Telemedicine and Its Potential Impacts on ... - Mary Ann Liebert, Inc.

Brief Communication Telemedicine and Its Potential Impacts on Reducing Inequalities in Access to Health Manpower

Mojtaba Nouhi, M.Sc. Student1 Ahmad Fayaz-Bakhsh, M.D., M.Sc., Ph.D.,2 Efat Mohamadi, M.Sc. Student,3 and Milad Shafii, Ph.D. Cand.1 1

Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. 2 Department of Healthcare Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran. 3 Department of Health Services Management, School of Health Management and Information, Isfahan University of Medical Sciences, Isfahan, Iran.

Abstract Human resources for health have many diverse aspects that sometimes bring about conflicts in the healthcare market. In recent decades issues such as attrition, migration, and different types of imbalances in health workers were not only considered as international problems, but also took on new particular dimensions and complications. Rapid growth in establishing infrastructure of communications and many diseases such as human immunodeficiency virus/AIDS and malaria, as well as shortages in skilled healthcare providers in developing countries, interested many health economists and health professionals to consider telemedicine as an approach to deliver some healthcare and to pursue its effects on human resources management in healthcare. The objective of this communication is to offer a better understanding of the value of telemedicine in human resources management in healthcare. This article briefly reviews related literature on potential contributions of telemedicine in mitigating four different types of imbalances in health workers and points out some of its capabilities. Although there is a great need for systematic, scientific, and analytical studies in effects of telemedicine on health workers, expansion of communication infrastructure throughout and especially in remote areas, political commitment, and provision of useful information and education to reduce problems of human resources for health are beneficial. Key words: telemedicine, policy, e-health

Introduction

O

ne of the critical resources in any market is skilled manpower to the extent that any productive system without skilled workers cannot achieve its goals. Inherently, a healthcare system is strictly labor-intensive,1 and health workers have important roles in provision of effective healthcare.2 In

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recent years, costs due to education, employment, wages,3 motivation, and amenities of healthcare providers have attracted health economists’ attention to this area. On the one hand, scarcity of resources in healthcare increases these costs, and, on the other hand, the increasing demands of an aging population4 for healthcare bring pressure on the workload of health workers. Finally, this pressure—as seen—disturbs the equilibrium of supply and demand, and this failure induces some problems such as attrition, different types of imbalances, and migration, reduces quality of care, and subsequently raises dissatisfaction among patients. One of the international issues concerning human resources for healthcare is geographic imbalances of the health workforce. Most countries have reported some imbalances in gender, profession, and geographic distribution5 of their health workforce. For example, in Iran the central provinces have a higher density of health workers, whereas border provinces are still short of medical service providers.6 So, adopting wise policies and using new instruments and technologies to mitigate these problems are priorities. Taking all these factors in account, the main purpose of this communication was investigating the role of telemedicine and e-health communication in health workforce trends and examining the effects of the choice of healthcare provision location as well as its development on mitigating different types of imbalances due to health workers. For ease of reading, this article has been divided into sections. First definitions and dimensions of telemedicine are reviewed. Then the focus is on misdistribution of health workers in healthcare and explained disadvantages of this phenomenon. Next some merits of applying telemedicine in mitigating this inefficient distribution are examined. Finally, this article ends with some concluding remarks.

Telemedicine A brief review of the literature leaves us many definitions for telemedicine. In a single article 104 peer-reviewed definitions of telemedicine were found.7,8 The term "telemedicine" was coined in the 1970s, meaning ‘‘healing at a distance.’’9 The World Health Organization defines the following comprehensive description: ‘‘the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals’ using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.’’10 In addition, the American Telemedicine Association defines it as ‘‘the use of medical information exchanged from one site to another

DOI: 10.1089/tmj.2011.0242

TELEMEDICINE AND HUMAN RESOURCES

via electronic communications to improve patients’ health status.’’11 But, the operational definition of telemedicine has been defined as ‘‘the single most important way to equalize the differential in resources availability between rural and urban areas.’’12 All of these definitions mark telemedicine as a framework that integrates new advancements in technology and uses its capabilities in healthcare services and health needs. Telemedicine in its evolution has been subject to constant changes. One early great contribution of technology to telemedicine was the use of visual media such as television for convenient consultation between specialists and general practitioners at a mental hospital13 and psychiatric institutes14 in the United States. Successive applications of modern telemedicine have interested health workers. These growing interests and more prevalent sophisticated technology have turned people’s attention toward the applicability of telemedicine. The intrusion of technology into healthcare has gradually made traditional boundaries between healthcare settings fade away and successively redefined roles the of health workforce.15 Among its applications one can name decreasing costs of information communication technology by replacing analog forms of communication with digital forms and extending capabilities of telemedicine16 in other aspects of healthcare such as transmission of electrocardiograms and radiological images, remote fetal monitoring, education for health professionals, and promotion of accessibility to underserved areas. From the perspective of the World Health Organization four elements are essential to telemedicine7: 1. Its purpose is to provide clinical support. 2. It is intended to overcome geographical barriers, connecting users who are not in the same physical location. 3. It involves the use of various types of information and communication technology. 4. Its goal is to improve health outcomes. Element 2 is the basis for the next section.

diseases.21 In addition, with staff cutbacks during health reform, child malnutrition has worsened.21 There are various approaches to explain imbalances in health workers. In the economic approach, imbalances—shortages or surpluses—take place when the quantity of care supplied by health workers and quantity of demand by employers—patients—is not equivalent. In other words, there is a gap between supplied care and people’s demand.22 In contrast, the normative approach describes misdistributions considering a certain caregiver’s density with some standard or social norm.5,23 As seen, because the second approach takes further economic factors into account, it is more comprehensive. Regarding the second approach, there are various and complex factors affecting health workers’ misdistributions. Rural–urban inequalities, migration, medical education, public-to-private brain drain,24 violence, inadequate payments, and political and cultural factors are just a few of the determinants. Table 1 is a categorical display of factors associated with imbalances of health workers.5 However, care must be taken in treating these factors as absolute factors in the sense that they are not themselves inherently causing

Table 1. Some Categories Associated with Imbalances of Health Workers FACTOR Individual

Age; gender ; marital status; place of birth26; values; beliefs; education; ethnicity; social background; individual’s expectations

Organizational

Salary scale; management style; incentives and career structures; posting and retention practices; lack of equipment and facilities; lack of transparency in the process of posting and promotion management; heavy workload27

Institutional

Structure, organization, and role of national institution such as ministries and civil services; policy environment; healthcare reforms; decentralization28; and market-oriented

Economic

Level of national income; amount of payments; monetary incentives; elasticity of prices for human resources; rate of return on investments; economic priorities

Sociocultural

Community and local resources; amenities29; access to professional, educational, and cultural opportunities30; occupational dominated31; modernization and industrialization; NGOs; charitable organizations; traditional organizations

Educational

Resources invested in education and training; role models and content of training; years of education; location, recruitment, structure methods, and criteria of medical schools32; lack of opportunities for continuing education and career development

Imbalances in Health Workers Because health manpower is the most important input in the healthcare market, imbalances in health workers are serious challenges for health decision-making and health human resources management.17 Imbalance in health workforce is not a new issue. Nurse staff shortages were reported in hospitals in the United States as long ago as 1915.18 In addition, the sub-Saharan African countries of Cameroon, Ghana, Kenya, Tanzania, and Zambia have reported broad shortages in skilled providers.19 Although imbalances in health workers are almost a century old, they are still in full force. It is not only considered an international problem20—in both developed and developing countries—but also has taken on new particular dimensions and complications. Lack of health workers, especially physicians, in one area means lack of appropriate care, expert consultation, access to healthcare equipment, and eventually unfavorable health outcomes. For example, the number of physicians and the density of their distribution have correlated with positive outcomes in cardiovascular

EXAMPLES 25

Healthcare system Stock of health personnel, its volume and composition by sex, age, occupation, and dynamics of its evolution; shortage of health personnel; number of hospital beds per population; migration17,33 and aging of health workers; special diseases such as HIV/AIDS34; high-tech equipment HIV, human immunodeficiency virus; NGO, nongovernmental organization.

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the imbalance, but are subject to our proper or improper utilization, affecting the balance of health labor. In fact, policymakers can use such potential resources to gain the best results. For analytical purposes, some analysts have classified different types of imbalances of health workers based on different criteria into several categories.20,35 Zurn et al.20 have identified four types of imbalances that telemedicine can mitigate: profession/specialty imbalances, geographical imbalances, institutional and services imbalances, and gender imbalances. These types of misdistribution are selected as a basis for the following sections.

Potential Contribution of Telemedicine in Decreasing Imbalances in Health Workforce PROFESSIONAL/SPECIALTY IMBALANCES IN HEALTH WORKERS Imbalances have been seen in almost all areas of healthcare systems.20 Many countries have declared both a shortage and a maldistribution of their health workers. Recently, 57 countries faced serious shortages equivalent to a global deficit of 2.4 million doctors, nurses, and midwives.21 As mentioned before, a shortage or surplus in human resources indicates imbalances. In other words, this shortage goes hand in hand with imbalances of human resources for health. Although the importance of a correct skill mix (i.e., allocation throughout different occupations) in providing more useful care is readily accepted, for many reasons distributions of health workers are still disproportionate.36 For example, the ratio of nurses to physicians (a common indicator of skill mix) varies ‘‘between 5:1 in the WHO [World Health Organization] Africa Region and 1.5:1 in WHO Western Pacific Region.’’37

Simple strategies like reducing unnecessary routine work that takes much of healthcare providers’ useful time (e.g., by automatization) and encouraging health workers to learn new practical services to help in efficient substitution of health workers (e.g., highlevel cadre replaced by mid-level cadre) are inexpensive approaches for ameliorating the laborer shortage and skill mix problems of health professionals, especially in poor countries.37–39 So far, evidence of substitutability between different cadres is mostly descriptive, and there is no practical or analytical solution.36 The national referral hospital in Honiara, the Solomon Islands, did not have any pathologist. Instead of employing a pathologist, an e-mail interface system was used for telepathology consultations, which finally led to reduced processing time (from specimen collection to results).40 The breadth of health workforce (per capita population) across countries is depicted in Figure 1.

GEOGRAPHICAL IMBALANCES OF HEALTH WORKERS

In practice, there is no country, developed and developing, throughout the world that is safe from difficulties of geographical imbalances of the health workforce.41 Many studies have pointed out that rural and distant areas in comparison with urban areas—especially in developing and vast countries such as Indonesia27—suffer more from severe public health problems. Most caregivers prefer to reside in urban areas where they have opportunities for higher education, living with their families, enjoying amenities, and achieving personal ambitions.5,42–44 Although providing facilities and health workers in rural areas may be ethically acceptable and laudable, economically (e.g., need to exploit economies of scale) it is not practically efficient. Out of the never-ending conflicts and controversies over the trade-offs between efficiency and equality among policymakers, the only thing that remains is the vulnerable segment of the population living in villages and remote areas, deprived of the most basic healthcare. So, in order to provide healthcare for this vulnerable section of the population many solutions have been proposed, such as training some people already living in rural areas as healthcare givers and establishing commuting therapists. But, each of these solutions has its own complications.45 An alternative strategy is delivering healthcare via new technology, that is, telemedicine. Besides advantages like decreasing costs of treatments and consultations in rural areas46 and improving services,47,48 telemedicine sometimes can also improve the quality of care.49,50 For instance, Marcin et al.51 showed that a regional pediatric intensive care unitbased telemedicine program could provide quality care that was considered highly satisfactory to a group of ill pediatric patients. It must be noted that because of insufficient communication infrastructures (e.g., Internet bandwidth) in developing counFig. 1. Distribution of physicians, nurses and midwives, dentists, and pharmacists in tries, telemedicine is used typically for education and selected countries. World Health Organization data, 2011.53 consultation and rarely used for clinical purposes.52



To gain more advantages of telemedicine, we should educate the practitioners and improve managers’ skills in order to motivate providers and enhance coordination between patients and caregivers as well as a ‘‘better division of labor and or a capital/labor substitution.’’49 But, it must be considered that the critical requirement for efficient telemedicine in remote areas is establishing necessary communication facilities.

Table 2. Gender Imbalances in Health Workers in Selected Countries DENTISTS MALE

FEMALE

Egypt

60

40

Niger

74

INSTITUTIONAL AND SERVICES IMBALANCES

Iraq

The structure, role, and organization of national institutions such as a ministry of health also influence and form the composition and distribution of human resources for healthcare. It means institutions decide what takes place in the health sector.5 Policy and administrative affairs affect any health service settings, including how health workers are allocated. In plain words, ‘‘human resources systems reflect national institutional contexts and cultures and do not respond readily to the imperatives of technology or the market.’’53 For example, in the United States, the type of health insurance coverage of patient services affects physicians’ preferences for selected patients, but in Japan, which enjoys uniform health insurance policy, physicians work for all members of a population equally.54 So any allocation of facilities, budgets, and healthcare buildings in a country may be dependent on political decisions.55 Hospitals are places that strongly affect the distribution of physicians, especially those specialists who need high-end equipment. So, a community without a hospital lacks important health services.56 Among ways that telemedicine can mitigate side effects of institutional decisions are expansion of infrastructures for transmitting data such as from general hospitals to specialized hospitals where specialists work in order to consult for better diagnosis.57 But it must not be left for granted that like other decisions, growth of telemedicine application implementation and its acceptance by the staff need decision-makers’ political and financial support.

GENDER IMBALANCES Gender imbalances exist in many sectors of the health labor force (Table 2). One reason may be personal preferences. A study in the United States pointed out that women choose urban areas where they have better access to ‘‘salaried work’’ in institutional settings,58 whereas another study revealed that a married female physician will work in a city where her husband works.59 Healthcare markets with female dominance suffer from maldistribution of women workers. So, the proportion of women in professional posts and managerial and decision-making positions, in comparison with men, is extremely skewed in favor of men. For instance, in Sri Lanka 80% of the nurse workforce is women. In addition, in many locations in the world women cannot go to male doctors, for cultural reasons.20 Also, workplace violence (be it physical or psychological) alongside other factors prohibits women from delivering healthcare services and education in rural and remote areas effectively. Using other ways that decrease or eliminate direct and face-to-face contact, like tele-education and teleconsultation, can both mitigate the probability of any violence against women and promote the level of health and social awareness of healthcare in those areas.

PHYSICIANS MALE

NURSES

FEMALE

MALE

FEMALE

6

94

64

36

26

54

46

85

15

46

54

66

34

65

35

Benin

56

44

42

58

79

21

United States

86

14

7

93

72

28

Thailand

39

61

14

86

63

37

Oman

61

39

15

85

63

37

53

Data are percentages. World Health Organization data, 2011.

Conclusions The health workforce has a vital role in promoting the health level of people and improving quality of care. Attention to their numbers, composition, and locational characteristics are essential. Imbalances of caregivers are one of the international concerns in human resources management for health preoccupying policymakers. Although many factors affect location assignment of the health workforce, there are many strategies that can be used to mitigate inefficient assignment of staff in different areas. The challenge of equity in distribution of health resources and selection between alternatives is commonplace in developing countries. Different types of diseases such as human immunodeficiency virus/AIDS, malaria, and other healthcare problems as well as a shortage of health workers turn policymakers’ attention toward alternative approaches to deliver care. Telemedicine with its great capabilities can increase social acceptance on behalf of people and providers and can solve many healthcare troubles, not only in the near future but even now. Regarding the rapid growth of technologies, telemedicine has changed traditional boundaries in healthcare. Recognition of the expectations from health providers and redesign of their tasks are essential. Furthermore, there is a great need for systematic, scientific, and analytical studies in the telemedicine area that must be performed. 60 Strategies like expansion of its infrastructures throughout the health system and especially in remote areas, political commitment, provision of useful information and education, and—last but not least—a patience and acceptance of experiencing a totally new approach (telemedicine) to reduce problems of human resources for health are beneficial.

Disclosure Statement M.N. performed the literature search. All authors participated equally in the analysis of materials and in writing of the article. No competing financial interests exist.


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Address correspondence to: Ahmad Fayaz-Bakhsh, M.D., M.Sc., Ph.D. Department of Healthcare Management School of Allied Medical Sciences Tehran University of Medical Sciences Poursina Street Tehran 14155-6446 Islamic Republic of Iran E-mail: [email protected]

54. Matsumoto M, Inoue K, Bowman R, Noguchi S, Toyokawa S, Kajii E. Geographical distributions of physicians in Japan and US: Impact of healthcare system on physician dispersal pattern. Health Policy 2010;96:255–261.

Received: November 18, 2011 Revised: January 4, 2012 Accepted: January 6, 2012

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