Strategic information systems are concerned with aligning information systems with a firm’s business strategy to achieve competitive advantage (Arvidsson, Holmstrom & Lyytinen, 2014). Strategic alignment between information systems and the business involves a timely and appropriate fit between the business strategy, processes, and infrastructure and the IT infrastructure, strategy, and processes to achieve harmony in the management of information systems and the business (Gerow, Thatcher & Grover, 2014). Through such alignment, the performance of a business is positively affected (Yayla & Hu, 2012). The overarching argument for this is that firms perform well when IT resources including knowledge assets, managerial and technical IT skills and physical IT infrastructure elements are aligned with the business strategy, and when suitable structures are employed in effectively managing the IT resources and supervising their deployment (Coltman et al., 2015). This alignment is ever important in the current environment where new information technologies continue to fundamentally alter conventional business strategies by allowing firms to function across the boundaries of function, time, and distance by leveraging these technologies (Bharadwaj et al., 2013).
This report discusses the role of strategic information systems in expanding the health service in rural areas. Specifically, it focuses on the implementation of a telemedicine program for managing diabetes for patients in rural areas by a hospital in an urban centre. The investigation focuses on the planning and the implementation of this technological solution by considering the perspectives of different stakeholders. The report starts by discussing literature on telemedicine in diabetes management.
Telemedicine and Diabetes Management
The management of diabetes and its associated complications is quite costly. Targeted glycaemic control is necessary for minimising the complications of this chronic condition. Conversely, less than 70% of individuals with diabetes are attaining targeted glycaemic control, showing that effective management of the disease continues to be a challenge (Fatehi et al., 2014a). Patients in rural areas are unable to attain targeted glycaemic control partly because of poor access to specialised healthcare providers. Because of the increasing need for quality healthcare and the declining availability of clinicians, information and communications technologies have demonstrated the potential for improving access to healthcare services and reducing the costs of delivering healthcare (Fatehi et al., 2014a). Telemedicine involves providing health and medical services remotely using ICT.
Telemedicine facilitates the expansion of healthcare by bridging the physical gap between consumers and healthcare providers thus reducing costs. Synchronous telemedicine entails consumers and healthcare providers interacting in real time by relying on communication technologies. For instance, video conferencing, where there is exchange of image and voice in real time, is increasingly becoming popular in telemedicine in the delivery of various healthcare and clinical services at a distance (Fatehi et al., 2014b). Verhoeven et al. (2010) systematically reviewed asynchronous and synchronous teleconsultations in diabetes and reported that these offer a reliable, cost-effective, and feasible solution for the delivery of diabetes care. Video conferencing is used in collaborative goal setting, nutrition counselling, self-management training, and diabetes education for patients (Siriwardena et al., 2012). According to Faruque et al. (2016), telemedicine is helpful in the provision of care to individuals with diabetes especially those in rural areas who are unable to travel to healthcare facilities due to large distances. Therefore, telemedicine, especially teleconference, is a technological solution for managing diabetes for individuals in rural areas who are underserved by specialists. The next section explains the methodology used to obtain stakeholders’ views on the adoption and use of teleconferencing for diabetes management.
This report collected data using interviews to understand the implementation of telemedicine for expanding access to healthcare services for people with diabetes in rural areas. The report included the views of various perspectives including patients, healthcare providers at the hospital, and in the rural areas to understand the adoption and implementation of this information system. Semi-structured interviews were conducted with these stakeholders in locations and time that were convenient for the stakeholders. The interview was based on the interview schedule found in Appendix 1. These interviews were digitally recorded followed by verbatim transcription. After transcription, the interviews were analysed using coding (Vaismoradi et al., 2016). The coding led to the identification of various thematic categories including the strategic intent of adoption of telemedicine, benefits of telemedicine, and challenges during implementation as explained in the section below.
Findings and discussion
Strategic intent of implementation of telemedicine
The telemedicine intervention was adopted by the hospital after it was discovered that some of the patients from the rural areas were not coming for the follow- up appointments to get information on ongoing management of their diabetes. An endocrinologist at the hospital stated that:
I noticed that some of my patients were not coming for their appointments… I looked at their records and realised that they were unable to do so because they came from rural areas. Therefore, we had to find a way of ensuring they got the much-needed information and support to manage diabetes at home
The hospital identified the need for providing cost-effective care for their diabetes patients in rural areas who were unable to access specialised care in their communities. The hospital considered the adoption of telemedicine as a way of providing quality care while minimising unnecessary patient admissions due to diabetes complications. Thus, this was a critical component of the hospital’s strategic intent. According to Coltman et al. (2015), having a strategic intent involves the allocation of resources and engaging in activities to assist in achieving their objectives. In line with this, the stakeholders at the hospital had to consider how the telemedicine program will improve access to healthcare for patients with diabetes in a cost-effective manner. The CEO of the hospital said that:
We recognised that the telemedicine would provide us with an opportunity for providing the required care to our patients… However, we had to consider the overhead costs to set-up the telemedicine infrastructure both on our side and the rural side. Additional funding was required for this initiative.
The implication of this is that the hospital had to set aside funds for the telemedicine infrastructure and this entailed working with managers from the finance and IT departments. The manager from the IT department determined the costs of using telemedicine intervention in terms of initial costs and ongoing upgrades to achieve a sustainable system. The IT manager identified a cost-effective technological solution provider for the information systems that was required for the provision of diabetes care and support to patients from rural areas. The manager from the finance department and the CEO worked together in determining how to get the funding for this initiative. The initiative was funded using funds from the hospital’s contingency budget. Furthermore, the CEO of the hospital had to talk with administrators and nurses, and pharmacists in the rural areas to participate in the project as they critical to its success. This is captured in this statement “we realised that we needed professionals on the ground to provide some aspects of the care. We approached healthcare providers to get their buy-in into this initiative’’ (hospital’s CEO).
Therefore, the strategic intent of the hospital in the implementation and use of video-conferencing in reaching individuals with diabetes in rural areas and providing them with the necessary care reflects a strategic alignment between IT and business, particularly, strategy execution. Specifically, the hospital adopted a strategy execution alignment where the business strategy influenced the IT infrastructure, but this was constrained by the business infrastructure (Gerow et al., 2014). In other words, the hospital’s business strategy was to provide quality care in a cost-effective way to individuals with diabetes in rural areas. In turn, this strategy influenced the IT infrastructure in terms of the kind of technological solution required to meet the business strategy. Therefore, the hospital ended up selecting videoconferencing as the appropriate IT infrastructure. However, this was constrained by the hospital’s business infrastructure in terms of skills and processes in the provision of diabetes care and support to individuals in rural areas.
The telemedicine initiative involved using interactive video-conferencing between a multidisciplinary diabetes care team from the hospital and the patients in the rural homes. The multidisciplinary team consisted of diabetes specialists including diabetes education experts, nurses, endocrinologist, and ophthalmologist who provided personalised care to diabetes patients based on their clinical status. The patients were provided with tablets that allowed them to engage in video conferences with the multidisciplinary team on a daily basis. The patients shared with the specialists about their psychological, emotional, and physical health during the interactive video conferences. Furthermore, the patients’ health data including glucose levels, blood pressure, and weight were automatically captured by the tablets and transmitted on a daily basis to the clinicians. The outcomes of the consultation between the specialists and the patient were then communicated to the physician in the rural area to facilitate care coordination. According to a local physician, “the implementation of this initiative required a change in how care was delivered to individuals with diabetes…the hospital’s care team got in touch with me and communicated their daily consultations with patients to ensure that I was prepared to provide the necessary care at the local level”. This approach to the implementation of video-conferencing reflects strategic information systems planning to achieve alignment between the business and IT. In particular, this planning was characterised by the identification of the required IT applications together with the necessary change management, resources, and infrastructure for implementing the technological solution (Maharaj & Brown, 2015).
Benefits of telemedicine
The diabetes specialists were positive on the potentiality of video-conferencing in enhancing and expanding access to diabetes services to individuals in rural areas to promote self-management of the disease. A diabetes education expert said that:
This technology increased my ability to provide education on exercise and diet modifications to my patients by talking to them via the video-conference, and this has empowered our patients to manage their diabetes in their homes.
Patients were enthusiastic that the telemedicine would support the clinical needs even though they had no or limited experiencing in using video-conferencing. Some of the patients stated that:
I didn’t have experience when it comes to telemedicine. But, I knew that it would be benefit me by providingwith ongoing support and information for diabetes management at home (patient 1)
I had never used video conference before, but it provided me a way to talk with the physician and get timely advice and guidance on managing my diabetes (patient 2)
In recognition of the limited experience that patients had in video-conferencing, the hospital’s IT department together with the external technological solution provider offered the required training. According to the IT manager at the technological solution provider:
We collaborated with the hospital’s IT department in sending out individuals to provide training to the patients. The patients were taught on how to use the video conference system and provided with the necessary equipment.
The stakeholders highlighted the benefits of video-conferencing for diabetes management for the patients in the rural areas. The statements below capture some of the stakeholders’ perspectives.
During the video-conferences, we used the daily clinical status reports of the patient, and we were able to discuss appropriate interventions to implement with the patient. This benefitted the patients because they got personalised interventions, information, and support (Hospital endocrinologist).
I got e-prescriptions from the healthcare team, and when the patients picked their medications, I talked to them about complying with their medications. By collaboratively working with the healthcare team, the quality of care of patients improved in terms of medication compliance (Rural Pharmacist)
The use of video conference has contributed to preventing unavoidable admissions for diabetes for these patients. The daily support and education they got from us has improved care coordination and connections between the patients and us to minimise the use of emergency departments (Hospital ophthalmologist)
A few months after the implementation of this project, we had seen a reduction in the admission of patients with diabetes in our area (Rural physician)
I had problems before in controlling my diabetes because I did not have access to the kind of doctors who provide the necessary care… but this changed with the daily video conferences (Patient 3)
I am satisfied with information and guidance I get from the consultations with the doctors each day in managing my diabetes. I no longer need to travel to the hospital to get the care I need (Patient 4)
The stakeholders’ perspectives highlight the impact of teleconferencing on the delivery of healthcare services to diabetes patients in rural areas. These perspectives have received support in literature. For instance, patient satisfaction is highlighted in the study by Fatehi et al. (2015) in an assessment of patient satisfaction levels with remote consultations for diabetes via video conference in a virtual outreach clinic using a cross-sectional survey. The results revealed that the patients were generally satisfied with remote consultation as they had no problem with building rapport with the clinical specialists over video conferences (Fatehi et al., 2015). Furthermore, the positive impact of telemedicine on the management of diabetes has been shown in the literature. Specifically, Huang and colleagues (2015) carried out a systematic review and meta-analysis of randomised controlled trials on the impacts of telecare intervention on glycaemic control in type 2 diabetes. It was demonstrated that patient monitoring by telecare demonstrated significant improvement in glycaemic control in comparison with patients monitored by routine follow-up (Huang et al., 2015). Weinstock et al. (2011) also found that improvement in glycaemic control related to telemedicine was sustained over a period of five years among medically underserved patients with diabetes. In their randomized controlled trial, Steventon et al. (2014) discovered that telemedicine led to modest improvements in glycemic control among patients with type 2 diabetes over 12 months.
Self-management as a critical aspect of diabetes management in telemedicine has been investigated by Young et al.(2014) who focused on the effect of person-centred health behaviour coaching model delivered through telehealth with patients with diabetes living in underserved, rural communities was assessed. The results showed that the interventions led to significantly higher scores in self-efficacy, which supported self-management of the disease (Young et al., 2014). According to Steventon et al. (2014), the greater self-care and oversight related to telemedicine might lead to fewer unplanned hospital admissions.
Challenges during implementation
Implementation of the technological solution was accompanied by some challenges. One of the major challenge identified by the stakeholders was unanticipated technical issues. This is explained by the IT manager at the hospital:
Sometimes the video conferences failed because of a drop in the internet connection. This meant that the encounter could not take place. When this occurred, communication occurred via cell phones to address important issues.
The technical issues had a negative impact on the interactions between the patients and diabetes care team. According to the endocrinologist,
Sometimes in the middle of the video-conference, the connection dropped. I could wait till past the time I had allocated for that specific consultation. Mostly, by the time the connection was up again, I would be consulting with a different patient at the hospital, and I missed my encounter with the patient in the rural area. In those cases, I worked with the rural nurses via a cell phone to communicate important information about the patient.
Technical difficulties in teleconference are due to problems with accessing broadband in rural areas, which is still lagging behind urban areas. Patients’ homes might lack high-speed cable internet that has more bandwidth capabilities and a highly reliable signal, and this causes connection problems during video conferencing (Batsis, Pletcher & Stahl, 2017). Schulz et al. (2014) reported in their study that 25% of all video conferences consultations experienced a drop in internet connection. Consequently, it is suggested that unanticipated technical issues with implementing teleconferencing should be anticipated and this highlights the importance of providing strong IT support with ongoing updates in protocols for patients in rural areas (Slusser et al., 2016).
Another challenge reported was issues with reimbursements. This was identified by the finance manager at the urban hospital. She said that:
I had problems with suitable billing of encounters between the patients and the doctors and capturing this. Sometimes, I billed an encounter, but the insurer failed to pay or took longer to do so. I had to go through convincing them [insurers] that the consultation actually occurred by talking with the patient and pharmacists or nurses in the rural areas for confirmation.
One of the patients also talked about this issue by stating that, “after talking with the doctors on the video conference they tell you to pick up the drugs at your pharmacy and when you get there, you are told there are problems with your insurer in terms of payment. I had to call my insurer to follow up and address this issue’’ (patient 5). According to Batsis et al. (2017), low reimbursement is a problem for the lasting sustainability of telemedicine systems in a fee-for-service model. This problem is due to limitations that are placed on the type of telemedicine covered by health insurers.
In conclusion, this report has focused on the strategic information systems in expanding the health service in rural areas. This has been achieved by examining the implementation of video-conferencing between individuals with diabetes and diabetes specialists in the provision of diabetes care to patients in rural areas. This report has highlighted how the hospital ensured alignment between its business strategy of providing cost-effective diabetes care to individuals with diabetes in rural areas and the use of the video-conferencing as its IT infrastructure. The hospital had to plan for its strategic information systems by identifying the appropriate IT infrastructure, processes, and changes to how care was delivered to the targeted population in rural areas. The analysis revealed how the implementation of video-conferencing addressed the interests of the different stakeholders including the hospital, diabetes specialist care team from the hospital, the patients, and healthcare providers at the local level. Thus, the implementation of this technological solution was beneficial to all the stakeholders. Overall, this report highlights how strategic information systems are vital in the expansion of health service in rural areas.
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Appendix 1: Interview Schedule
Please explain why the hospital decided to implement videoconferencing in providing diabetes care to individuals in rural areas
What was involved in the planning for the implementation of the technological solution
Did the hospital work with external stakeholders in the implementation process
How did the implementation of the technological solution affect the aims of the hospital and its specialist clinicians
How has the use of videoconference affected your (patient) access to diabetes care
Were there any challenges that were experienced during this processIf so, which ones
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