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

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

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

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

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], 22]–28] 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

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