Sustainable Rural Telehealth Innovation: A Public Health Case Study

Abstract

Objective. To examine adoption of telehealth in a rural public health district and to explain how the innovation became sustainable. Study Setting. Longitudinal, qualitative study (1988Longitudinal, qualitative study ( -2008 of the largest public health district in Georgia. Study Design. Case study design provided deep insights into the innovation's social dynamics. Punctuated equilibrium theory helped present and make sense of the process. We identified antecedent conditions and outcomes, and we distinguished between episodes and encounters based on the disruptive effects of events. Data Collection. Twenty-five semistructured interviews with 19 decision makers and professionals, direct observations, published papers, grant proposals, technical specifications, and other written materials. Principal Findings. Strong collaboration within the district, with local community, and with external partners energized the process. Well-functioning outreach clinics made telehealth desirable. Local champions cultivated participation and generative capability, and overcame barriers through opportunistic exploitation of technological and financial options. Telehealth usage fluctuated between medical and administrative operations in response to internal needs and contextual dynamics. External agencies provided initial funding and supported later expansion. Conclusions. Extensive internal and external collaboration, and a combination of technology push and opportunistic exploitation, can enable sustainable rural telehealth innovation.

Designing Engaged Scholarship: From Real-World Problems to Research Publications

“…To illustrate adaptation of the generic publication structure, we return to Singh et al (2010), which appeared in Health Services Research, a top academic journal in health management. The mission of Health Services Research is "to enhance knowledge and understanding of the financing, organization, delivery, and outcomes of health services through publication of thoughtful, timely, rigorously conducted, state-ofthe-art research and thinking. "…”

“…Although the design of a study does not necessarily start out from a specific problem, anchoring the research on a relevant type of P is what makes the research "engaged. " As an exemplar publication, Singh et al (2010) is based on engaged research into the situations rural communities face as they seek to leverage telehealth solutions in response to the lack of medical expertise and requisite health services (Table 1). The paper is co-authored by Rajendra Singh and me with expertise in digital innovation and two telehealth researchers with medical backgrounds.…”

“…In any case, the chosen analytical approach should allow for leveraging the available data from P to develop findings that realize the identified opportunity to make a contribution to A. In Singh et al (2010), the conceptual framework combines classical punctuated equilibrium theory (Gersick, 1991) with a specific process model that distinguishes between brief encounters of disruption and the longer episodes of evolution that follow them (Newman and Robey, 1992). We had several reasons for this choice of FI: (1) Our engagement with the many stakeholders revealed a process involving many serious disruptions that proved instrumental in explaining the rural institution's successful telehealth innovation path; (2) longitudinal process models based on punctuated equilibrium theory had not yet been applied in the literature on rural telehealth innovation; and (3) Rajendra Singh and I were very familiar with and had previously used the adopted FI.…”

“…In Singh et al (2010), the study is based on a longitudinal, qualitative case study design with retrospective analyses of the events that shaped the path toward successful rural telehealth innovation over a 20-year period. As such, it exemplifies engaged scholarship using informed basic research by asking a "how" question consistent with the choice of a case study design (Yin, 2009).…”

“…In fact, simpler designs with focused contributions are easier to develop and often more convincing to read. Singh et al (2010) rely on such a straightforward design with contributions to P and A (Table 1). The paper offers actionable knowledge on how managers in rural institutions can create a path toward sustainable telehealth innovation (CP); it also offers a detailed empirical account of a rural telehealth innovation-including a grounded process model-that describes how the innovation became sustainable and how actors addressed key challenges (CA).…”