Exploring factors associated with the uneven utilization of telemedicine in Norway: a mixed methods study

According to policy makers, Norway began after 2013 a significant shift towards a more global e-health strategy, which might partially explain the general decline and the low use of telemedicine in the country in the recent years.

This shift was explained by the fact that several telemedicine projects were conducted and different technologies tested over the years. However, telemedicine is still not widely integrated in the routine provision of health services. Respondents recognized that the proliferation of autonomous and fragmented local initiatives resulted in difficulties in the integration, harmonization and coordination of telemedicine activity. Moreover, some respondents believe that previous national strategies were mainly focused on messaging services and electronic exchange, while less attention was paid towards telemedicine services, especially videoconferencing [34]. This may also explain the low use of telemedicine in Norway. Telemedicine could no longer be considered separately from other national e-health initiatives. As a consequence, a comprehensive and integrated strategy for e-health has recently been implemented, with a need for systems of electronic exchange and stable infrastructure to ensure appropriate access to information.

At the regional level, respondents acknowledged that governance of telemedicine is difficult. Despite the recent shift towards e-health, infrastructure, expertise, and predisposition toward telemedicine differ across the four regions, with a consequent challenge for the implementation of the national strategy. This can explain the differences observed between Northern Norway and Western Norway in terms of telemedicine utilization. Moreover, there is still a lack of coordination between healthcare levels, especially between municipalities and hospitals. This fragmentation could be explained by institutional boundaries. Hospitals and municipalities belong to regional and local level, respectively, each involving different administrative, professional and political cultures, as well as different funding mechanisms. There is also a great variability in terms of expertise, needs and financial resources available at each level.

The diversity of governance levels and stakeholders makes the situation even more complex. Telemedicine requires a variety of technologies, services and procedures with fragmented ownership. As a consequence, responsibility (e.g. maintenance, updating, traceability, data management, authentication and security) of this set represents an unresolved issue. Fragmentation reduces exchange and sharing of information between organizations (hospitals) and levels (regions and municipalities).

« (…) One of the biggest problems is the integration of information. Information can be shared between systems [e.g. hospital-hospital, hospital-municipality] (...). But if you want to integrate systems, at the moment it’s far too complex (…). Expertly, we need to simplify the set-up, that it’s not easy too (…). Moreover, you should know that in Norway the information is recorded and classified by structure and not by the patient, which can cause a loss of information (…). So sharing and continuity of information is still a big problem (…). Paradoxically, we have more sharing of information between patients and organizations than between organizations, because patients have legal rights for access to their information (…) ». (R3).

Finally, the Coordination reform [35], which aimed at strengthening collaboration between primary care services and specialized healthcare services, had a significant impact on the decline in telemedicine utilization, especially after 2009. This reform introduced many changes in the division of work and responsibilities between organizations. For example, telemedicine services were unable to be operationalized for the lack of a clear division of responsibilities between stakeholders involved [3]. Additional challenges emerged also from the appearance of the first difficulties related to the implementation of the coordination agreements. Stakeholders were not sufficiently prepared on the complexity of this reform, particularly in terms of sharing of responsibilities and funding. The availability of regulatory and legal instruments to clarify responsibilities, including contractual arrangements, procedures and guidelines, was missing. Respondents also reported that the current national guidelines and standards are not detailed and do not fully meet the needs of organizations.

Telemedicine in Norway has been implemented mostly as projects, while a telemedicine strategy is still lacking in most organizations. Many projects were the result of leaders’ initiatives (managers or doctors), and only some hospitals included telemedicine in their medium and long-term organizational strategies. It was also reported that the success and continuity of these projects depend on the willingness of clinicians to use telemedicine. Some respondents stated that it takes time to convince people to use telemedicine and provide training and support. The high turnover of clinicians was highlighted as an additional barrier.

Telemedicine was also seen as an organizational development issue. According to respondents, telemedicine requires a long process of learning and adaptation, both individually and collectively, to ensure successful integration into an organization. This might include changes in processes, practices, cultures, communication, and division of work. Time, capacity and resources required may differ depending on the maturity of an organization and its ability to integrate changes and initiate restructuring. In most organization, such conditions are not yet sufficiently satisfied.

« (…) It’s still very hard to use telemedicine systems. It’s difficult to organize, especially if you don’t have so much time and many patients (…). Then, it’s easier to send them to the hospital than to organize a telemedicine consultation and keep responsibility for follow-up (…) ». (R5).

Telemedicine projects have been mostly supported by internal funding within organizations, and initiatives often promoted by local champions. This makes the sustainability and scaling-up of services difficult once the pilot phase is completed. Only a few projects could be considered to be integrated into the routine practice (e.g. eye diseases, neurosurgery, physical medicine-rehabilitation). However, due to the lack of recurrent funding, telemedicine services risk to be discontinued as the organization alone cannot bear the costs. External financing towards telemedicine comes mainly from regional or national programs supporting research projects and innovations. According to some respondents, this funding is very hard to obtain and requires several efforts for organizations. Moreover, funding is often oriented towards specific applications. This explains the higher utilization of telemedicine in selected clinical specialties. The presence of such non-recurring funding from research and innovation initiatives, which expires after the project end, might partially justify the decline of telemedicine activity in certain periods.

« (…) we hope that the project financing will become a financing activity. Or else, we are forced to look to other funds. If we don’t, we will have to close down the project (…) ». (R4).

Finally, small hospitals are more likely to refuse using telemedicine. As telemedicine decreases the need for physical presence (even part-time) of clinicians, small hospitals might face even more difficulties in retaining or recruiting clinicians on site.

There is a consensus that the current compensation model represents a major obstacle to the use of telemedicine, especially for services between primary care (municipalities) and specialized care (hospitals). Reimbursement is currently recognized solely to teleconsultations occurring via videoconferencing between the patient and at least one health professional, of whom at least one is a doctor, from two different physical locations. The reimbursement, equal to that of a face-to-face visit, is provided to the specialist doctor only, while there is not any reimbursement for GPs or other health professionals involved in a teleconsultation. Moreover, conducting a teleconsultation implies additional work for the GP (e.g. planning and organizing appointments with the specialist). As a consequence, GPs often decide to refer the patient to the hospital rather than using telemedicine. A lack of reimbursement applies also to telemedicine activities where only nurses and other healthcare professionals are normally involved in the service provision. The current funding model represents a major obstacle to a widespread use of telemedicine and interprofessional collaboration.

« (…) To be accounted in financing activity, there must be a doctor who consults a patient. But in one of our projects it is the nurse who is in contact with the patient. The activity-based funding does not take into account this aspect. We hope that this will change (…) ». (R3).

Another important factor reported was related to the redistribution of the savings among organizations, which could represent a disincentive to use telemedicine. For example, hospitals providing a specialist teleconsultation perform this activity without taking over the patient physically. At the same time, health authorities can save on travel expenses. The reimbursement of these costs in Northern Norway accounts for $1.4 billion per year, about 10% of its health budget [34, 36].

Finally, hospitals and municipalities have different budget and funding models, as well as distinct administrative operations. Telemedicine implies a redistribution of tasks, workload, costs and savings between different parties which have their own autonomy and funding sources. The establishment of co-financing and co-responsibility models is a challenge, especially for the management of investments in equipment and services, but also for sharing of savings and responsibilities.

« (…) The problem is that there is no connection between different levels or types of financing. You can see for transport, time used, technology, human resources, etc. Each one has a different source of financing. So, it’s not possible to see all this together (…). You have responsibilities, costs and benefits to share with many levels and stakeholders. This is a very big problem for telemedicine in Norway (…). So, it’s very important for leaders and institutions to try to study the whole economic situation. This is the most important issue (…) ». (R1).

Norway was the first country to implement a reimbursement for telemedicine in 1996, which had a positive impact on utilization [14]. Moreover, several national action plans have been implemented over the years to support technological infrastructure and regulation: «More health for each bIT» (2001–2003), «Say@!» (HOD, 2001), «Te@mwork (2004–2007), «Interaction 2.0» [37], and «One Citizen–One Record» (2012–2013) [34]. Add to this, the «Coordination reform» (2009) focused on ICTs as a leverage to strengthen coordination of services between healthcare levels [21, 35] and to offer the best services to the population with emphasis on collaboration and exchange of information [21, 35]. However, these national plans and strategies were mainly focused on messaging services and electronic exchange, and less on telemedicine services, especially videoconferencing [34], whereas it should be an integral part of these strategies.

There is still a lack of coordination across national, regional, and local level. Telemedicine initiatives are often characterized by a multitude of actors (e.g. hospitals and municipalities) who have different political, administrative, fiscal, legal, clinical and technological models, as well as different objectives, expectations, and perceptions [19]. Coordination around national plans is considered as an important prerequisite for successful implementation and integration of telemedicine [19].

The fragmentation characterizing the healthcare sector is another major obstacle to the development of an integrated nationwide telemedicine network. Issues related to management, storage, security, traceability and exchange of medico-administrative information between organizations are not yet fully resolved [19, 38]. Add to this that telemedicine involves services with fragmented stakeholders and owners, with consequent problems regarding shared responsibility of security, maintenance and use of technology.

Institutions have different infrastructures and processes, which are not necessarily interoperable. This adds complexity to the challenge of harmonizing and aligning different systems. Implementation of telemedicine requires adapting the solutions to the capacity of institutions to incorporate organizational changes, considering their needs, and making available the necessary resources and skills. Moreover, to build an integrated telemedicine network, it is necessary to coordinate institutional strategic plans and align them with national strategies and policies, while ensuring quality and safety for patients. Certification, quality, interoperability and security standards are relevant issues to be addressed [36, 39‐41].

As a strategic innovation, telemedicine may experience problems of incompatibility or conflict with established governance models [42]. For instance, the decision to integrate telemedicine into the healthcare system is under government control, while the decision to implement it in practice is under the responsibility of the organizations [43], which have their own political, organizational, administrative and professional autonomy [40]. This requires finding a synergy between different levels of governance, balancing the national vision for e-health with the flexibility necessary for organizations and professionals to make choices tailored to their needs. Such a balance would also allow organizations to develop new skills and organizational routines and, as a consequence, to innovate [44, 45]. Digital transformation is less a matter of technology than strategy, vision and the development of new abilities and skills to work, collaborate and to experiment [46].

Finally, implementation of telemedicine may redefine the nature of the activities that healthcare professionals have to perform. Resistance to change can occur when actors do not perceive clinical, professional or financial benefits (relative benefits) or when they feel that they don’t have the necessary skills or resources (visibility and complexity). This creates a situation of uncertainty [47‐50]. Change management strategies, communication and support, are central to the successful adoption and integration of innovations into organizations [51]. A collaborative, participatory and iterative approach involving all stakeholders can allow to better identify needs and priorities, thus translating them into clear and realistic objectives [50, 52].

Another challenge is the development of an economic model that allows sharing costs and benefits among stakeholders. Currently, reimbursement for telemedicine in Norway in specialized care is limited to teleconsultations occurring via videoconferencing deemed to replace physical consultations, and it is provided only to specialist doctors at the hospital. A number of store-and-forward telemedicine services have been used in Norwegian hospitals, such as teledermatology offered by means of still image referral, telepathology and telecardiology for home monitoring of patients with implantable cardioverter defibrillator and pacemaker [14, 19]. Despite Norway introduced the first reimbursement for telemedicine in 1996 for use of both store-and-forward and videoconferencing solutions in specialized care, reimbursement for store-and-forward telemedicine was discontinued in 2008 [2, 17]. Probably as a consequence, most services in routine use today occur via videoconferencing. Moreover, there are no financial incentives for GPs or other health professionals. Such economic constraints are often justified by the fear of increasing healthcare expenditures. However, the costs for the provision of telemedicine represent generally a small part of the total health expenditure [53]. It is therefore necessary to review the reimbursement policy to support routine use of telemedicine, interprofessional collaboration and information exchange. Reimbursement of services provided by specialists practising in private hospitals should also be explored [19]. The recent strategy for e-health in Norway seems to set the basis for a major shift towards nationwide large-scale use of digital health services to citizens and health professionals, including e-health and telemedicine in both specialized healthcare and primary care. An example is the recent introduction of a specific reimbursement for the conduction of (store-and-forward) e-consultations by GPs for patient follow-up. This is the first reimbursement policy to be introduced in Norway in primary care. Due to the current changes in strategy and policies for remuneration, it is important to monitor future revisions of reimbursement strategies and evaluate their impact on telemedicine adoption and utilization. The «EU eHealth Action Plan 2012–2020» should also contribute to drive changes in this direction, particularly in the light of recommendations aimed at implementing coherent policies and strategies to develop citizen/patient-centred care and services [54]. Moreover, new modes of professional health practice (e.g. use of smartphone or tablet to perform a medical consultation or follow-up by a health professional, mobility, work from home) and new forms of “network-organizations” should be considered in the future remuneration and financing mechanisms.

In addition to reimbursement policies, it is important to develop mechanisms promoting the redistribution of benefits (e.g. due to avoidance of travel) among all stakeholders. The lack of a suitable financing system contributes to a delay in the implementation of the restructuring changes necessary to achieve better integration of services between different levels. That said, the financing chain should take into account economic integration between front-line services (municipalities) and specialized services (hospital); so that this funding is adapted to the path of patients in the healthcare system and not the reverse [55]. In the same vein, investments in infrastructure and equipment must be covered by an economic framework of common expenses (e.g. between municipalities and hospitals) [19].

Otherwise, telemedicine projects have been mainly supported by internal funds within organizations, or through national or regional funding for research and innovation projects. Such mechanisms have a limited duration. Indeed, innovation involves slow organizational developments and transformations that require substantial investments, expensive sometimes, over long periods [56]. The development of long-term financing mechanisms, with flexible and suitable funding strategies, is important for the sustainability and scaling-up of telemedicine [45].

In sum, these elements echo the findings of other studies that recognize that the complexity characterizing telemedicine is often underestimated [57]. In this vein, it is reported that the factors of success and sustainability are multidimensional, ranging from technological and infrastructure issues, change management, professional practices, regulation, business and economic models, and organizational issues; this knowing that telemedicine allows to interconnect organizations that can have different practical models of governance, cultures, and organizational objectives, sometimes even antagonistic (e.g. performance criteria, etc.). The question of “e-readiness” (technological, professional, organizational, economic, political and societal) becomes thus unavoidable [57‐59].