Implementation of online video consultations in a regional health network: a management feasibility analysis from an orthopedic perspective

Digital transformation is increasingly influencing everyday life and, consequently, the health care system [1]. The overarching goal of these digital applications is to improve existing medical care offerings. In Germany, as well as in other European countries, relevant laws have been developed in recent years to ensure data security and promote digital health innovations [2‐4].

Telemedicine, for example, can be used to offer the expertise of specialists across long distances [5]. However, it was only with fast internet connections and their corresponding devices that this technology could be further developed and established in health systems in recent years, at least regarding nationwide online video consultations (OVCs). The pioneers in this were, among others, aerial states such as Australia [6]. One of the advantages of this special form of digital interaction is the independence of the location from which patients can present themselves digitally to doctors. Additionally, there are no expenses for travel and, under certain circumstances, costs for lost working hours [7]. As another positive aspect, a reduction in waiting times for patients has been demonstrated [8]. At the same time, the use of OVCs has been shown to reduce costs for health care systems and insurance providers in various studies [9, 10]. Patients generally describe a high acceptance of such digital contact methods [11]. From a professional medical perspective, studies have shown that OVCs can be equivalent to traditional doctor visits, depending on the clinical situation [12]. For physicians, the advantages of offering an OVC can be a better involvement of patients in their treatment if they have a digital affinity and the corresponding motivation, as well as attracting new patients via digital offers [4]. On the other hand, doctors also perceive OVCs as more time-consuming than regular consultations, and some doctors share concerns about the security of data exchange. The sometimes necessary deviation from usual treatment paths therefore urges the development of new processes for procedures and therapy decisions in OVCs [10].

In the context of the COVID-19 pandemic, digital doctor-patient communication quickly grew in importance from 2020 onward. While publications reporting on the clinical use of OVCs also increasingly appeared in the field of orthopedics [11, 13, 14], there are hardly any descriptions of the processes for establishing such offers for a regional network of players (or stakeholders) in health regions. When looking at regional or community health networks with close cooperation between hospitals, general practitioners and patients, it can be assumed that these networks could act more quickly and efficient with telemedical tools as communication and collaboration support [15].

However, the development and introduction of new digital processes in existing healthcare structures will need health management tools to be applied. In this context, organizational management aims to fulfill the institution´s goals by handling adequately all the processes and resources available [16]. Regarding processes specifically, health care management is increasingly applying process management strategies, which have proven to make a difference in organizational performance and competitiveness to the industry at large [17]. Here, total quality management serves as system implemented by the management of an organization to achieve the satisfaction of customers or patients, respectively [18]. Tracking a new strategy as it is being implemented needs then strategic control, with detecting problems or changes in the premises and making necessary adjustments while action is taking place [19]. Finally, change management addresses the transition of individuals, teams, and organizations to a desired future state, with changes to the scope of a project being formally introduced and approved [20].

The aim of this research was to analyze the establishment of OVCs in an orthopedic clinic with affiliated referring troop physicians, forming a community health network. Focus was set on the perspective of organizational and process management with total quality management [21, 22], strategic control [23, 24] and change management approaches [25] to develop best practice examples for possible further approaches in this context.

A digital network was set up with 16 regional medical facilities for the consultative presentation of patients with an average distance of 126 km (6 km to 328 km) from the hospital in eastern Germany. The patients themselves had a mean travel distance of 141 km, depending on their place of residence, ranging up to 650 km in some cases. The evaluation of OVCs of the two study arms is part of other studies and is not shown here ([30]; Estel et al. The use of video consultations to support orthopedic patients’ treatment at the interface of a clinic and general practitioners, submitted).

For the relative utilization of OVCs compared to the clinic's regular consultations, the ratio of OVCs (n = 176) to physical outpatient visits (n = 2374) was 7.4%.

Direct contact of the specialists with the GPs and patients was also indicated as very helpful. By getting to know each other personally and jointly developing treatment approaches, GP colleagues were able to perceive their participation in the therapy process in a positive way (Estel et al. The use of video consultations to support orthopedic patients’ treatment at the interface of a clinic and general practitioners, submitted).

Digitalization poses novel challenges to health care systems worldwide by supporting – in some cases, sometimes radically – changing existing mindsets, processes and structures [31, 32].

In this case, OVCs were introduced as a supporting link between orthopedic specialists, GPs and patients in a defined health region in eastern Germany to improve existing processes in the clinic/rural region interfaces in patient care.

In the existing approach, an overall positive conclusion could be drawn. The patients and doctors involved were, for the most part, very satisfied with the use of OVCs, in accordance with existing international data [33]. At the same time, the percentage frequency of use of OVCs, in relation to the total population of military patients treated in the outpatient clinic, was even slightly above the data of other international study data on OVCs at 9% [6]. The process analysis of the roll-out experience revealed several benefits and challenges, as discussed below.

As an implication for the regional establishment and expansion of offering OVCs in a (supra)regional health region, it seems sensible to map this within the framework of a process organization to enable spatial and temporal structuring of the processes as a basis for an organizational structure. To do so, responsibilities and strategic goals for OVCs need to be clearly defined and controlled in advance.

In the described case, Alfred D. Chandler's credo "structure follows strategy" was not fully followed [34]. While the goals and identification of resources were initially set, it was not possible to fully align the structure of the clinic and patient pathways in OVCs within the framework of this pilot project. It must therefore be discussed whether "strategy follows structure" does not apply, since the OVC project grew out of the recognized and addressed potential for the improvement of existing processes in the Bundeswehr Medical Service.

Total quality management was used as an important component for process optimization. Its application has often been successfully used to improve processes in the health sector [35] and represents an important framework structure in the presented project.

In the project, however, fixed setup structures were not initially established according to a traditional organizational approach [36], as the extent of use and implementation was not initially foreseeable. When planning an expansion of OVCs to other locations, a systematic definition of the processes of an OVC should take place for easier implementation [37].

In addition, a concrete process cost analysis [10] with a comparison of not only the costs (caused by travel/waiting time, personnel expenditure and technology for the implementation of OVCs) but also the revenue from online appointments and, in the medium and long term, with regard to the quality of treatment. If applicable, patient acquisition should be taken into account.

The involvement of staff in the sense of change management concepts, e.g., according to Kotter [28], should take place from the very beginning when introducing digital innovations in health care companies. According to the experience gained here, the implementing facilities can do without a permanent additional expenditure of personnel with the corresponding additional costs. Existing outpatient clinic staff can manage the organizational operation of online video consultations well based on the experience gained, especially if an online appointment booking system is linked to the respective hospital information system [38]. For a period of approximately 2 months, however, personal contact and supervision by a competent "facilitator" who is familiar with the system should be possible (e.g., from the provider company or from the system environment) to be able to immediately address procedural questions or problems and thus promote acceptance and willingness to use the system. In addition, staff should be provided with training and handouts, as well as email and telephone advice and support.

Using the example of regional cooperation between GPs and clinic outpatient departments ("local" hospitals), a new form of digital telemedical integrated care structures in a health region can be envisaged for the future. The described project can be considered a population-based model for a regional network [39]. Here, the exchange and cooperation between outpatient and inpatient care providers, general practitioners and specialists is digitally enabled. In this concept, military doctors act as gatekeepers for the Bundeswehr, which is especially important in rural areas with only a few regional hospitals compared to urban areas. In addition to networking through OVCs, digital communication channels such as email traffic and digital interfaces for the rapid transmission of images and findings between practices and hospitals must be created in parallel.

In health care companies with clinical and practice components, the use of OVCs and other digital services could further strengthen the idea of a company network as a cooperative patient-oriented overall system and bring the individual elements closer together [40]. This form of creating proximity through direct collegial consultative exchange was also positively emphasized by medical users within the framework of the current project. In this way, specialized medical providers could benefit the patients entrusted to them in the best possible way. At the same time, current professional standards could be safely used on a broad scale [41].

Looking at strengths and weaknesses of the current project, among the main strengths can be seen the evidence of avoidance of travel efforts and the acceleration of decision processes within patient care. Also, the improved interaction of medical key players like GPs and clinical specialists has to be enlightened as potential basis for a better networking and patient care. The SWOT and portfolio analysis confirmed the potential for improving existing health care processes by the use of OVCs. With an adequate change management strategy, process management approaches based on e.g. the PDCA cycle could be used for implementation of new digital telemedical approaches also in health care networks in the field of orthopedics.

However, in the course of the implementation of the OVC, also weaknesses of the chosen approach became evident. There was a learning phase, in which the GPs had to be won and trained for the use of the OVC. Repetitive consultative discussions took place between the project team and the GPs to explain the benefits and to motivate an ongoing use. The project experiences also showed, that for many months of implementation phase, a continuous support in organizational and technological structures has to be provided. Technical problems, such as insufficient mobile internet or communication-device malfunction, deserve an immediate problem management to ensure users´ compliance and adherence to new processes.

Finally, the study itself also had some limitations. First, the number of selected regional facilities and included patient cases was not large enough to make a differentiated statement for all potential existing orthopedic pathologies. In addition, the voluntary nature of participation in the study may have led to biased selection. Among doctors and patients, those with an interest in digital topics may have been more willing to participate in the project, resulting in a higher acceptance of this digital technique. In the future, more patients with different ages and a more balanced gender distribution should be included.

For the future, the first experiences of the here presented telemedical health network approach should be further followed up. Digital solutions have a high potential to support existing communication structures between patients and health care providers, but also in between the latter themselves. Decisive seems to be a scientific analysis and both multicenter and international exchanges about useful approaches for a digitally enhanced improvement of healthcare network based patient care.

The introduction of online video consultations in a clinic with an associated care region is associated with a change in existing processes and should be addressed with strategic management approaches for the establishment of digital integrated care structures in a health region. It makes sense to apply the tools of total quality management and strategic control. Changes in management approaches are important to involve the staff in a timely manner and to support acceptance of the new measures.