Perspectives
Commentary on:
Neurosurgery and Telemedicine in
the United States: Assessment of the
Risks and Opportunities
by Kahn et al. World Neurosurg 89:133-138, 2016
The Philosophy of Kaizen and Telemedicine
James R. van Dellen
I n their article recently published in WORLD NEUROSURGERY
on neurosurgery and telemedicine, defined as “remote care
of patients, aided by Internet-based or telephone based
telecommunications technology,” Kahn et al.1 concentrate on
the circumstances surrounding the opportunities and the risks,
and they raise a number of important points, such as the need
for and availability of such technology, finances, legal issues,
and patient confidentiality. They cite the example of
telemedicine activities in the Veterans Health Administration in
the United States, which has provided major cost savings and
patient satisfaction for chronic neurologic conditions. The
Veterans Health Administration as a single health care provider
was able to reduce hospital days by 25% and hospital
admissions by 19% together with providing patient satisfaction.
The authors further propose that economic and clinical benefits
will accrue from diminished travel times and availability of
remote consultation by subspecialists and remote triage for
more acute problems. In a 2001 publication from the Institute
of Medicine,2 the authors defined 6 aims for telemedicine:
safety, effectiveness, patient centeredness, timeliness,
efficiency, and equity. There has been criticism by some
experts that telemedicine lacks quality, evidence countered by
reports of effectiveness in some contexts, promising reports in
other contexts, and reports that telemedicine is limited or
inconsistent in other contexts.1 In their article, Kahn et al.1
enlarge on aspects that govern telemedicine in the United
States, including the specific circumstances surrounding patient
confidentiality and liability issues. They further reference
studies in the United States as well as international reports
with cost-efficiencies without outcome compromise.1
The authors provide a section on “Telemedicine Across the
World” that includes a reference to a World Health Organization
publication outlining several specific barriers.3 These barriers
include lack of technical infrastructure and literacy, climatic
Key words
- Health policy
- Neurosurgery
- Telemedicine
600 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.02.112
problems, and financial concerns. The authors also raise human
and cultural matters such as linguistic and cultural differences,
especially in economically underdeveloped countries, as
obstacles in creating remote access across boundaries. In most
developed and affluent countries, the concerns were largely
mirrored in the U.S. experience. About half of European
countries and three quarters of Southeast Asia countries have
established programs.3 The authors discuss the educational
role of telemedicine and the possibility that contact at an
appropriate level and for specific purposes might assist in
countering “brain drain.”3 They conclude by stating, “Published
standards of care and technologies in isolation do not
determine the best care for every patient, and the legal liability
standard should not be premised on such an assumption.”1
The Japanese philosophy for process improvement known as
“kaizen” may offer a model for the development of neurosurgical
telemedicine. Kaizen is aimed at continuous, step-by-step
improvement of a process that involves everyone in the organi-
zation—senior and political decision makers, managers at all
levels, and providers and health care workers. It has been pro-
posed that the word “kaizen” can be traced to the words “kai”
and “zen,” which can be loosely translated to mean “break apart
and analyze” and “improve the existing circumstances.” Kaizen
uses both common-sense and scientific methodology and an
adaptive framework of agreed values and beliefs. The starting
point is acceptance that every process and/or organization has
problems but that these should be considered as soluble or as
opportunities for change and continuous improvement, with
involvement of all responsible and empowered cross-functional
teams to challenge the status quo. Confidence in and involve-
ment of individuals most knowledgeable about a task or process
and at all levels create inclusive ownership to the highest level. It
breaks down existing and imagined barriers so that everyone can
be regarded as a contributor. It aims at making everyone’s task
Bupa Cromwell Hospital, London, United Kingdom
To whom correspondence should be addressed: James R. van Dellen, M.D. Ph.D.
[E-mail: profjvandellen@btinternet.com]
Citation: World Neurosurg. (2016) 91:600-602.
http://dx.doi.org/10.1016/j.wneu.2016.02.112

easier because they wish to improve circumstances that have
been dismantled, studied, and improved. The status quo in all its
forms must be challenged, and no matter how insurmountable
problems appear or how small a problem may seem, the aim is to
trace the root causes and implement solutions. Improvements
and success are achieved by process-oriented thinking and par-
ticipants’ efforts. The participants should not be seen to be the
problem. However, they do need to understand how their jobs
and decisions impact the process and how this can be modified
or replicated and improved. This understanding can be easily
achieved by process mapping and understanding the service
flow. The process of the management of change needs to be
long-term improvement and exhibit continuity and not be short-
term “breakthroughs.” The challenge is not to introduce
change, but to maintain momentum and then step-by-step con-
tinuity of change. “Start small, but think big.” Inclusivity can
involve sophisticated processes as well as day-to-day activities
by different people from different departments or organizations
working together to problem solve. Most importantly, the start is
recognition of the need for change. Once a change plan is star-
ted, it can be initially on a small scale, observing and evaluating
the results and establishing what has been learned and clues to
identifying problems. When a problem is identified, it must be
resolved, mandating higher standards and continuous and sys-
tematic evolution. It should not be a process of “controlling”
quality and conformance to standards and specifications, but
rather an approach centered on improvement of quality with the
status quo being challenged by continuous innovation and prob-
lem solving. Each step must achieve added value before moving
to the next step, or it should not be part of the process.
Kaizen would lead to a wider use of telemedicine in 2 ways: first,
recognizing that we need to change the traditional model of
health care delivery, whether increasing its sophistication or
managing its deficiencies, and, second, challenging the status
quo. This challenge encompasses the highest levels of “politics”
and legislature and judiciary as well as the circumstances of the
lowest recipient of health care in the most remote and under-
developed regions. Change and introduction of telemedicine as a
viable option of health care delivery and diagnostic input need not
be, and will not be, in all spheres at the same time; however,
incremental kaizen can make necessary changes. Individuals and
health care systems that have found benefit or learned lessons or
have had successful change in the use of telemedicine can pro-
vide valuable templates.
Shortage of resources, especially subspecialist resources,
means access to an appropriate level of care or referral to a
higher level of care or input in remote areas may be denied to
patients in well-off as well as impoverished countries and re-
gions, with not only individual suffering but even death, and with
“global” financial consequences. Even the most sophisticated
health care system and professional can use telemedicine and
kaizen to manage time better and to be more productive and
offer more patient-centered service. For example, if we do not
add value to a patient’s care by his or her personal visit to a
health care location, suitable to the physician, and the patient’s
care can be safely and appropriately managed by telemedicine
links when necessary, why should this traditional practice from a
bygone time be continued? Chronic conditions have been
WORLD NEUROSURGERY 91: 600-602, JULY 2016
PERSPECTIVES
documented to be well managed by remote electronic moni-
toring. We work increasingly in multidisciplinary teams, and re-
sponsibility and consultation for aspects of care with appropriate
electronic links can provide better quality care and follow-up or
diagnostic input without the patient or the medical practitioner
having to travel, invoking unnecessary costs and loss of time.
We are encouraged to use multidisciplinary team meetings to
ensure consistency and excellence of care. Not all of these
meetings lead to a sensible use of time, and the need to gather
expensive and often scarce human resources in a single physical
locale is questionable. The ability to use electronic means to
maximize efficacy, both financial and medical, is a progressive
and appropriate step forward and not beyond current technology.
All neurosurgeons should critically evaluate their current prac-
tices and explore or introduce some form of the “broad church”
of telemedicine. As with kaizen, it may be only an initial small
step—for example, following the incidence of postoperative
wound infections by electronic means to accurately establish the
“true rate” of complications—but with time and experience, this
can be expanded into many more elaborate, innovative, time-
efficient, and quality electronic “consultations.”
It is not beyond the wit of the physician to find an electronic
solution for a critically ill patient needing subspecialty input
regarding referral or the possibility of local care when vast dis-
tances in very remote or rural areas need to be traversed to reach
a subspecialist. The explosion of cellular phone technology and
its use for personal, economic, and financial transactions,
particularly in rural Kenya, but also other parts of Africa, put to
bed the concept of a technology or electronic illiteracy gap that
cannot be bridged. If financial security is possible in these cir-
cumstances, I believe patient confidentiality in this age of
increasing computerization is not insurmountable. The benefits
and cost-efficiencies to the health care provider in terms of
telemedicine and the location of diagnostic equipment for pa-
tients with neurosurgical disorders have been explored, and very
positive financial and risk benefits have been documented.4
With respect to legal licensure, liability, and legislation, the status
quo and its current relevance needs to be challenged repeatedly
with respect to the risk-benefit ratio with changing medical
practice and technology, and further urgent political consultation
is needed regarding events should there be a true dire emer-
gency requiring “Good Samaritan” input and the only available
measure is telemedicine. It seems unlikely that a patient with
imminent threat of death would support legislation that denied
him or her access to specialist or subspecialist telemedicine input
or guidance. Vested interests frequently cloud these issues, and
the poor human traits of “sloth” and “avarice” can also create
obstacles to implementation. Circumstances regarding cultural
and linguistic concerns in nonurgent and elective conditions are
probably justifiable obstacles in some instances of telemedicine
input, but these concerns need challenging to achieve safe
quality care where there is no local option.
In conclusion, the future of telemedicine to provide high-quality,
patient-centered care is in our hands, and we can profitably use
the philosophy of kaizen to advance “remote care of patients,
aided by Internet-based or telephone based telecommunications
technology.”1
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PERSPECTIVES

3. World Health Organization. Telemedicine: Opportu- Citation: World Neurosurg. (2016) 91:600-602.
REFERENCES nities and Developments in Member States: Report on the http://dx.doi.org/10.1016/j.wneu.2016.02.112
Second Global Survey on eHealth. Geneva, Switzerland:
1. Kahn EN, La Marca F, Mazzola C. Neurosurgery Journal homepage: www.WORLDNEUROSURGERY.org
WHO; 2010.
and telemedicine in the United States of America:
assessment of the risks and opportunities. World Available online: www.sciencedirect.com
Neurosurg. 2016;89:133-138.
4. Nadvi SS, Parboosing R, van Dellen JR. Benefits to 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All
2. Institute of Medicine. Crossing the Quality Chasm: A a regional neurosurgical unit following the intro- rights reserved.
New Health System for the 21st Century. Washington, duction of a decentralised imaging facility. S Afr
DC: National Academies Press; 2001. Med J. 1997;87:1669-1671.

602 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.02.112