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Adoption of routine telemedicine in Norwegian hospitals: progress over 5 years

BMC Health Services ResearchBMC series – open, inclusive and trusted201616:496

https://doi.org/10.1186/s12913-016-1743-5

Received: 6 December 2015

Accepted: 13 September 2016

Published: 20 September 2016

Abstract

Background

Although Norway is well known for its early use of telemedicine to provide services for people in rural and remote areas in the Arctic, little is known about the pace of telemedicine adoption in Norway. The aim of the present study was to explore the statewide implementation of telemedicine in Norwegian hospitals over time, and analyse its adoption and level of use.

Methods

Data on outpatient visits and telemedicine consultations delivered by Norwegian hospitals from 2009 to 2013 were collected from the national health registry. Data were stratified by health region, hospital, year, and clinical specialty.

Results

All four health regions used telemedicine, i.e. there was 100 % adoption at the regional level. The use of routine telemedicine differed between health regions, and telemedicine appeared to be used mostly in the regions of lower centrality and population density, such as Northern Norway. Only Central Norway seemed to be atypical. Twenty-one out of 28 hospitals reported using telemedicine, i.e. there was 75 % adoption at the hospital level. Neurosurgery and rehabilitation were the clinical specialties where telemedicine was used most frequently. Despite the growing trend and the high adoption, the relative use of telemedicine compared to that of outpatient visits was low.

Conclusions

Adoption of telemedicine is Norway was high, with all the health regions and most of the hospitals reporting using telemedicine. The use of telemedicine appeared to increase over the 5-year study period. However, the proportion of telemedicine consultations relative to the number of outpatient visits was low. The use of telemedicine in Norway was low in comparison with that reported in large-scale telemedicine networks in other countries. To facilitate future comparisons, data on adoption and utilisation over time should be reported routinely by statewide or network-based telemedicine services.

Keywords

TelemedicineTelehealthAdoptionImplementationBarriers

Background

Telemedicine can improve access to healthcare services, especially in sparsely populated and less developed regions, by facilitating contact between patients and providers. Telemedicine has been widely tested over the past 20 years and represents a viable and significant adjunct to the delivery of healthcare [1]. However, adoption into routine practice has been slower than anticipated [2], and evidence for its effectiveness [3, 4] and cost-effectiveness [5] is still limited. Nevertheless, results are improving and several telemedicine applications appear to be promising candidates for widespread use [6]. The widespread deployment of telemedicine might improve quality of life, raise productivity in the health sector [7], avoid travel to underserved populations [8], and contribute to the sustainability of national health systems [9].

Norway has 5 million inhabitants who are spread over nearly 400,000 square kilometres, making it one of the most sparsely populated countries in Europe [10]. The responsibility for specialist care lies with the state, administered by four Regional Health Authorities (Northern, Central, Western, and South-Eastern Norway). Each region operates a number of public hospitals (Fig. 1). Municipalities are responsible for primary care. Private specialist health facilities are invited as partners to the system on a contractual basis [11]. Despite having one of the highest densities of physicians in Europe, Norway still struggles to ensure geographical and social equity in access to healthcare [12].
Fig. 1

Health regions and public hospitals in Norway

Norway is well known for its early adoption of telemedicine to provide services for the population in rural and remote areas in the Arctic [13]. Telemedicine applications have been tested since the early 1990s in the form of pilot projects or small-scale services, some of which have become fully operational [14]. Telemedicine was initially provided as a routine service only to a minor degree, with variations between health regions, but gradually several telemedicine services became ready for large-scale implementation [15]. Recently, adoption of telemedicine was reported in all health regions and most hospitals in Norway. However, the level of use was low [16].

Providing access to telemedicine does not mean that the services will be used to capacity [17]. More efforts are required internationally to provide evidence and data about the deployment of telemedicine [7]. The aim of the present study was to explore the statewide implementation of telemedicine services in Norway over time, to analyse the adoption and level of use of telemedicine by health region, by hospital, and by clinical specialty, and to examine the hypothesis that routine telemedicine is mainly used to increase access to healthcare services in remote areas. A secondary aim was to perform an international comparison of the level of telemedicine activity in Norway with other statewide telemedicine networks.

Methods

Data collection

Data on the use of routine telemedicine in Norwegian hospitals were collected from the Norwegian Patient Registry (NPR). The NPR is the central health registry created in 1997 by the Norwegian Directorate of Health to provide data for planning, evaluation, and financing of publicly funded specialised healthcare, as well as for medical and health services research [11]. Data registered in the NPR cover inpatient and outpatient care delivered by publicly funded hospitals. Only telemedicine consultations for which hospitals are reimbursed are included. In Norway, a ‘telemedicine consultation’ is defined as the use of videoconferencing to perform an outpatient consultation, examination, or treatment at a distance. To be registered as a telemedicine activity, a consultation must occur: a) via videoconferencing equipment, meaning that patient and health personnel can see each other through video transmission, b) in real-time, c) between the patient and at least one health professional, of whom at least one is a doctor, from two different physical locations [18]. The use of store-and-forward telemedicine, including the transmission of still images or remote monitoring of a patient’s health parameters, is not covered by any reimbursement scheme in Norway. Contacts occurring by telephone, SMS, or similar means are not considered to be telemedicine consultations. The reimbursement for a telemedicine consultation is equal to that of a traditional outpatient visit.

We sent a formal request to the NPR in April 2014 to obtain data on the telemedicine consultations delivered by Norwegian hospitals from 2009 to 2013. Data related to the outpatient visits were also collected as a means of comparing telemedicine activity with overall hospital activity. The study did not involve human participants, and no personally identifiable data related to individuals were collected. Ethics approvals from the Regional Ethics Committees and informed consents were therefore not required, according to the Norwegian Health Research Act and the Personal Data Act. The Norwegian Directorate of Health approved the request and delivered completed data in November 2014.

Data analysis

Outpatient visits and telemedicine consultations were stratified by health region, hospital, year, and clinical specialty. Adoption was expressed as the percentage of the number of adopters over the potential users [19]. Since telemedicine can be used to replace outpatient visits, the proportion of telemedicine consultations over the number of outpatient visits was also calculated. The remoteness of each health region was measured through two indexes used to assess the peripherality of Norwegian municipalities: the centrality index (scored 0-20) and the population index (scored 0-10) [20]. Centrality describes the geographic location of a municipality based on the size of the largest urban centre that can be reached within a given travel time. The population index is based on the population density of a municipality. Low values correspond to more isolated and less populated areas, respectively. The indexes for each health region were calculated as the median of the values of all municipalities belonging to that region. Hospitals were arbitrarily stratified by size according to the number of outpatient visits delivered in 2013. Small hospitals had less than 50,000 outpatient visits per year, medium hospitals had 50,000 to 200,000 outpatient visits, while large hospitals had more than 200,000 outpatient visits. Clinical specialties were also arbitrarily stratified by size according to the number of outpatient visits delivered in 2013. Specialties with less than 50,000 outpatient visits per year were considered as low activity, specialties with medium activity had between 50,000 and 200,000 yearly outpatient visits, while high activity was considered as more than 200,000 outpatient visits.

There is a lack of agreed standard measures to calculate telemedicine activity, which makes international comparisons problematic [17]. The number of consultations per site per week has been proposed as a metric to measure telemedicine service use [21]. However, sites may differ in terms of healthcare providers and population served. We selected studies reporting telemedicine activity as the number of telemedicine consultations per year, and compared that to the population served by each telemedicine network. We then calculated the pro capita rate of telemedicine usage.

Results

Adoption and use per health region

Table 1 summarises the number of outpatient visits and telemedicine consultations in publicly funded Norwegian hospitals from 2009 to 2013. The number of outpatient visits increased steadily over the 5-year period and in 2013 there were 11.8 % more outpatient visits than in 2009. Growth differed from region to region. The highest growth was recorded in Western Norway and Central Norway, with rates of 16.8 % and 15.8 %, respectively. Growth rates were lower in South-Eastern Norway (9.5 %) and Northern Norway (9.4 %).
Table 1

Outpatient visits and telemedicine consultations in the period 2009-2013 in the four health regions in Norway

Health region

Centrality (0-20)a

Population (0-10)a

Outpatient visits (2009)

Outpatient visits (2010)

Outpatient visits (2011)

Outpatient visits (2012)

Outpatient visits (2013)

Telemedicine consultations (2009)

Telemedicine consultations (2010)

Telemedicine consultations (2011)

Telemedicine consultations (2012)

Telemedicine consultations (2013)

Western Norway

10

0.80

879,911

930,840

947,303

994,769

1,027,463

240 (0.03 %)

246 (0.03 %)

821 (0.09 %)

1586 (0.16 %)

1686 (0.16 %)

Central Norway

11

0.50

695,162

724,617

763,467

784,757

804,753

448 (0.06 %)

23 (0.00 %)

1 (0.00 %)

0 (0.00 %)

32 (0.00 %)

Northern Norway

4

0.20

470,078

484,151

502,839

515,029

514,316

1739 (0.37 %)

876 (0.18 %)

986 (0.20 %)

955 (0.19 %)

991 (0.19 %)

South-Eastern Norway

14

1.30

2,573,532

2,625,076

2,711,593

2,783,087

2,819,054

318 (0.01 %)

41 (0.00 %)

19 (0.00 %)

159 (0.01 %)

170 (0.01 %)

Total

12

0.6

4,618,683

4,764,684

4,925,202

5,077,642

5,165,586

2745 (0.06 %)

1186 (0.02 %)

1827 (0.04 %)

2700 (0.05 %)

2879 (0.06 %)

aValues are expressed as median

Values in brackets (%) represent the percentage of telemedicine consultations compared to the number of outpatient visits, by year

All four health regions reported the use of telemedicine during the 5-year period, i.e. there was 100 % adoption at the regional level. However, there was a decline in the overall number of telemedicine consultations from 2009 to 2010 (Fig. 2). After 2010 there was a steady increase until 2013. Overall, the number of telemedicine consultations in 2013 was 4.9 % higher than in 2009.
Fig. 2

Telemedicine consultations in the period 2009-2013 in Norway and in the four health regions

The use of routine telemedicine differed between the health regions (Fig. 2). Western Norway was the only region in which the number of telemedicine consultations increased continually during the study period. In 2013 there were six times more consultations compared to 2009. In the other three regions there was a decline from 2009 to 2010, and then a stable use of routine telemedicine until 2013. Northern Norway, the region delivering most of the telemedicine consultations in 2009, had only half of the consultations in 2010. Western Norway only contributed to the consistent growth characterising the period from 2010 to 2013, thus becoming the region delivering most of the telemedicine consultations.

The use of routine telemedicine seemed to be higher in regions characterised by a lower centrality (Table 1). Similarly, telemedicine appeared to be used to a greater degree in scarcely populated regions. Central Norway seemed to be atypical, using telemedicine less than expected in relation to centrality and population.

Adoption and use per publicly funded hospital

The number of outpatient visits grew for almost all hospitals over the 5-year period (Table 2). Growth rates ranged from 3.1 % to 63.1 %. Only two hospitals had a change lower than 1 %.
Table 2

Outpatient visits and telemedicine consultations in the period 2009-2013 in the publicly funded hospitals in Norway

Hospital

Size

Outpatient visits (2009)

Outpatient visits (2010)

Outpatient visits (2011)

Outpatient visits (2012)

Outpatient visits (2013)

Telemedicine consultations (2009)

Telemedicine consultations (2010)

Telemedicine consultations (2011)

Telemedicine consultations (2012)

Telemedicine consultations (2013)

 Western Norway

 

879,911

930,840

947,303

994,769

1,027,463

240 (0.03 %)

246 (0.03 %)

821 (0.09 %)

1586 (0.16 %)

1686 (0.16 %)

  Helse Stavanger HF

Large

236,601

274,315

268,052

279,797

289,860

124 (0.05 %)

201 (0.07 %)

806 (0.30 %)

1583 (0.57 %)

1684 (0.58 %)

  Helse Fonna HF

Medium

115,059

118,160

117,049

121,380

122,381

103 (0.09 %)

41 (0.03 %)

13 (0.01 %)

1 (0.00 %)

0 (0.00 %)

  Helse Bergen HF

Large

376,996

388,058

409,798

432,519

448,597

0 (0.00 %)

1 (0.00 %)

2 (0.00 %)

2 (0.00 %)

0 (0.00 %)

  Helse Førde HF

Medium

110,630

109,995

112,956

114,554

119,052

11 (0.01 %)

2 (0.00 %)

0 (0.00 %)

0 (0.00 %)

2 (0.00 %)

  Betanien Hospital (Hordaland)a

Small

1675

2059

2097

2104

2192

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

  Haugesund San. Revmatismesykehusa

Small

21,914

21,066

18,082

24,333

23,915

2 (0.01 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

  Haraldsplass Diakonale Sykehusa

Small

17,036

17,187

19,269

20,082

21,466

0 (0.00 %)

1 (0.01 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

 Central Norway

 

695,162

724,617

763,467

784,757

804,753

448 (0.06 %)

23 (0.00 %)

1 (0.00 %)

0 (0.00 %)

32 (0.00 %)

  St. Olavs Hospital HF

Large

327,390

350,338

368,701

382,669

393,556

448 (0.14 %)

23 (0.01 %)

1 (0.00 %)

0 (0.00 %)

10 (0.00 %)

  Helse Nord-Trøndelag HF

Medium

100,797

99,562

109,382

109,110

112,597

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

22 (0.02 %)

  Helse Møre og Romsdal HF

Large

266,975

274,717

285,384

292,978

298,600

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

 Northern Norway

 

470,078

484,151

502,839

515,029

514,316

1739 (0.37 %)

876 (0.18 %)

986 (0.20 %)

955 (0.19 %)

991 (0.19 %)

  Helse Finnmark HF

Medium

55,048

54,132

55,108

59,607

59,092

14 (0.03 %)

33 (0.06 %)

39 (0.07 %)

105 (0.18 %)

76 (0.13 %)

  Universitetssykehuset i Nord-Norge HF

Large

214,538

227,831

235,486

238,232

241,248

1325 (0.62 %)

780 (0.34 %)

848 (0.36 %)

558 (0.23 %)

778 (0.32 %)

  Nordlandssykehuset HF

Medium

122,723

126,532

130,953

132,566

133,766

147 (0.12 %)

63 (0.05 %)

99 (0.08 %)

292 (0.22 %)

137 (0.10 %)

  Helgelandssykehuset HF

Medium

77,769

75,656

81,292

84,624

80,210

253 (0.33 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

 South-Eastern Norway

 

2,573,532

2,625,076

2,711,593

2,783,087

2,819,054

318 (0.01 %)

41 (0.00 %)

19 (0.00 %)

159 (0.01 %)

170 (0.01 %)

  Sunnaas sykehus HF

Small

2691

3922

3598

3285

4388

0 (0.00 %)

4 (0.10 %)

5 (0.14 %)

132 (4.02 %)

154 (3.51 %)

  Vestre Viken HF

Large

287,427

277,960

296,535

306,315

326,293

0 (0.00 %)

3 (0.00 %)

1 (0.00 %)

0 (0.00 %)

1 (0.00 %)

  Akershus universitetssykehus HF

Large

175,830

185,536

233,530

254,194

248,798

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

  Sykehuset Innlandet HF

Large

317,634

320,325

327,537

335,019

341,459

97 (0.03 %)

14 (0.00 %)

1 (0.00 %)

4 (0.00 %)

1 (0.00 %)

  Sykehuset Østfold HF

Large

200,674

195,314

196,563

205,507

212,247

137 (0.07 %)

5 (0.00 %)

2 (0.00 %)

3 (0.00 %)

0 (0.00 %)

  Sørlandet sykehus HF

Large

267,781

271,263

279,041

292,567

298,291

74 (0.03 %)

15 (0.01 %)

8 (0.00 %)

18 (0.01 %)

13 (0.00 %)

  Sykehuset i Vestfold HF

Large

196,826

195,674

205,989

215,857

213,254

0 (0.00 %)

0 (0.00 %)

2 (0.00 %)

1 (0.00 %)

0 (0.00 %)

  Sykehuset Telemark HF

Medium

155,306

164,000

169,598

173,197

154,658

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

  Oslo universitetssykehus HF

Large

825,891

859,476

828,164

815,140

832,613

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

1 (0.00 %)

0 (0.00 %)

  Betanien Hospital (Telemark)a

Small

14,868

16,983

18,760

19,815

19,642

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

1 (0.01 %)

  Lovisenberga

Medium

43,071

45,088

52,065

53,489

57,058

10 (0.02 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

  Martina Hansens hospitala

Small

22,934

22,964

25,021

29,528

29,568

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

  Revmatismesykehuset Lillehammera

Small

10,701

10,803

12,351

13,916

13,960

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

  Diakonhjemmeta

Medium

51,898

55,768

62,841

65,258

66,825

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

 Total

 

4,618,683

4,764,684

4,925,202

5,077,642

5,165,586

2745 (0.06 %)

1186 (0.02 %)

1827 (0.04 %)

2700 (0.05 %)

2879 (0.06 %)

aPrivate specialist health facilities

Values in brackets (%) represent the percentage of telemedicine consultations compared to the number of outpatient visits, by year and hospital

Twenty-one out of 28 hospitals reported that they had used telemedicine in at least one year during the period 2009-2013, i.e. there was a 75 % adoption at the hospital level. However, not all hospitals used telemedicine continuously over the study period. The number of hospitals reporting telemedicine consultations was 14 in 2010, 15 in 2009 and 2011, and 16 in 2012 and 2013. Telemedicine usage (Fig. 3) and growth (Fig. 4) did not appear to be related to hospital size.
Fig. 3

Telemedicine usage compared to hospital size, expressed as outpatient visits in 2013

Fig. 4

Telemedicine growth compared to hospital size, expressed as outpatient visits in 2013

Eleven hospitals delivered more than 50 consultations for at least one year from 2009 to 2013. All the four hospitals in Northern Norway were active in delivering telemedicine over the 5-year study. Three hospitals increased steadily their activity over the period, 7 experienced a decline, while 1 had a variable trend. Helse Stavanger had a large increase of telemedicine activity, with a level in 2013 more than 12 times higher than in 2009, compared to a growth rate of 22.5 % for outpatient visits. This hospital is mainly responsible for the growth trend characterizing Western Norway and the overall national trend as well. Helse Finnmark also increased considerably its telemedicine activity, with a level in 2013 more than 4 times higher than in 2009. This is a medium-sized hospital whose overall outpatient visits grew only by 7.3 % during the same period. Finally, Sunnaas sykehus is a small-sized hospital specialised in rehabilitation. This hospital did not have any telemedicine consultations in 2009, very few in 2010 and 2011, while in 2012 and 2013 the activity was much higher.

Comparing the number of telemedicine consultations to the number of outpatient visits, Sunnaas sykehus was the hospital which performed best, reporting in 2013 a relative use of telemedicine of 3.51 % of all outpatient activity, consisting mainly of rehabilitation visits. That is, the hospital has been replacing outpatient face-to-face visits with remote consultations performed via videoconferencing. Helse Stavanger, the most active hospital delivering telemedicine, reached a relative use of 0.58 % of the overall outpatient activity. Despite this remarkable growth, the level was still low compared to the number of outpatient visits, indicating great potential for using telemedicine to replace traditional outpatient visits. Of the other hospitals, Universitetssykehuset i Nord-Norge had a modest relative use of telemedicine in 2009 (0.61 %) compared to outpatient visits. However, this declined in the following years.

Adoption and use per clinical specialty

The results show that the use of routine telemedicine differed significantly from region to region, and was only used by some of the Norwegian hospitals. Table 3 shows the overall activity in terms of outpatient visits and telemedicine consultations in the period from 2009 to 2013 stratified by clinical specialty. Data are ordered by relative use of telemedicine compared to the overall outpatient activity in the final year, that is the proportion of telemedicine consultations over the total number of outpatient visits in 2013.
Table 3

Outpatient visits and telemedicine consultations in the period 2009-2013 in the different clinical specialties

Clinical specialty

Activity

Outpatient visits (2009)

Outpatient visits (2010)

Outpatient visits (2011)

Outpatient visits (2012)

Outpatient visits (2013)

Telemedicine consultations (2009)

Telemedicine consultations (2010)

Telemedicine consultations (2011)

Telemedicine consultations (2012)

Telemedicine consultations (2013)

Neurosurgery

Small

14,701

16,858

19,144

20,401

21,037

803 (5.46 %)

384 (2.28 %)

469 (2.45 %)

274 (1.34 %)

469 (2.23 %)

Rehabilitation

High

162,434

174,216

194,161

203,567

198,229

389 (0.24 %)

162 (0.09 %)

789 (0.41 %)

1719 (0.84 %)

1853 (0.93 %)

Eye diseases

High

228,680

266,363

287,130

301,316

311,324

154 (0.07 %)

137 (0.05 %)

231 (0.08 %)

229 (0.08 %)

291 (0.09 %)

Endocrinology

Medium

108,866

117,577

119,423

125,502

130,146

16 (0.01 %)

2 (0.00 %)

5 (0.00 %)

23 (0.02 %)

26 (0.02 %)

Cardiovascular diseases

High

222,183

228,739

249,516

260,106

263,619

152 (0.07 %)

58 (0.03 %)

51 (0.02 %)

30 (0.01 %)

42 (0.02 %)

Obstetrics

High

482,661

502,400

513,143

508,829

510,189

102 (0.02 %)

18 (0.00 %)

14 (0.00 %)

87 (0.02 %)

71 (0.01 %)

Digestive diseases

Medium

122,480

142,525

162,385

174,526

175,016

23 (0.02 %)

1 (0.00 %)

11 (0.01 %)

31 (0.02 %)

23 (0.01 %)

Pulmonary diseases

Medium

100,842

112,729

118,963

121,942

124,625

16 (0.02 %)

4 (0.00 %)

20 (0.02 %)

16 (0.01 %)

16 (0.01 %)

Plastic surgery

Medium

52,588

55,257

59,980

56,998

63,413

0 (0.00 %)

1 (0.00 %)

3 (0.01 %)

0 (0.00 %)

7 (0.01 %)

Kidney diseases

Medium

53,312

52,288

54,164

57,058

58,516

12 (0.02 %)

3 (0.01 %)

3 (0.01 %)

11 (0.02 %)

6 (0.01 %)

Urology

Medium

135,833

148,557

160,630

166,324

170,295

49 (0.04 %)

9 (0.01 %)

17 (0.01 %)

32 (0.02 %)

15 (0.01 %)

Neurology

Medium

143,640

150,588

184,850

170,295

170,908

369 (0.26 %)

12 (0.01 %)

20 (0.01 %)

32 (0.02 %)

12 (0.01 %)

General surgery

Medium

166,569

146,575

133,809

128,941

120,954

35 (0.02 %)

10 (0.01 %)

7 (0.01 %)

16 (0.01 %)

4 (0.00 %)

Children’s diseases

High

212,285

215,727

198,207

219,036

218,822

120 (0.06 %)

25 (0.01 %)

5 (0.00 %)

11 (0.01 %)

7 (0.00 %)

Orthopaedic surgery

High

647,839

708,595

739,050

744,014

782,384

60 (0.01 %)

72 (0.01 %)

76 (0.01 %)

139 (0.02 %)

23 (0.00 %)

Oncology and radiotherapy

High

94,416

196,456

206,934

229,263

239,773

71 (0.08 %)

9 (0.00 %)

2 (0.00 %)

6 (0.00 %)

7 (0.00 %)

Skin and venereal diseases

High

197,707

204,552

189,415

222,658

216,227

220 (0.11 %)

239 (0.12 %)

93 (0.05 %)

9 (0.00 %)

5 (0.00 %)

Gastroenterological surgery

Medium

114,129

123,111

126,741

130,506

141,967

9 (0.01 %)

4 (0.00 %)

1 (0.00 %)

25 (0.02 %)

2 (0.00 %)

Anaesthesiology

Small

41,515

44,411

36,567

47,811

47,342

2 (0.00 %)

3 (0.01 %)

1 (0.00 %)

0 (0.00 %)

0 (0.00 %)

Haematology

Medium

61,811

75,488

84,666

91,659

94,146

14 (0.02 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

Cardiovascular surgery

Medium

43,410

47,502

53,060

54,176

53,752

1 (0.00 %)

1 (0.00 %)

3 (0.01 %)

4 (0.01 %)

0 (0.00 %)

Ear, nose and throat diseases

High

324,964

333,776

353,326

356,885

365,251

15 (0.00 %)

9 (0.00 %)

3 (0.00 %)

2 (0.00 %)

0 (0.00 %)

General internal medicine

Medium

68,642

65,136

61,923

53,627

55,204

29 (0.04 %)

2 (0.00 %)

1 (0.00 %)

0 (0.00 %)

0 (0.00 %)

Geriatrics

Small

16,338

16,931

18,427

19,370

18,797

10 (0.06 %)

0 (0.00 %)

0 (0.00 %)

2 (0.01 %)

0 (0.00 %)

Infectious diseases

Small

28,603

31,889

34,297

38,322

39,646

1 (0.00 %)

0 (0.00 %)

0 (0.00 %)

1 (0.00 %)

0 (0.00 %)

Maxillofacial and mouth disease

Small

29,634

27,554

26,746

28,005

29,006

10 (0.03 %)

2 (0.01 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

Other clinical specialities

High

622,864

410,120

367,172

365,899

358,590

61 (0.01 %)

18 (0.00 %)

2 (0.00 %)

0 (0.00 %)

0 (0.00 %)

Pregnancy/parathyroid surgery

Small

2171

9883

15,717

17,186

21,182

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

0 (0.00 %)

Rheumatology

Medium

117,566

138,881

155,656

163,420

165,226

2 (0.00 %)

1 (0.00 %)

0 (0.00 %)

1 (0.00 %)

0 (0.00 %)

Total

 

4,618,683

4,764,684

4,925,202

5,077,642

5,165,586

2745 (0.06 %)

1186 (0.02 %)

1827 (0.04 %)

2700 (0.05 %)

2879 (0.06 %)

Values in brackets (%) represent the percentage of telemedicine consultations compared to the number of outpatient visits, by year and clinical specialty

Neurosurgery and rehabilitation were the clinical specialties where telemedicine was used most, with a relative use in 2013 corresponding to 2.23 % and 0.79 %, respectively. Neurosurgery can be considered as a clinical specialty with a low activity, which appears to be suitable to the use of telemedicine to deliver visits remotely. Early in 2009 over 5 % of all outpatient visits in neurosurgery were delivered via videoconferencing. The use decreased during the following years. Rehabilitation is a clinical specialty with a high level of activity in terms of outpatient visits. Looking at the number of telemedicine consultations in this field, there was a steady growth over the 5 years, and the level in 2013 was almost 4 times higher than in 2009. Rehabilitation became largely the most common clinical specialty in telemedicine. Apart from neurosurgery and rehabilitation, only six other clinical specialties recorded more than 100 telemedicine consultations. These included eye diseases, endocrinology, cardiovascular diseases, neurology, children’s diseases, and skin and venereal diseases. All these specialties, however, experienced a decline in the number of telemedicine consultations occurred from 2009 to 2013.

International comparison

Table 4 summarises data from eight different telemedicine networks providing consultations in multiple specialties [17, 2228] in addition to the data from Norway. The pro capita rate of telemedicine varied from about 1 consultation per year per 1000 persons to over 20 in the largest and well-established telemedicine networks. Figure 5 compares the level of activity in the different statewide networks to the size of the population served by each network. It is apparent that the larger is the population served, the larger is the telemedicine network in terms of sites, and the higher is the telemedicine service usage. This might be explained by the presence of economies of scale. The data can be fitted by a sigmoid curve. While most of the telemedicine networks still have a lower level of activity, the Veterans Health Administration Telehealth Network [22], the Ontario Telemedicine Network [17] and the Alaska Federal Health Care Access Network [26] seem to have succeeded in scaling up both adoption and use of telemedicine. The large telemedicine operations employ both store-and-forward technology and videoconferencing.
Table 4

Comparison of telemedicine activity among nine different statewide networks delivering multispecialty services

 

Reference

Technology

Year

Network size

Population served

Telemedicine consultations

Pro capita ratea

Veterans Health Administration, USA

[Darkins 2014] [22]

VC and SF

2013

152 Medical Centers, 600 community-based outpatient clinics, patients’ homes

21,600,000

600,000

27.8

Alaska, USA

[Kokesh 2011] [26]

VC and SF

2009

248 sites, more than 700 health-care providers

700,000

14,000

20.0

Ontario, Canada

[O’Gorman 2015] [17]

VC and SF

2013

2026 sites

13,550,900

221,353

16.3

African Francophone Telemedicine Network, Bolivia

[Vargas 2014] [23]

VC and SF

2013

more than 20 health institutions

200,000

700

3.5

Alberta, Canada

[Ohinmaa 2006] [24]

VC

2003

212 sites

3,000,000

5766

1.9

Georgia, USA

[Brewer 2011] [25]

VC and SF

2009

51 statewide access points

9,829,211

18,000

1.8

Nebraska, USA

[Meyers 2012] [27]

Mainly VC

2010

over 110 sites

1,800,000

2600

1.4

Western Australia

[Dillon 2005] [28]

VC

2003

104 sites

2,000,000

2151

1.1

Norway

[present study]

VC

2013

28 hospitals

5,165,802

2879

0.6

aPro capita rate: consultations/1000 inhabitants

Abbreviations: VC videoconferencing, SF store-and-forward

Fig. 5

Telemedicine activity in nine statewide networks compared to the population served. The fitted line is a sigmoid. Networks mainly using videoconferencing are shown with red symbols; networks using both videoconferencing and store-and-forward telemedicine are shown with blue symbols. The square symbol represents Norway

Discussion

Overall trend of telemedicine

The present paper reports unique statewide data on the routine use of telemedicine in Norwegian hospitals over a 5-year period. The number of telemedicine consultations increased and followed a similar trend to that of outpatient visits. This presumably reflects the increase of the population and their health needs. An overall growing trend in the delivery of telemedicine has been described in other studies reporting statewide or network-based data over time. Since 1994, telemedicine has become an integral part of the Veterans Health Administration in the United States. Data show a continuous increase in the number of veterans served by telemedicine over 20 years as well as in the number of telemedicine consultations. Telemedicine activity followed an S-shaped innovation curve [22], confirming the hypothesis that telemedicine adoption follows the growth curve typical of health technologies and other innovations [6]. The Ontario Telemedicine Network, the largest telemedicine service provider in Canada and one of the largest in the world, facilitates access to medical care in areas that are often underserved. The number of telemedicine consultations increased in all four Ontario regions from 2008 to 2013, with higher rates in rural North Ontario [17]. The Municipal Department of Health of Belo Horizonte, Brazil, established a telemedicine program in which specialist support was offered to primary care providers. The number of store-and-forward consultations grew from 2006 to 2009 [29]. The African Francophone Telemedicine Network was established to improve access to medical care in the rural Altiplano region of Bolivia, serving a population of about 200,000 inhabitants. The number of telemedicine consultations increased from 2011 to 2013, reaching a yearly average of 700 consultations [23].

Activity decline in 2010

The data from Norwegian hospitals showed a considerable reduction of telemedicine consultations in 2010. This observed decline might be due to organisational factors [29], such as lack of resources [30], or state-level policies, including reimbursement [31, 32]. In 2009 the Norwegian Health Network was established to provide an infrastructure for secure communication in the health sector in Norway. The implementation and temporary transition to this statewide network might explain the decline of telemedicine in 2010. Another factor to be considered is the nature of the telemedicine consultations. Similar studies showed increased use of store-and-forward consultations over time, while real-time consultations via videoconferencing become less frequent [33, 34]. In 1996, Norway became the first country to implement an official telemedicine fee, without distinction between video and still image solutions [14]. In 2008, however, reimbursement for store-and-forward telemedicine was discontinued, and only telemedicine consultations performed via videoconferencing were reimbursed. While store-and-forward telemedicine appears to be efficient and suitable in routine clinical practice, a lack of reimbursement represents a barrier to its use. We believe that a revision of the current reimbursement policies might create incentives which would result in a wider use of telemedicine by Norwegian hospitals.

Adoption of telemedicine

Adoption at the regional level was 100 %, that is, use of telemedicine consultations was reported in all four health regions during the period 2009-2013. The results confirm the hypothesis that telemedicine is mainly used to increase access to healthcare services in remote areas with underserved population. Twenty-one out of 28 hospitals reported using telemedicine, i.e. there was 75 % adoption at the hospital level. Thus adoption of telemedicine by Norwegian hospitals appeared to be high, both at regional level and at institutional level. Only a minority of late potential users [19] have still to adopt telemedicine. All the four hospitals in Northern Norway were active in delivering telemedicine over the 5-year study. This might be explained by the higher needs for delivering services remotely due to barriers related to distance and transportation difficulties such as in Northern Norway. Most of the hospitals delivering telemedicine were based in regions characterised by higher remoteness. Adoption rate by percentage of physicians who used the store-and-forward consultations in Belo Horizonte, Brazil, reached 6 % at network level and 18.5 % at district level. Of the adopting physicians, some stopped using telemedicine, while a few remained responsible for most telemedicine consultations [29]. All 21 geographical regions from the Veterans Health Administration Telehealth Network used teledermatology in 2014, with 4 of them collectively reporting 51 % of the patient encounters [34]. The presence of “heavy users” is confirmed by the data from Norway, where only a few hospitals delivered more than 50 telemedicine consultations per year. In the United States, the distribution of telemedicine-related costs covered by Medicare varies across states, services, and specialties. This suggests that factors other than simply rurality or need have driven adoption [35].

Use of telemedicine

Despite the growing trend and the high adoption, the relative use of telemedicine compared to that of outpatient visits was low. Hospitals in Norway therefore appear not ready yet to replace a substantial proportion of outpatient face-to-face visits with remote consultations. Medicare has been a key payer for telemedicine in the United States since late 1990s, but telemedicine-related costs remain a relatively miniscule part of overall expenditures [35]. A recent report identified six important prerequisites for successful implementation of telemedicine: 1) the national plans exist, but are not well enough coordinated and not supported by sufficient resources; 2) access to a secure communications infrastructure is to a great extent in place; 3) the use of standards is not mandatory; 4) the implementation of Electronic Health Records is very good, but interoperability should be improved; 5) laws should be adapted to the modern way of working; and 6) reimbursement for new ways of health service delivery is not in place [36]. Norway still has some way to go in its use of telemedicine. For example, if it had the same pro capita rate of telemedicine usage as in the Ontario Telemedicine Network [17], the use of routine telemedicine in Norway would increase from 2879 to 78,213 telemedicine consultations every year, almost 30 times more than the current value.

Telemedicine can be used to replace referrals to an outpatient clinic [37], thus reducing travel [8] and unnecessary hospital accesses [38], especially to those living in remote areas. However, it is difficult to estimate the proportion of outpatient visits which could be potentially replaced with telemedicine consultations, since there have been no reports to date of the large-scale use of outpatient telemedicine. It is unlikely that all outpatient visits in all specialties can be replaced by telemedicine visits. On the other hand, there is evidence that in some specialties, substantial numbers of visits can be avoided. Wootton et al. estimated that approximately half of all outpatient visits could be avoided in dermatology [8]. Jaatinen et al. found that a similar proportion of internal medicine and geriatric visits could be avoided in Finland [37]. McGill et al. found that 13 % of visits to a rural fracture clinic in Queensland could be saved by use of telemedicine [39]. If telemedicine was used in just 10 % of all outpatient visits in Norway, this would equate to about 500,000 telemedicine consultations per year, suggesting that there is room for about 100 times as many telemedicine consultations in the future.

Conclusions

We examined telemedicine adoption in Norway, exploring its level of utilisation overall, by health region, hospital, and clinical specialty. Adoption of telemedicine is Norway is high, with all the health regions and most of the hospitals reporting using telemedicine. The hospitals delivering telemedicine are mostly based in regions characterised by lower centrality and population density. Use of telemedicine has increased over the past five years. However, its relative use compared to the number of outpatient visits is still low. An international comparison shows that only few statewide telemedicine networks seem to have succeeded in scaling up both adoption and use of telemedicine. The present study provides new insights regarding the uptake of routine telemedicine delivered in a large scale. To facilitate future comparisons we recommend reporting data on adoption and utilisation over time from other statewide or network-based telemedicine services.

Abbreviations

NPR: 

Norwegian Patient Registry

SF: 

Store-and-forward

VC: 

Videoconferencing

Declarations

Acknowledgements

We acknowledge the Norwegian Directorate of Health for providing the data used in this study.

Funding

We acknowledge the Northern Norway Regional Health Authority for financial support in collecting data from the Norwegian Patient Registry.

Availability of data and materials

The datasets analysed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

PZ and RW jointly initiated the study, analysed the data and interpreted the results. Both authors wrote, read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Not applicable.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Norwegian Centre for E-health Research, University Hospital of North Norway
(2)
Faculty of Health Sciences, The Arctic University of Norway

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Copyright

© The Author(s). 2016

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