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Lesson learned from years of Telehealth implementation

6 years ago, I was the owner of Medcarelive, my own Telehealth company. I also became a Telehealth enthusiastic and later a telehealth and innovation consultant. I was involved in over 40 implementation projects from large ones across health care systems and states, to small single layered, to consulting platform companies on how to best use their models. In the past 2 years, I was part of Kaiser Southern California, Health Innovation Team, where I learned first hand the difficulty in utilizing technology and leverage innovation in a large system with complex health care need.

In 2013, I read an article written by Hayim Makabee Veteran software developer, enthusiastic programmer, and a fellow innovative Influencer. The article Simplicity in Software Design: KISS, YAGNI and Occam’s Razor. Was really about simplicity. Simplicity is a desirable quality attribute in any software system, I like to share those with you as base for successful telehealth program implementation.

#1 KISS means “Keep it simple, stupid”. It is probably one of the oldest principles of software design (but we keep forgetting it). The KISS principle states that most systems work best if they are kept simple rather than made complex; therefore, simplicity should be a key goal in design and unnecessary complexity should be avoided. Software systems must be maintained by human developers with limited capabilities, thus any increase in a system’s complexity also augments the difficulty to maintain it. “Debugging is twice as hard as writing the code in the first place. Therefore, if you write the code as cleverly as possible, you are, by definition, not smart enough to debug it.” -Brian Kernighan. If you use a complex platform to initiate your telehealth program, and add layers of tools, gadgets, and other programs, you don’t only make it complex for your users but impossible for your IT to maintain and control.

#2 YANGI means “You Aren’t Gonna Need It”. It is a principle of programming that states that a programmer should not add functionality until necessary. “Always implement things when you actually need them, never when you just foresee that you need them.” – Ron Jeffries

Every telehealth program should start with answer to the following questions:

    • What- what problems are we trying to solve? What criteria are going to be used to measure success?


    • Who- is the best provider to conduct the visit? MA, RN, Pharmacy tech, NP, physician.


    • Where- should the provider/patient be? home, clinic, hospital, hub


    • How- how can this visit be conducted? Do I need “eyes on this patient?” can I conduct this visit over a phone? Can we do asynchronous tele medicine at this case via email?


In many cases using the “minimum licensed level” and the phone is more cost effective than using “the highest license level and video”. Large consideration to project location and tools to measure success are crucial as well.

#3 OCCAM’S RAZOR “A principle of parsimony, economy, or succinctness used in logic and problem-solving. It states that among competing hypotheses, the hypothesis with the fewest assumptions should be selected.” – Michael Lant

Working on assumptions of need vs “learned need “can have poor ROI and poor outcomes. The need for telehealth cannot rely on assumptions. I constantly hear statements such as “all patient would love to talk to their physician rather than coming in”. If only 10% of the patients can use a service and only 5% will benefit from it, is it worth the efforts and budget developing a whole program around that? . Hype vs reality is the start of many failed programs in health care and directly related to poor ROI and outcomes. Successful implementation come with true and accurate needs assessment, study of the population, the providers readiness, and the ability to scale once goals had been obtained. The “Last Responsible Moment” concept of lean software development Can be easily be applied to Telehealth implementation: “Decide as late as possible: Delaying decisions as much as possible until they can be made based on facts and not on uncertain assumptions and predictions.”

As Hayim Makabee said in his article: I think that the danger of simplistic design is very well expressed by this quote: “Keep it simple, as simple as possible, but not simpler.” – Albert Einstein

Good luck!

Sigi marmorstein FNP-BC, CEO Telehealth Consulting Services, Kaiser Permanente health innovation team, Nurse Practitioner, Assistant Professor.The founder and President of companies such as Telehealth Conulting Services and Currently working at kaiser permanente, member of the health innovation team devoted to expansion of Telehealth services.

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