, and has primed the unit for further e-health readiness research and evaluation opportunities (e.g., SuperNet Broadband e-Health Research Project, Canadian Institutes for Health Research (CIHR) Rural / Remote Research Grouping Project). University of British Columbia partners are looking to use the results to assist in further work in e-homecare in rural communities, and there is interest within the Health Telematics Unit in how the results apply to telehealth readiness activities in developing countries (rural Chile is being considered for future study).
4. Collaborations between investigators, institutions, and health organizations within two provinces (Alberta and British Columbia) have developed as a result of this project. As well, project liaisons at a global level have also been supported; i.e., ABC collaborators have been able to discuss and promote the activities of the project to a global audience. International as well as national contacts and connections have allowed for the exchange and sharing of experiences and lessons learned. Feedback from these exchanges was built into the concepts of 'readiness' and 'communities', as well as into the ABC Research process.
   
   In addition, these connections allowed for an opportunity to disseminate information of Canadian activities to a global audience. Telehealth experts in Sweden, Germany, Finland, Norway, UK, and elsewhere have shown a specific interest in the project and its findings. One particular contact, the ACTION (Assisting Carers using Telematics Interventions to meet Older person's Needs) Project, which involves multiple European Union partners led by Sweden, was an asset to the ABC research project. The ACTION team provided the material (paper and video content) used in the ABC awareness sessions. The ACTION Project Manager also offered expertise surrounding the provision of e-homecare in rural communities.
5. The results of this project (i.e., a superior understanding of readiness within rural communities) may be vital to telehealth companies looking to provide services to rural and remote Canadian communities. The presentation at the Canadian Society of Telehealth (CST) meeting in October 2001 created significant interest from Canadian commercial entities. There was feedback that the lack of understanding over readiness, and the technology change process in general were huge obstacles to the successful marketing of telehealth products.
6. A Dissemination Plan, which consists of a list of all completed work resulting from the ABC Project, is included in Volume III. This plan includes a list of all manuscripts, abstracts, presentations, and other previously outlined deliverables completed to date.

Volume II: Evaluation of Project

2.1 Evaluation Activity Summary

The Alliance for Building Capacity (ABC) Project utilized a qualitative phenomenological approach to explore the meaning of telehealth readiness in four community domains: patient, practitioner, organization, and public. Phenomenology allows for the elucidation of meaning from reality produced internally and enables the researcher to discover meaning by interpreting the perspective of the respondent (Heidegger, 1962; Holstein & Gubrium, 1994). This approach acknowledges that people are self-interpreting and that they construct their own meanings, which are shaped by culture, context, time, and history (Benner, 1996).

The ABC Project investigators conducted key-informant, semi-structured telephone interviews within their specified community domains (3-5 in each domain; 16 in total). Key informants, who are experts in rural telehealth programs, provided both retrospective and prospective views of readiness. The interviews, rich in information, identified types of readiness (i.e., non-readiness, core readiness, engagement, and structural readiness), factors that affect readiness, and indicators of the level of readiness in each domain. In addition to the interviews, two community awareness sessions, five focus groups in the domains of practitioner, patient, and public, as well as two in-depth interviews with community physicians were conducted. These approaches assured data collection on telehealth readiness from the expert key-informant level, the grassroots clinical level, and the lay community level.

The data were organized using both implementation theory and program theory (Weiss, 1998). Implementation theory identifies steps that need to be taken and factors that need to be ensured for successful program implementation. Program theory focuses on how people react to program activities and, in turn, how those reactions affect program results. Reactions may be cognitive, affective, social, and / or cultural, and are often the less obvious factors. Combined together, these two theories make up the program's theory of change which guided the organization and analysis of the data. The interaction between steps in the implementation theory and the reactions of various respondents in the program were examined in order to assess how they affected successful telehealth implementation.

Transcripts were produced from the audio-taped interviews and focus groups. Significant elements were extracted from the text, organized in Microsoft Word files, and coded by theme in order to show how a particular piece of text exemplified the element in question. The program's theories of change were kept in mind while reading and coding the data, but the analyst remained open to other processes that emerged throughout the analysis. Specific questions guided the organization, coding, and analysis: What factors do key informants believe contribute to a successful service? How do these relate to readiness (the degree to which a community is ready to participate and succeed in telehealth)? How do various communities react to the prospect of telehealth? What does this tell us about readiness from the perspective of various communities?

Answers to the above questions provided the results and addressed the issue of telehealth readiness from the perspective of each community group. Four 'types' of readiness and factors within each type of readiness evolved. There was some overlap between the key-informant interviews and the focus groups, and between the key-informant interviews in each domain. Respondents were able to speak from a variety of viewpoints and speculate about the viewpoints in other areas. This provided additional valuable information which confirmed or complemented other data sources. Caution was used when analyzing text that crossed over between various data sets, and the analyst paid close attention to the context in which the information was given. All citations reference the group for which they were originally interviewed. Evaluation results, by type and factors, were synthesized, categorized by group, and displayed in tables as appropriate. Findings of the evaluation can be found in Volume II, Appendix E.

2.2 Program Evaluation - Team Feedback

1) What, in your view, went well in the collaborative research process?

Team Member #1
Dr. Jennett's leadership was much appreciated. Too many research projects pay only lip service to collaboration. Her consistent and dedicated commitment to collaboration showed up at many levels; how she chaired meetings, how she sought input from a variety of stakeholders, how respectful she was of northern differences. I think it was also reflected in the high calibre and interest of the research team in general. She knew and drew on the varied strengths around the table, and she took time to mentor junior colleagues, such as myself.

The pairing of team members - I was lucky to be paired with a UBC colleague who has been fantastic - this networking and mentoring process I don't believe was anywhere in our proposal but - to my mind - has been one of the strongest components for understanding 'collaborative research' as a verb, not a noun.

TeamMember #2
The leadership of Dr. Jennett and her team. Great learning experience for me in participating. The wonderful discussion of the ideas and approaches to assessment.

TeamMember #3
Community awareness sessions at the start of the project were very positively received by the community, and were effectively conducted.

2) What, in your view, did not go well in the collaborative research process?

TeamMember #1
We did not receive enough funding for our initial plans. We saw other projects with less capacity and commitment receive funding under the CIHR model and had to let go of the major central piece of our work which -in my undoubtedly biased opinion - had far more potential for improving rural and remote access than some of the other research we saw funded. We did not have the budget to include the community capacity and enhancement that would have underpinned the research more solidly in the community.

We did not have the funds to encourage the training and analysis in the community. So, the collaboration was excellent within and across universities, not as intricate and integrated across the university community divide.

Turnover and an ability of team members to stay committed without the funding base was also a problem.

TeamMember #2
Primarily my own limitation in a lack of time to fully engage.

TeamMember #3
Project management. The project budget could not support a full-time project manager, due to the delay in acquiring a portion of the matching funds. We were only able to hire a part-time research assistant to perform management duties.

Feedback to the community by the close of the project, March 31, 2003, was not as strong as had been planned.

Assigned roles and responsibilities of various team members shifted during the course of the project.

3) If you were to begin again, what would you suggest be done differently, and how?

Team Member #1
Ensure that the model we wanted to explore is the one that got funding, (we revamped our model to suit the funding sources).

Include community members in equal positions on the research enquiry team - which means funding them.

Ensure more community site visits and some kind of project base to the project. In the communities.

Team Member #2
My Division would be very interested, and I will ensure representation from my Division to participate.

Team Member #3
The project could have benefited from a full-time project manager, who would have been able to monitor milestones, tasks, expectations and deliverables of each partner more closely.

Ensure that roles and responsibilities regarding community feedback at the close of the project are activated.

Ensure that there is solid communication and commitment to assigned roles and responsibilities, and that back up plans are agreed to by all players.

4) Additional comments

Team Member #1
This multi-disciplinary, cross-university, cross-province and cross-region project had ambitious aims and succeeded in spite of obstacles as diverse as weather (traveling to a community site in a blizzard!) and inadequate funds. It was an amazing experience...

Team Member #2
None

Team Member #3
None

Volume III: Dissemination Plan

3.1 Deliverables

Manuscripts:

Jennett P, Bates J, Healy T, Ho K, Kazanjian A, Woollard R, Jackson A, Haydt S. "The Essence of Telehealth Readiness in Rural Communities: Organizational Perspective". Submitted to the Telemedicine Journal and e-Health. (submitted February 2003)

Jennett P, Bates J, Healy T, Ho K, Kazanjian A, Woollard R, Jackson A. "A Study of the 'Readiness' for Telehealth in Rural Communities". Journal of Telemedicine and Telecare. (accepted February 2003)

Jennett P, Bates J, Healy T, Ho K, Kazanjian A, Woollard R, Jackson A, Haydt S. "A 'Readiness' Model for Telehealth - Is it Possible to Pre-Determine how Prepared Communities are to Implement Telehealth"? Invited participant in Regensburg book.

Presentations:

Jennett P, Pauls M, Yeo M. "Successes and Failures in Telehealth: Organizational Readiness". 3^rd International Conference on Successes and Failures in Telehealth. Royal Children's Hospital, Brisbane, Queensland, Australia, August 25-26, 2003. (draft)

Jennett P, Bates J, Jackson A, Healy T, Ho K, Kazanjian A, Woollard R, Haydt S. "What Really Constitutes Organizational 'Readiness'? A View From the Field..." e-Health 2003, A Catalyst for Change. Toronto, Ontario, May 24-27, 2003. (draft)

Jennett P, Jackson A, Healy T, Woollard R, Ho K, Kazanjian A, Linn G, Haydt S, Bates J. "The Essence Of Telehealth Readiness In Rural Communities: Organizational Perspective". American Telemedicine Association (ATA) 2003. Orlando, Florida, April 27-30, 2003. (submitted Sept 2002, peer reviewed Jan 2003, accepted as oral presentation, Abstract #352)

Jennett P, Bates J, Jackson A, Healy T, Kazanjian A, Linn G, Ho K, Woollard R, Haydt SM. "The Essence of Telehealth Readiness in Rural Communities: Factors and Challenges". e-HealthCare - What Constitutes Return on Investment? 5^th Annual Conference of the Canadian Society of Telehealth. Vancouver, British Columbia, October 3-5, 2002.

Jennett P, Kazanjian A, Bates J, Ho K, Woollard R, Healy T, Jackson A, Haydt S (presented by M. Watanabe). "A Readiness Model for Telehealth: Can We Pre-Determine How Prepared 'Communities' and Users Are"? International Society for Telemedicine (ISfT)-ICT 2002, 7^th International Conference on Telemedicine. Regensburg, Germany, September 22-25, 2002.

Jennett P, Healy T, Jackson A, Kazanjian A, Woollard R, Ho K, Bates J. "Alliance for Building Capacity: Rural and Remote Readiness for Telehealth". Continuing Professional Development (CPD) in Medicine in the 21^st Century: Current Practice and Future Challenges. Bonn, Germany, December 10-11, 2001.

Jackson A, Jennett P, Healy T, Kazanjian A, Ho K, Wollard R, Bates J. "Instrument Development in Telehealth Readiness". Canadian Society of Telehealth Conference. Toronto, Ontario, October 20-23, 2001.

Jennett P & Jackson A (submitted by A Jackson). "Alliance for Building Capacity - Rural and Remote Readiness for Telehealth". Report on the Canada - Germany Health Telematics Workshop on E-Homecare. Nonweiler, Germany, June 25-26, 2001.

Jennett P, Healy T, Kazanjian A, Jackson A, Ho K, Woollard R, Bates J. "Preparing for Success - Developing a Framework for Telehealth Readiness in Rural/Remote Canada". ISfT-ICT 2002, 6th International Conference on Medical Aspects of Telemedicine. Uppsala, Sweden, June 22-25t, 2001. (peer reviewed)

Jennett P, Healy T, Kazanjian A, Jackson A, Ho K, Woollard R, Bates J. "Alliance for Building Capacity: Rural and Remote Readiness for Telehealth". E-Health 2001 - The Future of Health Care. Toronto, Ontario, May 28, 2001.

Jennett P, Healy T, Jackson A, Woollard R, Ho K, Bates J. "Framework for Remote and Rural Readiness in Telehealth - First Steps". E-Health 2001 - The Future of Health Care Proceedings on CD COACH Conference. Toronto, Ontario, May 26-29, 2001.

Jennett P (presented by B. Wollard). "Building Capacity by Connecting Rural and Remote Areas for Improved Health Services and Quality of Care". 2000 Canadian Farm Safety and Rural Health Conference, in collaboration with the Rural Health Research Consortium. Ottawa, Canada, Oct 22-24, 2000.

Other:

ABC Public Information (draft)

Recognition of the Final Ethics Report by the Conjoint Health Research Ethics Board, Office of Medical Bioethics, Faculty of Medicine, University of Calgary.

3.2 Questionnaire on Knowledge Dissemination/Transfer

1. I am planning to publish the report of my Knowledge Development and Exchange project.
   
   Yes
2. If yes, I expect to disseminate the report or its results on -
   
   A wide basis. Methods and results of work have already been disseminated internationally, nationally, provincially, and locally. Health Canada has been recognized as a contributor on dissemination activities since receipt of their support.
3. I would be interested in OHIH assisting in publication of my project report.
   
   Yes
4. If yes, I would expect my report to undergo peer review.
   
   Yes. Our work has already undergone peer review by an international journal (see item 4 in Deliverables). A second manuscript is currently out for review (see item 12 in Deliverables). Further, all presentations at international and national conferences were peer reviewed.
5. I am providing the names of some appropriate reviewers for my report.
   
   Already completed.
6. I normally write articles about my research work, and feel my KDE project would be a good subject for an article.
   
   Yes. Already completed two.
7. If you responded 'yes', please indicate the time frame you would need to prepare an article, after your project is completed in March 31, 2003.
   
   1-3 months (spring 2003).
8. OHIH is thinking of identifying one or two journals and having an issue dedicated to the topic of information and communication technologies and health care, to feature the KDE work. The articles submitted for publication in the journal would be peer-reviewed.
   
   I think this is a good approach.
9. If OHIH were to undertake identifying a journal for this purpose, could you suggest some appropriate journals?
   
   Canadian:
   International:
   We have already targeted:
   • Telemedicine Journal and e-Health
   • Journal of Telemedicine and Telecare
     
10. OHIH is also considering holding a knowledge sharing workshop, possibly in spring or later in 2003. Would you be interested in attending such an event?
    
    Yes.
11. Would you be interested in presenting your project findings at such an event?
    
    Yes.
    Name of Project Official completing this: Dr. Penny Jennett
    Title of Project: Framework for Rural and Remote Readiness in Telehealth
    Alliance for Building Capacity