The Challenge of Expressing Evidence-based Practice (EBP) through a Telehealth Platform
INTRODUCTION: This report represents the first phase of a sequential mixed methods study by the proVizor Telehealth Community Project (proVizor Project), a collaboration between White Pine Systems (proVizor), Indiana University Purdue University at Indianapolis (IUPUI) and a select group of healthcare and social service providers and payers from across the nation (collectively, Team). In this Phase I, we discuss the broad landscape of evidence-based practices and interventions that could be positively affected by a user-configurable telehealth platform. Phase II will expand the qualitative investigation by documenting EBP and related therapy workflows and reporting requirements for specific user organizations in each of the domains. Phase III will consist of quantitative data collection and analysis of implementing user-configurable telehealth workflows.
OBJECTIVE: To describe the challenges of expressing common evidence-based practices (EBPs) and therapy workflows through an online and mobile telehealth platform across the continuum of care, including physical health (behavioral medicine), mental health, substance use disorder, housing (social determinants of health–SDOH) and offender reentry (criminal justice). The purpose is to inform business requirements for a new patent-pending telehealth platform that allows workflow user/administrators of all experience levels, in any health or social domain, to easily and efficiently create evidence-based telehealth workflows across the continuum of care.
METHODS: Our team, consisting of practitioners and technologists, conducted a limited-scope literature review to understand how EBPs are promulgated across the continuum of care and the factors that account for variation in outcomes. The team then applied a continuum of care model to translate the findings into high level workflow requirements and to identify and describe challenges in expressing EBPs and therapeutic workflows through a telehealth platform.
FINDINGS: Studies show that descriptions and guidance for evidence-based practice is available, but that resources that provide that guidance are inconsistent, confusing and sometimes conflicting. By their nature, EBPs are flexible, to express the practitioner’s experience and the consumer’s unique needs while protecting the core evidence-based components. Studies show that while therapy in general, and EBPs in particular, yield significant improvement in outcomes, there is little evidence to suggest that, in general, one EBP is better than another, although one specific EBP might be more effective than another for a particular consumer. In the last few years, a new class of internet-enabled EBPs, e.g., Internet-based cognitive behavioral therapy (iCBT), has emerged, but these allow only limited configurability to modify the EBP workflow. They require the practitioner to accept the implementation of the EBP as interpreted by the technology designer. Further, when considering all the attributes that might affect outcomes, EBPs account for only a small part of outcomes or the variation in outcomes. Other factors must be incorporated in the design of the telehealth solution. Thus, the range of variation in implementation of EBPs and related workflows makes it difficult to define a fixed set of EBP-based requirements that can be expressed through a telehealth platform that is applicable for all practitioners.
DISCUSSION: Given the wide range in how EBP workflows are configured and implemented, and the large impact of other non-EBP factors that influence outcomes, the challenge for developers is to deliver a telehealth platform that is sufficiently flexible to express the range of workflow variation while protecting fidelity to EBP core components and still be easy enough to configure and use without costly consulting and programming services.
CONCLUSION: The critical requirement for successfully implementing not just EBPs but the full range of therapy workflow is a guided user configurable platform that protects fidelity to the core components of the EBPs while allowing an appropriate range of flexibility in implementation and use. Following models developed for other industries, like SurveyMonkey or Qualtrix for surveys or Wix or Square Space for web design, now is the time to create a low cost, easy to support telehealth platform that provides a guided configuration process that allows practitioner/users to configure the telehealth platform for their unique requirements without costly consulting or programming services. As important is the creation of a marketplace that allows providers and practitioners to exchange configurations. The resulting data base of user experience provides a resource for research to improve treatment, not just through telehealth but broadly. Such a user-configurable telehealth platform can improve outcomes and lower cost across the continuum of care.
Further research is needed to translate these broad principles into specific use-case workflows and calculate the return on investment for providers and payers.
The draft of this paper is presently undergoing review by our team and colleagues. If you would like to see the complete draft paper, or participate in the proVizor Telehealth Community Project, please let us know by completing the form below.
