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STUDY DESIGN: We collected qualitative data from semistructured interviews with thematic analysis.
POPULATION: The study population included physicians, nurses, and administrative personnel located in 10 health care practices in 4 communities in 3 rural Missouri counties.
OUTCOMES MEASURED: We measured how often health providers used telemedicine technology and their perceptions of the advantages, disadvantages, barriers, and facilitators involved in adopting it.
RESULTS: Participants varied widely in their perceptions of telemedicine. Providers in practices affiliated with the university’s tertiary center were more likely to use it than those in private practice. Interviews and other data yielded 6 themes related to a provider’s receptivity to technological change: These themes were turf, efficacy, practice context, apprehension, time to learn, and ownership. Each theme applies to the computer and videoconferencing components of telemedicine, and each may operate as a perceived barrier or facilitator of change.
CONCLUSIONS: Care providers and administrators consider a range of factors, including economic ramifications, efficacy, social pressure, and apprehension, when deciding whether and how fast to adopt telemedicine. Since adopting this technology can be a major change, agencies trying to introduce it into rural areas should take all these factors into account in their approach to health care providers, staff, and communities.
Telemedicine can be broadly defined as the use of telecommunications to provide medical information and services.1 It includes a computer connected to the Internet and videoconferencing. The Internet, for example, could be used to improve patient care and enhance biomedical research by connecting practitioners to up-to-date information.2 With nearly 110,000 American physicians routinely using the Internet in 1995,3 some believe that it will change the patterns of physician-patient relationships.4 A few physicians claim that communicating by E-mail with patients about nonemergent care and test results has saved time and money.3,5,6
Videoconferencing can help physicians manage the medical and financial risks of providing care to rural and underserved patients.1 It has been used successfully throughout the United States in such specialties as dermatology,7-9 psychiatry,10-15 pulmonary medicine,16 and cardiology.17-19 Efforts to expand the use of telemedicine have contributed to making it a cheaper method of providing medical information and education.20-22
Rural health providers face unique challenges in delivering care: isolation, lack of communication, and lack of access to current medical information and continuing medical education.23-28 Although telemedicine promises to address these problems with computers and videoconferencing, rural physicians have been slow to accept it.29-36
The Missouri Telemedicine Network (MTN) consists of 21 videoconferencing sites in 16 Missouri counties. We evaluated a demonstration project in 3 of the counties where a high-speed computer data infrastructure was installed in 10 outpatient practices in 4 communities with populations ranging from 3000 to 8000. The infrastructure included a computer workstation with E-mail, access to the World Wide Web, medical databases including MEDLINE, community-specific demographic information, a calendar, and access to a medical librarian. Important goals of the workstation included fostering networking and access to educational opportunities and current medical information. The videoconferencing facilities were located in the hospitals in the 3 demonstration counties, plus one large group practice clinic. Participation in the project was voluntary.
Because changing physician behavior has proved difficult,31,36-40 we investigated how rural health care providers perceive the introduction of telemedicine (videoconferencing and a computer workstation) to their practices. We also wanted to create a framework for assessing the readiness of rural providers to adopt telemedicine and to develop a guide for fostering the adoption of this technology.
Methods
We collected qualitative data during semistructured interviews using questions developed from pilot interviews with information specialists and MTN participants. Data were gathered at 10 outpatient practices in the 4 communities with both a computer infrastructure and videoconferencing. Three of the out-patient practices were affiliated with a public tertiary care center; 7 were private practices; and 3 were group practices. Our sampling matrix included physicians, nurses, and administrative staff from all the clinics. Between March and August 1998 we individually interviewed all physicians at the site and at least 2 nurses and administrative staff from each clinic. All interviews were conducted by the second author.
After giving their consent, all participants responded to the following open-ended questions regarding both the video and computer components of telemedicine: (1) What do you perceive are the advantages and disadvantages of the telemedicine technology? (2) What do you perceive are the barriers and facilitators to using the telemedicine technology? (3) How do you use the telemedicine technology? (4) Can you describe the ways in which the telemedicine technology has changed your role? (5) How has the telemedicine technology affected the quality of care you deliver? (6) Do you have any suggestions for improving the telemedicine technology? In addition to these 6 questions, we collected demographic information on age, sex, length of practice, and provider status at the end of the interview.
To guard against any bias toward advocating telemedicine, we stated to respondents at the beginning of the interview that we wanted their honest observations about telemedicine and that their responses would be confidential. We confirmed their observations throughout the interview. Also, before analyzing the data we noted our own bias and preconceptions toward telemedicine, so we could consciously avoid them while reviewing the data.41
Study staff transcribed the interviews verbatim and entered them into a computer database program, Ethnograph, which was designed to help organize textual material.42 We divided interviews by technology type—videoconferencing versus the computer component—and made an initial template analysis to organize and code the data.43 The investigators’ multiple readings of the interviews led to further revisions of the codes until consensus was reached on the identification of salient issues or themes.44,45 The coding scheme and the salient themes were then reviewed independently by a panel of information specialists and health care providers from nursing and medicine who were familiar with the demonstration project. The panel represented individuals with expertise in informatics and qualitative methods.
Quantitative outcome data were also obtained for each participant. Between March 1998 and February 1999, file servers in each county automatically collected data on use of the Web (number of pages accessed) and E-mail (number sent and received) through the workstation. The content of E-mails remained confidential.
Results
We completed 57 interviews. Thirteen were with physicians (9 men, 4 women) averaging 52 years of age and 19 years in rural practice. Eight were family practice physicians; 4 were in internal medicine; and one physician was in general surgery. Twenty interviews were with nurses or nurse practitioners (17 women, 3 men) averaging 43 years of age and 15 years in rural practice. Twenty-four interviews were with the administrative staff (18 women, 6 men) averaging 45 years of age and 14 years in administration. Before the implementation of telemedicine, all of the participants had minimal experience with information technology.
Those practices that were affiliated with a public tertiary care center had higher telemedicine use than those in private practices, although the overall use level would be considered low. For example, the monthly average number of E-mail messages sent from practices that were affiliated with a public tertiary care center was 25.6, while for those in private practice the average was 11.3. For E-mail messages received, the monthly average was 48.8 and 20.2, respectively. Nine of the 13 physicians used the Web, and those affiliated with the tertiary care center used it far more than those in private practice. A yearly total of 8140 visits to a single Web page was recorded for those affiliated with the tertiary care center (mean = 22.3 per day) compared with a yearly total of 734 visits to a single Web page for those in private practice (mean = 2.01 per day; P=.111). Computer use was also higher for the 4 practice sites that had a nurse practitioner.
Data were systematically gathered on the use of the videoconferencing system. However, the majority of the data represent regular dermatology or psychiatric clinics that were conducted between university physicians and patients from the rural site. The rural physicians rarely participated.
Interviews and other data yielded 6 themes related to the care providers’ receptivity to technologic change: turf, efficacy, practice context, apprehension, time to learn, and ownership. Each of these themes applies to the computer and video components of telemedicine, and each may operate as a perceived barrier or facilitator of change, depending on the provider in question. Some providers saw telemedicine as a welcome opportunity to learn, and others were resistant. The themes inevitably overlap at times, because we were qualitatively assessing the social context in which technologic changes take place.
Turf
This theme summarizes our findings from care providers who perceived telemedicine as a threat to their livelihood or professional autonomy or both. Health care practices are enmeshed in networks of social relationships. Satellite practices with direct ties to larger health care systems employ patterns of referral and consultation as part of the larger system. Private practices are autonomous units that have relationships with other providers and systems based on patterns of referral and consultation initiated by the physician.
Purveyors of telemedicine may assume that simply making this technology available will somehow persuade providers to automatically accept it and use it successfully.46 However, some rural physicians see telemedicine as an intrusion on their territory by the urban tertiary care center.47
Although some participants affiliated with the tertiary center saw the technology as a “good thing…it was nice to be connected to a big university,” others, particularly those in private practice, saw it as a potential threat to their sense of competency, autonomy, and livelihood.37 One office staff participant in a private practice remarked on the perception among the rural providers that they “are not seen as practicing their craft correctly, that they’re not up to speed, and that’s why this [telemedicine] has come out here.”
A nurse practitioner in a private practice alluded to telemedicine as a threat to professional autonomy when she said, “I have experienced times when, although the intentions were good, the community has rejected it hands down because they didn’t need help from the outside.”
Efficacy
This theme refers to the participants’ desire to know that telemedicine will fill a functional need in their practice before they invest time and money in making such a big change. Telemedicine has no track record of directly improving patient care outcomes. Unlike drug therapies or medical procedures, telemedicine exerts indirect effects on outcomes with its abilities to enhance, streamline, or improve the process of health care delivery.
Some physicians we interviewed saw no compelling reason to integrate telemedicine into their practices. One physician in private practice who rarely used the computer said, “It doesn’t really help a lot. I think computers are good for specialists, and in primary care you know basically most of the stuff…then the other 20% of it that’s more difficult, you look it up in routine journals.”
Although some physicians saw no reason to integrate the new technology, others simply “don’t think about it.” Still other physicians—mostly those affiliated with a tertiary care center where computer technology figured prominently in patient care—welcomed telemedicine and quickly saw capabilities that would enhance their practices.
Practice Context
This theme refers to barriers to adopting telemedicine that clinics may face because they practice in rural areas where technologic change moves at a slower pace than in urban communities. One nurse practitioner in a private practice said, “We got 911 [emergency] 3 years ago. Three years before that, we finally had a 7-digit phone number. So, I think that the expectations for the rate of change and the learning curve should be pretty generous.” However, several participants, particularly those affiliated with a tertiary center, were positive that telemedicine would eventually catch on.
Apprehension
In contrast to the practice context, this theme refers to the apprehension of individual providers. When it comes to adopting new technology, some participants were philosophical about what they described as a human aversion to change. “People are scared of technology,” said one physician. Another physician in private practice said, “We don’t want to change. Everybody’s just fine the way it is…. I’m not prepared for this.”
Some providers had little confidence in their ability to operate the technology, and one nurse feared that her ignorance would get her into legal trouble: “I’m always afraid I’ll push the wrong button and…something will come up and it will say ‘illegal action.’ It scares me. I think ‘Oh my gosh, I’ve done something against the law.’“
Participants were also concerned about whether the information they would get though the videoconferencing channel would be reliable. A similar concern applied to information on the Internet. A physician in a private practice who was reluctant to use the computer workstation said: “The biggest problem I have with it (the Internet) is you don’t know [what] you’re getting…. There’s a lot of stuff on the Internet that’s no good.”
Although several physicians, particularly those in private practice, were apprehensive about telemedicine, they were willing to let others in their practice learn and use the technology. Some physicians in private practice, however, reflected on the seeming inevitability of change and were resigned to having to learn the technology.
Time to learn
This theme refers to hesitancy among providers to take the time to learn a new technology and to persuade patients of its worth.
One nurse/office manager said, “If I’m looking up something in a book, maybe the book is old, but at least I could have it done in 5 minutes…until I get good at this [computer], it’s taking me much longer.”
One physician in private practice bemoaned spending his time persuading patients that this new technology could benefit them. In contrast, a physician affiliated with a tertiary center noted several advantages of videoconferencing.
Ownership
This theme refers to participants who were professionally and emotionally invested in the technology—stakeholders who acknowledged its benefits, adapted it to their needs, and tried to help others learn. Predictably, this higher level of investment was most common in administrators, because of their familiarity with computerized procedures and records. One administrator affiliated with a tertiary center offered an example of this keen interest: “Yeah, we developed our own policies. We took some of the training modules and modified them to match what we thought. And we really had…everybody buy into using the same policies.”
The stakeholders often encourage others to “buy in” to the new technology, as described by this administrator affiliated with a tertiary center: “I don’t worry about the members of this group using it in a negative way. I want them to use it more…. The more exposure that they have to it, the more accustomed they’re going to be to using it.”
Discussion
These 6 themes (turf, efficacy, practice context, apprehension, time to learn, and ownership) provide a framework for understanding some consequences of introducing telemedicine into a rural setting. Although these themes have been noted to varying degrees by others,29-37,46,48 we grouped all of them as key contextual elements of the rural health environment. Aside from technical issues, such as the user-friendliness of the technology, the elemental themes that emerged from our data helped us explore this broader context.
Introducing telemedicine into a rural setting is analogous in many ways to introducing managed care into such areas. Some rural providers perceive managed care as an opportunity, while others see it as a threat to their practices, taking the local health care dollar away.49 Similarly, providers’ perceptions of telemedicine range from seeing it as a chance to improve health care delivery, as nonessential technology, or, at worst, as a threat.
Those introducing telemedicine to these areas appear to be most likely to succeed if they begin with an understanding of how the new technology is perceived by rural providers. The 6 themes we identified provide some essentials for understanding the initial process of technological change in a rural health care practice. Based on our results, rural providers’ acceptance of telemedicine is most likely to occur when there is a greater organizational integration of the new technology, a perceived increase in time efficiency, greater affiliation with a tertiary care center, a perceived increase in ownership, an enhanced ability to accommodate the changes, a reduction in apprehension, and the realization of the slower pace of change in a rural community.
These themes can be considered core issues for developing a plan that can be used when introducing telemedicine. Specific questions can then be formulated to aid in this process, including: Is there a perceived need for the technology? (turf); Who is initiating the technological change, and how it that perceived? (efficacy); How is the rate of technologic change perceived in the community? (practice context); How flexible are the users toward technologic change? What is the level of anxiety about using the technology? (apprehension); How is the time expended to learn and use the technology perceived? (time to learn); and Who manages and supports the technology? (ownership). Answers to these questions can help those introducing telemedicine to structure specific strategies for implementation that are tailored to fit the needs and concerns of each practice.
Strategies for change
After acknowledging the variability of rural practices and practice behaviors and the environmental conditions of the 10 practices in our study, we grouped them into 3 categories according to their readiness for implanting telemedicine: fertile soil, somewhat fertile soil, and barren soil. For each of these conditions, we propose strategies for change that enhance the potential for the growth of telemedicine as illustrated in the Table 1.50-52 For those practices that have been identified as fertile soil, it is important to include the physicians and administrators in the entire planning and implementation process.53 They are more likely to use physician extenders, so it is important to facilitate team building with regard to new innovations, while at the same time building various coalitions with other affiliated physicians. Empowerment is also a key to making sure the innovation is successfully implemented. Appropriate resources need to be provided, such as space for the innovation (or technology) and adequate personnel, access, and training.52
For practices identified as having partly fertile soil for change, it is important to establish a sense of urgency for the implementation of the new technology and to engage in coalition building within the community and with other specialty physicians. Help is needed to create a new vision for the practice, and this should be communicated to all employees. It also helps to provide for short-term incentives regarding the new technology.52
Engaging barren soil types of practices in implementing new technologies is difficult. It is possible, however, to facilitate change in the practice by developing a perceived need for the technology through presenting the physician(s) with current evidence-based medical information, for example. All the physicians need to be included in the planning and implementing process,53 and steps should be taken to facilitate coalition building within the community.52
Implementation strategies need to be tailored to the environmental conditions of practice sites that are carefully chosen for their potential to cultivate telemedicine. Successful sites can become exemplars to others. Establishing relationships with a practice site, however, begins with diplomatic negotiation that is sensitive to local conditions. A commitment must be made to nurture the relationship.
Limitations
The strength of our study lies in the initial investigation of rural health care providers’ perceptions of telemedicine, and we are not aware of any similar qualitative studies in the literature. The results of our study are limited, however, to the recent introduction of telemedicine technologies into rural settings. We presented perceptions of providers who were just beginning to adjust to new technologies. Future research is needed to determine the extent of these perceptions among rural health care providers in general and in particular whether some of the negative perceptions of telemedicine of the providers in our study will change over time.
Conclusions
Rural health care providers and administrators consider a range of factors, including economic ramifications, efficacy, social pressure, and apprehension, in deciding whether and how fast to adopt telemedicine technology. Since adopting this technology can be a major change, agencies trying to introduce it into rural areas should take all these factors into account in their approach to rural health care providers, staff, and communities.
Acknowledgments
Our study was funded by the National Library of Medicine, contract number: NO1-LM-6-3538.
Related resources
- Telemedicine Information Exchange (TIE) A National Library of Medicine-funded web page which offers comprehensive information on telemedicine and telehealth. http://tie.telemed.org
- Telemedicine And Health Care Informatics Legal Issues Web site A resource for providers, lawyers, professionals or anyone interested in learning more about health care law and, more specifically, the regulatory and transactional aspects of health care. http://www.netreach.net
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2. Gallagher K, McFarland MA. The wired physician: current clinical information on the Internet. Mo Med 1996;93:334-39.
3. Engstrom P. Can you afford not to travel the Internet? Med Econ 1996;73:172-74.
4. Pareras LG, Martin-Rodriguez JG. Neurosurgery and the Internet: a critical analysis and a review of available resources. Neurosurgery 1996;39:216-32.
5. Neill RA, Mainous AG, III, Clark JR, Hagen MD. The utility of electronic mail as a medium for patient-physician communication. Arch Fam Med 1994;3:268-71.
6. Green L. A better way to keep in touch with patients. Med Econ 1996;73:153-54.
7. Norton SA, Burdick AE, Phillips CM, Berman B. Teledermatology and underserved populations [published erratum appears in Arch Dermatol 1997; 133:819]. Arch Dermatol 1997;133:197-200.
8. Menn ER, Kvedar JC. Teledermatology in a changing health care environment. Telemed J 1995;1:303-08.
9. High WA, Houston MS, Calobrisi SD, Drage LA, McEvoy MT. Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. J Am Acad Dermatol 2000;42:776-83.
10. Callahan EJ, Hilty DM, Nesbitt TS. Patient satisfaction with telemedicine consultation in primary care: comparison of ratings of medical and mental health applications. Telemed J 1998;4:363-69.
11. Cukor P, Baer L, Willis BS, et al. Use of videophones and low-cost standard telephone lines to provide a social presence in telepsychiatry. Telemed J 1998;4:313-21.
12. Ball C, McLaren P. The tele-assessment of cognitive state: a review. J Telemed Telecare 1997;3:126-31.
13. Graham MA. Telepsychiatry in Appalachia. Am Behav Sci 1996;39:602-15.
14. Baer L, Cukor P, Jenike MA, Leahy L, O’Laughlen J, Coyle JT. Pilot studies of telemedicine for patients with obsessive-compulsive disorder. Am J Psychiatry 1995;152:1383-85.
15. Brown FW. A survey of telepsychiatry in the USA. J Telemed Telecare 1995;1:19-21.
16. Pacht ER, Turner JW, Gailiun M, et al. Effectiveness of telemedicine in the outpatient pulmonary clinic. Telemed J 1998;4:287-92.
17. Tsagaris MJ, Papavassiliou MV, Chatzipantazi PD, et al. The contribution of telemedicine to cardiology. J Telemed Telecare 1997;3(suppl):63-64.
18. Afset JE, Lunde P, Rasmussen K. Accuracy of routine echocardiographic measurements made by an inexperienced examiner through tele-instruction. J Telemed Telecare 1996;2:148-54.
19. Grigsby J, Kaehny MM, Sandberg EJ, Schlenker RE, Shaughnessy PW. Effects and effectiveness of telemedicine. Health Care Financ Rev 1995;17:115-31.
20. Bergmo TS. An economic analysis of teleconsultation in otorhinolaryngology. J Telemed Telecare 1997;3:194-99.
21. Folberg R, Linberg JV, Verdick RE, Weingeist TA. Distance education for the professional: the Web and beyond. Opthalmol Clin North Am 2000;13:225-37.
22. Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. BMJ 2000;320:1517-20.
23. Conte SJ, Imershein AW, Magill MK. Rural community and physician perspectives on resource factors affecting physician retention. J Rural Health 1992;8:185-96.
24. Harned MA. The saga of rural health care. W V Med J 1993;89:54-55.
25. Mackesy R. Physician satisfaction with rural hospital. Hosp Health Serv Adm 1993;38:375-86.
26. Anderson EA, Bergeron D, Crouse BJ. Recruitment of family physicians in rural practice. Minn Med 1994;77:29-32.
27. Harris KD. Acceptance of computer-based telemedicine in three rural Missouri counties (rural health care). Thesis/dissertation. University of Missouri; 1999.
28. Orkin FK. Rural realities. Anesthesiology 1998;88:568-71.
29. Mazmanian PE, Banks RA, Self P, Hampton C. Increasing access to medical information. Changing communication patterns in southside Virginia. Va Med Q 1996;123:176-78.
30. Menduno M. Prognosis: wired. Why Internet technology is the next medical breakthrough. Hosp Health Netw 1998;72:28-30.
31. Treister NW. Physician acceptance of new medical information systems: the field of dreams. Physician Exec 1998;24:20-24.
32. Appleby C. Web-o-matic isn’t automatic—yet. Internet technology hasn’t broken the barrier between doctors & computers. Hosp Health Netw 1997;71:30-31.
33. Keoun B. At last, doctors begin to jump online. J Natl Cancer Inst 1996;88:1610-12.
34. Chi-Lum BI, Lundberg GD, Silberg WM. Physicians accessing the Internet, the PAI Project. An educational initiative. JAMA 1996;275:1361-62.
35. Bergman R. The computer revolution snags some physicians in & out of the office: it’s time to recognize the new era of the techno docs. Hosp Health Netw 1995;69:68-70.
36. Gleiner JA. Information technology: the next wave. Clinician acceptance of information technology. Physician Exec 1996;22:4-8.
37. Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med 1993;329:1271-73.
38. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-05.
39. Robertson N, Baker R, Hearnshaw H. Changing the clinical behavior of doctors: a psychological framework. Qual Health Care 1996;5:51-54.
40. Nobel J. Influence of physician perceptions on putting knowledge into practice. Lancet 1996;347:1571.-
41. Crabtree BF, Miller WL, eds. Doing qualitative research. 2nd ed. Thousand Oaks, Calif: Sage Publications; 1999.
42. The ethnograph Version 4.0. Amherst, Mass: Qualis Research Associates; 1994.
43. Crabtree BF, Miller WL. A template approach to text analysis: developing and using codebooks. In: Crabtree BF, Miller WL, eds. Doing qualitative research. Newbury Park, Calif: Sage Publications; 1992;93-109
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45. Boyatzis RE. Transforming qualitative information: thematic analysis and code development. Thousand Oaks, Calif: Sage Publications; 1998.
46. Yellowlees P. Successful development of telemedicine systems—seven core principles. J Telemed Telecare 1997;3:215-22.
47. Carlson B. Telemedicine changing practice of medicine. Indiana Med 1994;87:352-59.
48. Leckie GJ, Pettigrew KE, Sylvain C. Modeling the information seeking of professionals: a general model derived from research on engineers, health care professionals, and lawyers. Library Q 1996;66:161-93.
49. Gibbons B. How do we make managed care work for us? Tate Rural Health Watch 1998;2-3,8-9,12.-
50. Kanter RM. The new managerial work. Harv Bus Rev 1989;67:85-92.
51. Beer M, Eisenstat RA, Spector B. Why change programs don’t produce change. Harv Bus Rev 1990;68:158-66.
52. Kotter JP. Leading change: why transformation efforts fail. Harv Bus Rev 1995;73:59-67.
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STUDY DESIGN: We collected qualitative data from semistructured interviews with thematic analysis.
POPULATION: The study population included physicians, nurses, and administrative personnel located in 10 health care practices in 4 communities in 3 rural Missouri counties.
OUTCOMES MEASURED: We measured how often health providers used telemedicine technology and their perceptions of the advantages, disadvantages, barriers, and facilitators involved in adopting it.
RESULTS: Participants varied widely in their perceptions of telemedicine. Providers in practices affiliated with the university’s tertiary center were more likely to use it than those in private practice. Interviews and other data yielded 6 themes related to a provider’s receptivity to technological change: These themes were turf, efficacy, practice context, apprehension, time to learn, and ownership. Each theme applies to the computer and videoconferencing components of telemedicine, and each may operate as a perceived barrier or facilitator of change.
CONCLUSIONS: Care providers and administrators consider a range of factors, including economic ramifications, efficacy, social pressure, and apprehension, when deciding whether and how fast to adopt telemedicine. Since adopting this technology can be a major change, agencies trying to introduce it into rural areas should take all these factors into account in their approach to health care providers, staff, and communities.
Telemedicine can be broadly defined as the use of telecommunications to provide medical information and services.1 It includes a computer connected to the Internet and videoconferencing. The Internet, for example, could be used to improve patient care and enhance biomedical research by connecting practitioners to up-to-date information.2 With nearly 110,000 American physicians routinely using the Internet in 1995,3 some believe that it will change the patterns of physician-patient relationships.4 A few physicians claim that communicating by E-mail with patients about nonemergent care and test results has saved time and money.3,5,6
Videoconferencing can help physicians manage the medical and financial risks of providing care to rural and underserved patients.1 It has been used successfully throughout the United States in such specialties as dermatology,7-9 psychiatry,10-15 pulmonary medicine,16 and cardiology.17-19 Efforts to expand the use of telemedicine have contributed to making it a cheaper method of providing medical information and education.20-22
Rural health providers face unique challenges in delivering care: isolation, lack of communication, and lack of access to current medical information and continuing medical education.23-28 Although telemedicine promises to address these problems with computers and videoconferencing, rural physicians have been slow to accept it.29-36
The Missouri Telemedicine Network (MTN) consists of 21 videoconferencing sites in 16 Missouri counties. We evaluated a demonstration project in 3 of the counties where a high-speed computer data infrastructure was installed in 10 outpatient practices in 4 communities with populations ranging from 3000 to 8000. The infrastructure included a computer workstation with E-mail, access to the World Wide Web, medical databases including MEDLINE, community-specific demographic information, a calendar, and access to a medical librarian. Important goals of the workstation included fostering networking and access to educational opportunities and current medical information. The videoconferencing facilities were located in the hospitals in the 3 demonstration counties, plus one large group practice clinic. Participation in the project was voluntary.
Because changing physician behavior has proved difficult,31,36-40 we investigated how rural health care providers perceive the introduction of telemedicine (videoconferencing and a computer workstation) to their practices. We also wanted to create a framework for assessing the readiness of rural providers to adopt telemedicine and to develop a guide for fostering the adoption of this technology.
Methods
We collected qualitative data during semistructured interviews using questions developed from pilot interviews with information specialists and MTN participants. Data were gathered at 10 outpatient practices in the 4 communities with both a computer infrastructure and videoconferencing. Three of the out-patient practices were affiliated with a public tertiary care center; 7 were private practices; and 3 were group practices. Our sampling matrix included physicians, nurses, and administrative staff from all the clinics. Between March and August 1998 we individually interviewed all physicians at the site and at least 2 nurses and administrative staff from each clinic. All interviews were conducted by the second author.
After giving their consent, all participants responded to the following open-ended questions regarding both the video and computer components of telemedicine: (1) What do you perceive are the advantages and disadvantages of the telemedicine technology? (2) What do you perceive are the barriers and facilitators to using the telemedicine technology? (3) How do you use the telemedicine technology? (4) Can you describe the ways in which the telemedicine technology has changed your role? (5) How has the telemedicine technology affected the quality of care you deliver? (6) Do you have any suggestions for improving the telemedicine technology? In addition to these 6 questions, we collected demographic information on age, sex, length of practice, and provider status at the end of the interview.
To guard against any bias toward advocating telemedicine, we stated to respondents at the beginning of the interview that we wanted their honest observations about telemedicine and that their responses would be confidential. We confirmed their observations throughout the interview. Also, before analyzing the data we noted our own bias and preconceptions toward telemedicine, so we could consciously avoid them while reviewing the data.41
Study staff transcribed the interviews verbatim and entered them into a computer database program, Ethnograph, which was designed to help organize textual material.42 We divided interviews by technology type—videoconferencing versus the computer component—and made an initial template analysis to organize and code the data.43 The investigators’ multiple readings of the interviews led to further revisions of the codes until consensus was reached on the identification of salient issues or themes.44,45 The coding scheme and the salient themes were then reviewed independently by a panel of information specialists and health care providers from nursing and medicine who were familiar with the demonstration project. The panel represented individuals with expertise in informatics and qualitative methods.
Quantitative outcome data were also obtained for each participant. Between March 1998 and February 1999, file servers in each county automatically collected data on use of the Web (number of pages accessed) and E-mail (number sent and received) through the workstation. The content of E-mails remained confidential.
Results
We completed 57 interviews. Thirteen were with physicians (9 men, 4 women) averaging 52 years of age and 19 years in rural practice. Eight were family practice physicians; 4 were in internal medicine; and one physician was in general surgery. Twenty interviews were with nurses or nurse practitioners (17 women, 3 men) averaging 43 years of age and 15 years in rural practice. Twenty-four interviews were with the administrative staff (18 women, 6 men) averaging 45 years of age and 14 years in administration. Before the implementation of telemedicine, all of the participants had minimal experience with information technology.
Those practices that were affiliated with a public tertiary care center had higher telemedicine use than those in private practices, although the overall use level would be considered low. For example, the monthly average number of E-mail messages sent from practices that were affiliated with a public tertiary care center was 25.6, while for those in private practice the average was 11.3. For E-mail messages received, the monthly average was 48.8 and 20.2, respectively. Nine of the 13 physicians used the Web, and those affiliated with the tertiary care center used it far more than those in private practice. A yearly total of 8140 visits to a single Web page was recorded for those affiliated with the tertiary care center (mean = 22.3 per day) compared with a yearly total of 734 visits to a single Web page for those in private practice (mean = 2.01 per day; P=.111). Computer use was also higher for the 4 practice sites that had a nurse practitioner.
Data were systematically gathered on the use of the videoconferencing system. However, the majority of the data represent regular dermatology or psychiatric clinics that were conducted between university physicians and patients from the rural site. The rural physicians rarely participated.
Interviews and other data yielded 6 themes related to the care providers’ receptivity to technologic change: turf, efficacy, practice context, apprehension, time to learn, and ownership. Each of these themes applies to the computer and video components of telemedicine, and each may operate as a perceived barrier or facilitator of change, depending on the provider in question. Some providers saw telemedicine as a welcome opportunity to learn, and others were resistant. The themes inevitably overlap at times, because we were qualitatively assessing the social context in which technologic changes take place.
Turf
This theme summarizes our findings from care providers who perceived telemedicine as a threat to their livelihood or professional autonomy or both. Health care practices are enmeshed in networks of social relationships. Satellite practices with direct ties to larger health care systems employ patterns of referral and consultation as part of the larger system. Private practices are autonomous units that have relationships with other providers and systems based on patterns of referral and consultation initiated by the physician.
Purveyors of telemedicine may assume that simply making this technology available will somehow persuade providers to automatically accept it and use it successfully.46 However, some rural physicians see telemedicine as an intrusion on their territory by the urban tertiary care center.47
Although some participants affiliated with the tertiary center saw the technology as a “good thing…it was nice to be connected to a big university,” others, particularly those in private practice, saw it as a potential threat to their sense of competency, autonomy, and livelihood.37 One office staff participant in a private practice remarked on the perception among the rural providers that they “are not seen as practicing their craft correctly, that they’re not up to speed, and that’s why this [telemedicine] has come out here.”
A nurse practitioner in a private practice alluded to telemedicine as a threat to professional autonomy when she said, “I have experienced times when, although the intentions were good, the community has rejected it hands down because they didn’t need help from the outside.”
Efficacy
This theme refers to the participants’ desire to know that telemedicine will fill a functional need in their practice before they invest time and money in making such a big change. Telemedicine has no track record of directly improving patient care outcomes. Unlike drug therapies or medical procedures, telemedicine exerts indirect effects on outcomes with its abilities to enhance, streamline, or improve the process of health care delivery.
Some physicians we interviewed saw no compelling reason to integrate telemedicine into their practices. One physician in private practice who rarely used the computer said, “It doesn’t really help a lot. I think computers are good for specialists, and in primary care you know basically most of the stuff…then the other 20% of it that’s more difficult, you look it up in routine journals.”
Although some physicians saw no reason to integrate the new technology, others simply “don’t think about it.” Still other physicians—mostly those affiliated with a tertiary care center where computer technology figured prominently in patient care—welcomed telemedicine and quickly saw capabilities that would enhance their practices.
Practice Context
This theme refers to barriers to adopting telemedicine that clinics may face because they practice in rural areas where technologic change moves at a slower pace than in urban communities. One nurse practitioner in a private practice said, “We got 911 [emergency] 3 years ago. Three years before that, we finally had a 7-digit phone number. So, I think that the expectations for the rate of change and the learning curve should be pretty generous.” However, several participants, particularly those affiliated with a tertiary center, were positive that telemedicine would eventually catch on.
Apprehension
In contrast to the practice context, this theme refers to the apprehension of individual providers. When it comes to adopting new technology, some participants were philosophical about what they described as a human aversion to change. “People are scared of technology,” said one physician. Another physician in private practice said, “We don’t want to change. Everybody’s just fine the way it is…. I’m not prepared for this.”
Some providers had little confidence in their ability to operate the technology, and one nurse feared that her ignorance would get her into legal trouble: “I’m always afraid I’ll push the wrong button and…something will come up and it will say ‘illegal action.’ It scares me. I think ‘Oh my gosh, I’ve done something against the law.’“
Participants were also concerned about whether the information they would get though the videoconferencing channel would be reliable. A similar concern applied to information on the Internet. A physician in a private practice who was reluctant to use the computer workstation said: “The biggest problem I have with it (the Internet) is you don’t know [what] you’re getting…. There’s a lot of stuff on the Internet that’s no good.”
Although several physicians, particularly those in private practice, were apprehensive about telemedicine, they were willing to let others in their practice learn and use the technology. Some physicians in private practice, however, reflected on the seeming inevitability of change and were resigned to having to learn the technology.
Time to learn
This theme refers to hesitancy among providers to take the time to learn a new technology and to persuade patients of its worth.
One nurse/office manager said, “If I’m looking up something in a book, maybe the book is old, but at least I could have it done in 5 minutes…until I get good at this [computer], it’s taking me much longer.”
One physician in private practice bemoaned spending his time persuading patients that this new technology could benefit them. In contrast, a physician affiliated with a tertiary center noted several advantages of videoconferencing.
Ownership
This theme refers to participants who were professionally and emotionally invested in the technology—stakeholders who acknowledged its benefits, adapted it to their needs, and tried to help others learn. Predictably, this higher level of investment was most common in administrators, because of their familiarity with computerized procedures and records. One administrator affiliated with a tertiary center offered an example of this keen interest: “Yeah, we developed our own policies. We took some of the training modules and modified them to match what we thought. And we really had…everybody buy into using the same policies.”
The stakeholders often encourage others to “buy in” to the new technology, as described by this administrator affiliated with a tertiary center: “I don’t worry about the members of this group using it in a negative way. I want them to use it more…. The more exposure that they have to it, the more accustomed they’re going to be to using it.”
Discussion
These 6 themes (turf, efficacy, practice context, apprehension, time to learn, and ownership) provide a framework for understanding some consequences of introducing telemedicine into a rural setting. Although these themes have been noted to varying degrees by others,29-37,46,48 we grouped all of them as key contextual elements of the rural health environment. Aside from technical issues, such as the user-friendliness of the technology, the elemental themes that emerged from our data helped us explore this broader context.
Introducing telemedicine into a rural setting is analogous in many ways to introducing managed care into such areas. Some rural providers perceive managed care as an opportunity, while others see it as a threat to their practices, taking the local health care dollar away.49 Similarly, providers’ perceptions of telemedicine range from seeing it as a chance to improve health care delivery, as nonessential technology, or, at worst, as a threat.
Those introducing telemedicine to these areas appear to be most likely to succeed if they begin with an understanding of how the new technology is perceived by rural providers. The 6 themes we identified provide some essentials for understanding the initial process of technological change in a rural health care practice. Based on our results, rural providers’ acceptance of telemedicine is most likely to occur when there is a greater organizational integration of the new technology, a perceived increase in time efficiency, greater affiliation with a tertiary care center, a perceived increase in ownership, an enhanced ability to accommodate the changes, a reduction in apprehension, and the realization of the slower pace of change in a rural community.
These themes can be considered core issues for developing a plan that can be used when introducing telemedicine. Specific questions can then be formulated to aid in this process, including: Is there a perceived need for the technology? (turf); Who is initiating the technological change, and how it that perceived? (efficacy); How is the rate of technologic change perceived in the community? (practice context); How flexible are the users toward technologic change? What is the level of anxiety about using the technology? (apprehension); How is the time expended to learn and use the technology perceived? (time to learn); and Who manages and supports the technology? (ownership). Answers to these questions can help those introducing telemedicine to structure specific strategies for implementation that are tailored to fit the needs and concerns of each practice.
Strategies for change
After acknowledging the variability of rural practices and practice behaviors and the environmental conditions of the 10 practices in our study, we grouped them into 3 categories according to their readiness for implanting telemedicine: fertile soil, somewhat fertile soil, and barren soil. For each of these conditions, we propose strategies for change that enhance the potential for the growth of telemedicine as illustrated in the Table 1.50-52 For those practices that have been identified as fertile soil, it is important to include the physicians and administrators in the entire planning and implementation process.53 They are more likely to use physician extenders, so it is important to facilitate team building with regard to new innovations, while at the same time building various coalitions with other affiliated physicians. Empowerment is also a key to making sure the innovation is successfully implemented. Appropriate resources need to be provided, such as space for the innovation (or technology) and adequate personnel, access, and training.52
For practices identified as having partly fertile soil for change, it is important to establish a sense of urgency for the implementation of the new technology and to engage in coalition building within the community and with other specialty physicians. Help is needed to create a new vision for the practice, and this should be communicated to all employees. It also helps to provide for short-term incentives regarding the new technology.52
Engaging barren soil types of practices in implementing new technologies is difficult. It is possible, however, to facilitate change in the practice by developing a perceived need for the technology through presenting the physician(s) with current evidence-based medical information, for example. All the physicians need to be included in the planning and implementing process,53 and steps should be taken to facilitate coalition building within the community.52
Implementation strategies need to be tailored to the environmental conditions of practice sites that are carefully chosen for their potential to cultivate telemedicine. Successful sites can become exemplars to others. Establishing relationships with a practice site, however, begins with diplomatic negotiation that is sensitive to local conditions. A commitment must be made to nurture the relationship.
Limitations
The strength of our study lies in the initial investigation of rural health care providers’ perceptions of telemedicine, and we are not aware of any similar qualitative studies in the literature. The results of our study are limited, however, to the recent introduction of telemedicine technologies into rural settings. We presented perceptions of providers who were just beginning to adjust to new technologies. Future research is needed to determine the extent of these perceptions among rural health care providers in general and in particular whether some of the negative perceptions of telemedicine of the providers in our study will change over time.
Conclusions
Rural health care providers and administrators consider a range of factors, including economic ramifications, efficacy, social pressure, and apprehension, in deciding whether and how fast to adopt telemedicine technology. Since adopting this technology can be a major change, agencies trying to introduce it into rural areas should take all these factors into account in their approach to rural health care providers, staff, and communities.
Acknowledgments
Our study was funded by the National Library of Medicine, contract number: NO1-LM-6-3538.
Related resources
- Telemedicine Information Exchange (TIE) A National Library of Medicine-funded web page which offers comprehensive information on telemedicine and telehealth. http://tie.telemed.org
- Telemedicine And Health Care Informatics Legal Issues Web site A resource for providers, lawyers, professionals or anyone interested in learning more about health care law and, more specifically, the regulatory and transactional aspects of health care. http://www.netreach.net
STUDY DESIGN: We collected qualitative data from semistructured interviews with thematic analysis.
POPULATION: The study population included physicians, nurses, and administrative personnel located in 10 health care practices in 4 communities in 3 rural Missouri counties.
OUTCOMES MEASURED: We measured how often health providers used telemedicine technology and their perceptions of the advantages, disadvantages, barriers, and facilitators involved in adopting it.
RESULTS: Participants varied widely in their perceptions of telemedicine. Providers in practices affiliated with the university’s tertiary center were more likely to use it than those in private practice. Interviews and other data yielded 6 themes related to a provider’s receptivity to technological change: These themes were turf, efficacy, practice context, apprehension, time to learn, and ownership. Each theme applies to the computer and videoconferencing components of telemedicine, and each may operate as a perceived barrier or facilitator of change.
CONCLUSIONS: Care providers and administrators consider a range of factors, including economic ramifications, efficacy, social pressure, and apprehension, when deciding whether and how fast to adopt telemedicine. Since adopting this technology can be a major change, agencies trying to introduce it into rural areas should take all these factors into account in their approach to health care providers, staff, and communities.
Telemedicine can be broadly defined as the use of telecommunications to provide medical information and services.1 It includes a computer connected to the Internet and videoconferencing. The Internet, for example, could be used to improve patient care and enhance biomedical research by connecting practitioners to up-to-date information.2 With nearly 110,000 American physicians routinely using the Internet in 1995,3 some believe that it will change the patterns of physician-patient relationships.4 A few physicians claim that communicating by E-mail with patients about nonemergent care and test results has saved time and money.3,5,6
Videoconferencing can help physicians manage the medical and financial risks of providing care to rural and underserved patients.1 It has been used successfully throughout the United States in such specialties as dermatology,7-9 psychiatry,10-15 pulmonary medicine,16 and cardiology.17-19 Efforts to expand the use of telemedicine have contributed to making it a cheaper method of providing medical information and education.20-22
Rural health providers face unique challenges in delivering care: isolation, lack of communication, and lack of access to current medical information and continuing medical education.23-28 Although telemedicine promises to address these problems with computers and videoconferencing, rural physicians have been slow to accept it.29-36
The Missouri Telemedicine Network (MTN) consists of 21 videoconferencing sites in 16 Missouri counties. We evaluated a demonstration project in 3 of the counties where a high-speed computer data infrastructure was installed in 10 outpatient practices in 4 communities with populations ranging from 3000 to 8000. The infrastructure included a computer workstation with E-mail, access to the World Wide Web, medical databases including MEDLINE, community-specific demographic information, a calendar, and access to a medical librarian. Important goals of the workstation included fostering networking and access to educational opportunities and current medical information. The videoconferencing facilities were located in the hospitals in the 3 demonstration counties, plus one large group practice clinic. Participation in the project was voluntary.
Because changing physician behavior has proved difficult,31,36-40 we investigated how rural health care providers perceive the introduction of telemedicine (videoconferencing and a computer workstation) to their practices. We also wanted to create a framework for assessing the readiness of rural providers to adopt telemedicine and to develop a guide for fostering the adoption of this technology.
Methods
We collected qualitative data during semistructured interviews using questions developed from pilot interviews with information specialists and MTN participants. Data were gathered at 10 outpatient practices in the 4 communities with both a computer infrastructure and videoconferencing. Three of the out-patient practices were affiliated with a public tertiary care center; 7 were private practices; and 3 were group practices. Our sampling matrix included physicians, nurses, and administrative staff from all the clinics. Between March and August 1998 we individually interviewed all physicians at the site and at least 2 nurses and administrative staff from each clinic. All interviews were conducted by the second author.
After giving their consent, all participants responded to the following open-ended questions regarding both the video and computer components of telemedicine: (1) What do you perceive are the advantages and disadvantages of the telemedicine technology? (2) What do you perceive are the barriers and facilitators to using the telemedicine technology? (3) How do you use the telemedicine technology? (4) Can you describe the ways in which the telemedicine technology has changed your role? (5) How has the telemedicine technology affected the quality of care you deliver? (6) Do you have any suggestions for improving the telemedicine technology? In addition to these 6 questions, we collected demographic information on age, sex, length of practice, and provider status at the end of the interview.
To guard against any bias toward advocating telemedicine, we stated to respondents at the beginning of the interview that we wanted their honest observations about telemedicine and that their responses would be confidential. We confirmed their observations throughout the interview. Also, before analyzing the data we noted our own bias and preconceptions toward telemedicine, so we could consciously avoid them while reviewing the data.41
Study staff transcribed the interviews verbatim and entered them into a computer database program, Ethnograph, which was designed to help organize textual material.42 We divided interviews by technology type—videoconferencing versus the computer component—and made an initial template analysis to organize and code the data.43 The investigators’ multiple readings of the interviews led to further revisions of the codes until consensus was reached on the identification of salient issues or themes.44,45 The coding scheme and the salient themes were then reviewed independently by a panel of information specialists and health care providers from nursing and medicine who were familiar with the demonstration project. The panel represented individuals with expertise in informatics and qualitative methods.
Quantitative outcome data were also obtained for each participant. Between March 1998 and February 1999, file servers in each county automatically collected data on use of the Web (number of pages accessed) and E-mail (number sent and received) through the workstation. The content of E-mails remained confidential.
Results
We completed 57 interviews. Thirteen were with physicians (9 men, 4 women) averaging 52 years of age and 19 years in rural practice. Eight were family practice physicians; 4 were in internal medicine; and one physician was in general surgery. Twenty interviews were with nurses or nurse practitioners (17 women, 3 men) averaging 43 years of age and 15 years in rural practice. Twenty-four interviews were with the administrative staff (18 women, 6 men) averaging 45 years of age and 14 years in administration. Before the implementation of telemedicine, all of the participants had minimal experience with information technology.
Those practices that were affiliated with a public tertiary care center had higher telemedicine use than those in private practices, although the overall use level would be considered low. For example, the monthly average number of E-mail messages sent from practices that were affiliated with a public tertiary care center was 25.6, while for those in private practice the average was 11.3. For E-mail messages received, the monthly average was 48.8 and 20.2, respectively. Nine of the 13 physicians used the Web, and those affiliated with the tertiary care center used it far more than those in private practice. A yearly total of 8140 visits to a single Web page was recorded for those affiliated with the tertiary care center (mean = 22.3 per day) compared with a yearly total of 734 visits to a single Web page for those in private practice (mean = 2.01 per day; P=.111). Computer use was also higher for the 4 practice sites that had a nurse practitioner.
Data were systematically gathered on the use of the videoconferencing system. However, the majority of the data represent regular dermatology or psychiatric clinics that were conducted between university physicians and patients from the rural site. The rural physicians rarely participated.
Interviews and other data yielded 6 themes related to the care providers’ receptivity to technologic change: turf, efficacy, practice context, apprehension, time to learn, and ownership. Each of these themes applies to the computer and video components of telemedicine, and each may operate as a perceived barrier or facilitator of change, depending on the provider in question. Some providers saw telemedicine as a welcome opportunity to learn, and others were resistant. The themes inevitably overlap at times, because we were qualitatively assessing the social context in which technologic changes take place.
Turf
This theme summarizes our findings from care providers who perceived telemedicine as a threat to their livelihood or professional autonomy or both. Health care practices are enmeshed in networks of social relationships. Satellite practices with direct ties to larger health care systems employ patterns of referral and consultation as part of the larger system. Private practices are autonomous units that have relationships with other providers and systems based on patterns of referral and consultation initiated by the physician.
Purveyors of telemedicine may assume that simply making this technology available will somehow persuade providers to automatically accept it and use it successfully.46 However, some rural physicians see telemedicine as an intrusion on their territory by the urban tertiary care center.47
Although some participants affiliated with the tertiary center saw the technology as a “good thing…it was nice to be connected to a big university,” others, particularly those in private practice, saw it as a potential threat to their sense of competency, autonomy, and livelihood.37 One office staff participant in a private practice remarked on the perception among the rural providers that they “are not seen as practicing their craft correctly, that they’re not up to speed, and that’s why this [telemedicine] has come out here.”
A nurse practitioner in a private practice alluded to telemedicine as a threat to professional autonomy when she said, “I have experienced times when, although the intentions were good, the community has rejected it hands down because they didn’t need help from the outside.”
Efficacy
This theme refers to the participants’ desire to know that telemedicine will fill a functional need in their practice before they invest time and money in making such a big change. Telemedicine has no track record of directly improving patient care outcomes. Unlike drug therapies or medical procedures, telemedicine exerts indirect effects on outcomes with its abilities to enhance, streamline, or improve the process of health care delivery.
Some physicians we interviewed saw no compelling reason to integrate telemedicine into their practices. One physician in private practice who rarely used the computer said, “It doesn’t really help a lot. I think computers are good for specialists, and in primary care you know basically most of the stuff…then the other 20% of it that’s more difficult, you look it up in routine journals.”
Although some physicians saw no reason to integrate the new technology, others simply “don’t think about it.” Still other physicians—mostly those affiliated with a tertiary care center where computer technology figured prominently in patient care—welcomed telemedicine and quickly saw capabilities that would enhance their practices.
Practice Context
This theme refers to barriers to adopting telemedicine that clinics may face because they practice in rural areas where technologic change moves at a slower pace than in urban communities. One nurse practitioner in a private practice said, “We got 911 [emergency] 3 years ago. Three years before that, we finally had a 7-digit phone number. So, I think that the expectations for the rate of change and the learning curve should be pretty generous.” However, several participants, particularly those affiliated with a tertiary center, were positive that telemedicine would eventually catch on.
Apprehension
In contrast to the practice context, this theme refers to the apprehension of individual providers. When it comes to adopting new technology, some participants were philosophical about what they described as a human aversion to change. “People are scared of technology,” said one physician. Another physician in private practice said, “We don’t want to change. Everybody’s just fine the way it is…. I’m not prepared for this.”
Some providers had little confidence in their ability to operate the technology, and one nurse feared that her ignorance would get her into legal trouble: “I’m always afraid I’ll push the wrong button and…something will come up and it will say ‘illegal action.’ It scares me. I think ‘Oh my gosh, I’ve done something against the law.’“
Participants were also concerned about whether the information they would get though the videoconferencing channel would be reliable. A similar concern applied to information on the Internet. A physician in a private practice who was reluctant to use the computer workstation said: “The biggest problem I have with it (the Internet) is you don’t know [what] you’re getting…. There’s a lot of stuff on the Internet that’s no good.”
Although several physicians, particularly those in private practice, were apprehensive about telemedicine, they were willing to let others in their practice learn and use the technology. Some physicians in private practice, however, reflected on the seeming inevitability of change and were resigned to having to learn the technology.
Time to learn
This theme refers to hesitancy among providers to take the time to learn a new technology and to persuade patients of its worth.
One nurse/office manager said, “If I’m looking up something in a book, maybe the book is old, but at least I could have it done in 5 minutes…until I get good at this [computer], it’s taking me much longer.”
One physician in private practice bemoaned spending his time persuading patients that this new technology could benefit them. In contrast, a physician affiliated with a tertiary center noted several advantages of videoconferencing.
Ownership
This theme refers to participants who were professionally and emotionally invested in the technology—stakeholders who acknowledged its benefits, adapted it to their needs, and tried to help others learn. Predictably, this higher level of investment was most common in administrators, because of their familiarity with computerized procedures and records. One administrator affiliated with a tertiary center offered an example of this keen interest: “Yeah, we developed our own policies. We took some of the training modules and modified them to match what we thought. And we really had…everybody buy into using the same policies.”
The stakeholders often encourage others to “buy in” to the new technology, as described by this administrator affiliated with a tertiary center: “I don’t worry about the members of this group using it in a negative way. I want them to use it more…. The more exposure that they have to it, the more accustomed they’re going to be to using it.”
Discussion
These 6 themes (turf, efficacy, practice context, apprehension, time to learn, and ownership) provide a framework for understanding some consequences of introducing telemedicine into a rural setting. Although these themes have been noted to varying degrees by others,29-37,46,48 we grouped all of them as key contextual elements of the rural health environment. Aside from technical issues, such as the user-friendliness of the technology, the elemental themes that emerged from our data helped us explore this broader context.
Introducing telemedicine into a rural setting is analogous in many ways to introducing managed care into such areas. Some rural providers perceive managed care as an opportunity, while others see it as a threat to their practices, taking the local health care dollar away.49 Similarly, providers’ perceptions of telemedicine range from seeing it as a chance to improve health care delivery, as nonessential technology, or, at worst, as a threat.
Those introducing telemedicine to these areas appear to be most likely to succeed if they begin with an understanding of how the new technology is perceived by rural providers. The 6 themes we identified provide some essentials for understanding the initial process of technological change in a rural health care practice. Based on our results, rural providers’ acceptance of telemedicine is most likely to occur when there is a greater organizational integration of the new technology, a perceived increase in time efficiency, greater affiliation with a tertiary care center, a perceived increase in ownership, an enhanced ability to accommodate the changes, a reduction in apprehension, and the realization of the slower pace of change in a rural community.
These themes can be considered core issues for developing a plan that can be used when introducing telemedicine. Specific questions can then be formulated to aid in this process, including: Is there a perceived need for the technology? (turf); Who is initiating the technological change, and how it that perceived? (efficacy); How is the rate of technologic change perceived in the community? (practice context); How flexible are the users toward technologic change? What is the level of anxiety about using the technology? (apprehension); How is the time expended to learn and use the technology perceived? (time to learn); and Who manages and supports the technology? (ownership). Answers to these questions can help those introducing telemedicine to structure specific strategies for implementation that are tailored to fit the needs and concerns of each practice.
Strategies for change
After acknowledging the variability of rural practices and practice behaviors and the environmental conditions of the 10 practices in our study, we grouped them into 3 categories according to their readiness for implanting telemedicine: fertile soil, somewhat fertile soil, and barren soil. For each of these conditions, we propose strategies for change that enhance the potential for the growth of telemedicine as illustrated in the Table 1.50-52 For those practices that have been identified as fertile soil, it is important to include the physicians and administrators in the entire planning and implementation process.53 They are more likely to use physician extenders, so it is important to facilitate team building with regard to new innovations, while at the same time building various coalitions with other affiliated physicians. Empowerment is also a key to making sure the innovation is successfully implemented. Appropriate resources need to be provided, such as space for the innovation (or technology) and adequate personnel, access, and training.52
For practices identified as having partly fertile soil for change, it is important to establish a sense of urgency for the implementation of the new technology and to engage in coalition building within the community and with other specialty physicians. Help is needed to create a new vision for the practice, and this should be communicated to all employees. It also helps to provide for short-term incentives regarding the new technology.52
Engaging barren soil types of practices in implementing new technologies is difficult. It is possible, however, to facilitate change in the practice by developing a perceived need for the technology through presenting the physician(s) with current evidence-based medical information, for example. All the physicians need to be included in the planning and implementing process,53 and steps should be taken to facilitate coalition building within the community.52
Implementation strategies need to be tailored to the environmental conditions of practice sites that are carefully chosen for their potential to cultivate telemedicine. Successful sites can become exemplars to others. Establishing relationships with a practice site, however, begins with diplomatic negotiation that is sensitive to local conditions. A commitment must be made to nurture the relationship.
Limitations
The strength of our study lies in the initial investigation of rural health care providers’ perceptions of telemedicine, and we are not aware of any similar qualitative studies in the literature. The results of our study are limited, however, to the recent introduction of telemedicine technologies into rural settings. We presented perceptions of providers who were just beginning to adjust to new technologies. Future research is needed to determine the extent of these perceptions among rural health care providers in general and in particular whether some of the negative perceptions of telemedicine of the providers in our study will change over time.
Conclusions
Rural health care providers and administrators consider a range of factors, including economic ramifications, efficacy, social pressure, and apprehension, in deciding whether and how fast to adopt telemedicine technology. Since adopting this technology can be a major change, agencies trying to introduce it into rural areas should take all these factors into account in their approach to rural health care providers, staff, and communities.
Acknowledgments
Our study was funded by the National Library of Medicine, contract number: NO1-LM-6-3538.
Related resources
- Telemedicine Information Exchange (TIE) A National Library of Medicine-funded web page which offers comprehensive information on telemedicine and telehealth. http://tie.telemed.org
- Telemedicine And Health Care Informatics Legal Issues Web site A resource for providers, lawyers, professionals or anyone interested in learning more about health care law and, more specifically, the regulatory and transactional aspects of health care. http://www.netreach.net
1. Perednia DA, Allen A. Telemedicine technology and clinical applications. JAMA 1995;273:483-88.
2. Gallagher K, McFarland MA. The wired physician: current clinical information on the Internet. Mo Med 1996;93:334-39.
3. Engstrom P. Can you afford not to travel the Internet? Med Econ 1996;73:172-74.
4. Pareras LG, Martin-Rodriguez JG. Neurosurgery and the Internet: a critical analysis and a review of available resources. Neurosurgery 1996;39:216-32.
5. Neill RA, Mainous AG, III, Clark JR, Hagen MD. The utility of electronic mail as a medium for patient-physician communication. Arch Fam Med 1994;3:268-71.
6. Green L. A better way to keep in touch with patients. Med Econ 1996;73:153-54.
7. Norton SA, Burdick AE, Phillips CM, Berman B. Teledermatology and underserved populations [published erratum appears in Arch Dermatol 1997; 133:819]. Arch Dermatol 1997;133:197-200.
8. Menn ER, Kvedar JC. Teledermatology in a changing health care environment. Telemed J 1995;1:303-08.
9. High WA, Houston MS, Calobrisi SD, Drage LA, McEvoy MT. Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. J Am Acad Dermatol 2000;42:776-83.
10. Callahan EJ, Hilty DM, Nesbitt TS. Patient satisfaction with telemedicine consultation in primary care: comparison of ratings of medical and mental health applications. Telemed J 1998;4:363-69.
11. Cukor P, Baer L, Willis BS, et al. Use of videophones and low-cost standard telephone lines to provide a social presence in telepsychiatry. Telemed J 1998;4:313-21.
12. Ball C, McLaren P. The tele-assessment of cognitive state: a review. J Telemed Telecare 1997;3:126-31.
13. Graham MA. Telepsychiatry in Appalachia. Am Behav Sci 1996;39:602-15.
14. Baer L, Cukor P, Jenike MA, Leahy L, O’Laughlen J, Coyle JT. Pilot studies of telemedicine for patients with obsessive-compulsive disorder. Am J Psychiatry 1995;152:1383-85.
15. Brown FW. A survey of telepsychiatry in the USA. J Telemed Telecare 1995;1:19-21.
16. Pacht ER, Turner JW, Gailiun M, et al. Effectiveness of telemedicine in the outpatient pulmonary clinic. Telemed J 1998;4:287-92.
17. Tsagaris MJ, Papavassiliou MV, Chatzipantazi PD, et al. The contribution of telemedicine to cardiology. J Telemed Telecare 1997;3(suppl):63-64.
18. Afset JE, Lunde P, Rasmussen K. Accuracy of routine echocardiographic measurements made by an inexperienced examiner through tele-instruction. J Telemed Telecare 1996;2:148-54.
19. Grigsby J, Kaehny MM, Sandberg EJ, Schlenker RE, Shaughnessy PW. Effects and effectiveness of telemedicine. Health Care Financ Rev 1995;17:115-31.
20. Bergmo TS. An economic analysis of teleconsultation in otorhinolaryngology. J Telemed Telecare 1997;3:194-99.
21. Folberg R, Linberg JV, Verdick RE, Weingeist TA. Distance education for the professional: the Web and beyond. Opthalmol Clin North Am 2000;13:225-37.
22. Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. BMJ 2000;320:1517-20.
23. Conte SJ, Imershein AW, Magill MK. Rural community and physician perspectives on resource factors affecting physician retention. J Rural Health 1992;8:185-96.
24. Harned MA. The saga of rural health care. W V Med J 1993;89:54-55.
25. Mackesy R. Physician satisfaction with rural hospital. Hosp Health Serv Adm 1993;38:375-86.
26. Anderson EA, Bergeron D, Crouse BJ. Recruitment of family physicians in rural practice. Minn Med 1994;77:29-32.
27. Harris KD. Acceptance of computer-based telemedicine in three rural Missouri counties (rural health care). Thesis/dissertation. University of Missouri; 1999.
28. Orkin FK. Rural realities. Anesthesiology 1998;88:568-71.
29. Mazmanian PE, Banks RA, Self P, Hampton C. Increasing access to medical information. Changing communication patterns in southside Virginia. Va Med Q 1996;123:176-78.
30. Menduno M. Prognosis: wired. Why Internet technology is the next medical breakthrough. Hosp Health Netw 1998;72:28-30.
31. Treister NW. Physician acceptance of new medical information systems: the field of dreams. Physician Exec 1998;24:20-24.
32. Appleby C. Web-o-matic isn’t automatic—yet. Internet technology hasn’t broken the barrier between doctors & computers. Hosp Health Netw 1997;71:30-31.
33. Keoun B. At last, doctors begin to jump online. J Natl Cancer Inst 1996;88:1610-12.
34. Chi-Lum BI, Lundberg GD, Silberg WM. Physicians accessing the Internet, the PAI Project. An educational initiative. JAMA 1996;275:1361-62.
35. Bergman R. The computer revolution snags some physicians in & out of the office: it’s time to recognize the new era of the techno docs. Hosp Health Netw 1995;69:68-70.
36. Gleiner JA. Information technology: the next wave. Clinician acceptance of information technology. Physician Exec 1996;22:4-8.
37. Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med 1993;329:1271-73.
38. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-05.
39. Robertson N, Baker R, Hearnshaw H. Changing the clinical behavior of doctors: a psychological framework. Qual Health Care 1996;5:51-54.
40. Nobel J. Influence of physician perceptions on putting knowledge into practice. Lancet 1996;347:1571.-
41. Crabtree BF, Miller WL, eds. Doing qualitative research. 2nd ed. Thousand Oaks, Calif: Sage Publications; 1999.
42. The ethnograph Version 4.0. Amherst, Mass: Qualis Research Associates; 1994.
43. Crabtree BF, Miller WL. A template approach to text analysis: developing and using codebooks. In: Crabtree BF, Miller WL, eds. Doing qualitative research. Newbury Park, Calif: Sage Publications; 1992;93-109
44. Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. 2nd ed. Thousand Oaks, Calif: Sage Publications; 1994.
45. Boyatzis RE. Transforming qualitative information: thematic analysis and code development. Thousand Oaks, Calif: Sage Publications; 1998.
46. Yellowlees P. Successful development of telemedicine systems—seven core principles. J Telemed Telecare 1997;3:215-22.
47. Carlson B. Telemedicine changing practice of medicine. Indiana Med 1994;87:352-59.
48. Leckie GJ, Pettigrew KE, Sylvain C. Modeling the information seeking of professionals: a general model derived from research on engineers, health care professionals, and lawyers. Library Q 1996;66:161-93.
49. Gibbons B. How do we make managed care work for us? Tate Rural Health Watch 1998;2-3,8-9,12.-
50. Kanter RM. The new managerial work. Harv Bus Rev 1989;67:85-92.
51. Beer M, Eisenstat RA, Spector B. Why change programs don’t produce change. Harv Bus Rev 1990;68:158-66.
52. Kotter JP. Leading change: why transformation efforts fail. Harv Bus Rev 1995;73:59-67.
53. Heydt S. Helping physicians cope with change. Physician Exec 1999;25:40-45.
54. Schneider B, Gunnarson SK, Nilesjolly K. Creating the climate and culture of success. Organizational Dynamics 1994;23:17-22.
1. Perednia DA, Allen A. Telemedicine technology and clinical applications. JAMA 1995;273:483-88.
2. Gallagher K, McFarland MA. The wired physician: current clinical information on the Internet. Mo Med 1996;93:334-39.
3. Engstrom P. Can you afford not to travel the Internet? Med Econ 1996;73:172-74.
4. Pareras LG, Martin-Rodriguez JG. Neurosurgery and the Internet: a critical analysis and a review of available resources. Neurosurgery 1996;39:216-32.
5. Neill RA, Mainous AG, III, Clark JR, Hagen MD. The utility of electronic mail as a medium for patient-physician communication. Arch Fam Med 1994;3:268-71.
6. Green L. A better way to keep in touch with patients. Med Econ 1996;73:153-54.
7. Norton SA, Burdick AE, Phillips CM, Berman B. Teledermatology and underserved populations [published erratum appears in Arch Dermatol 1997; 133:819]. Arch Dermatol 1997;133:197-200.
8. Menn ER, Kvedar JC. Teledermatology in a changing health care environment. Telemed J 1995;1:303-08.
9. High WA, Houston MS, Calobrisi SD, Drage LA, McEvoy MT. Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. J Am Acad Dermatol 2000;42:776-83.
10. Callahan EJ, Hilty DM, Nesbitt TS. Patient satisfaction with telemedicine consultation in primary care: comparison of ratings of medical and mental health applications. Telemed J 1998;4:363-69.
11. Cukor P, Baer L, Willis BS, et al. Use of videophones and low-cost standard telephone lines to provide a social presence in telepsychiatry. Telemed J 1998;4:313-21.
12. Ball C, McLaren P. The tele-assessment of cognitive state: a review. J Telemed Telecare 1997;3:126-31.
13. Graham MA. Telepsychiatry in Appalachia. Am Behav Sci 1996;39:602-15.
14. Baer L, Cukor P, Jenike MA, Leahy L, O’Laughlen J, Coyle JT. Pilot studies of telemedicine for patients with obsessive-compulsive disorder. Am J Psychiatry 1995;152:1383-85.
15. Brown FW. A survey of telepsychiatry in the USA. J Telemed Telecare 1995;1:19-21.
16. Pacht ER, Turner JW, Gailiun M, et al. Effectiveness of telemedicine in the outpatient pulmonary clinic. Telemed J 1998;4:287-92.
17. Tsagaris MJ, Papavassiliou MV, Chatzipantazi PD, et al. The contribution of telemedicine to cardiology. J Telemed Telecare 1997;3(suppl):63-64.
18. Afset JE, Lunde P, Rasmussen K. Accuracy of routine echocardiographic measurements made by an inexperienced examiner through tele-instruction. J Telemed Telecare 1996;2:148-54.
19. Grigsby J, Kaehny MM, Sandberg EJ, Schlenker RE, Shaughnessy PW. Effects and effectiveness of telemedicine. Health Care Financ Rev 1995;17:115-31.
20. Bergmo TS. An economic analysis of teleconsultation in otorhinolaryngology. J Telemed Telecare 1997;3:194-99.
21. Folberg R, Linberg JV, Verdick RE, Weingeist TA. Distance education for the professional: the Web and beyond. Opthalmol Clin North Am 2000;13:225-37.
22. Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. BMJ 2000;320:1517-20.
23. Conte SJ, Imershein AW, Magill MK. Rural community and physician perspectives on resource factors affecting physician retention. J Rural Health 1992;8:185-96.
24. Harned MA. The saga of rural health care. W V Med J 1993;89:54-55.
25. Mackesy R. Physician satisfaction with rural hospital. Hosp Health Serv Adm 1993;38:375-86.
26. Anderson EA, Bergeron D, Crouse BJ. Recruitment of family physicians in rural practice. Minn Med 1994;77:29-32.
27. Harris KD. Acceptance of computer-based telemedicine in three rural Missouri counties (rural health care). Thesis/dissertation. University of Missouri; 1999.
28. Orkin FK. Rural realities. Anesthesiology 1998;88:568-71.
29. Mazmanian PE, Banks RA, Self P, Hampton C. Increasing access to medical information. Changing communication patterns in southside Virginia. Va Med Q 1996;123:176-78.
30. Menduno M. Prognosis: wired. Why Internet technology is the next medical breakthrough. Hosp Health Netw 1998;72:28-30.
31. Treister NW. Physician acceptance of new medical information systems: the field of dreams. Physician Exec 1998;24:20-24.
32. Appleby C. Web-o-matic isn’t automatic—yet. Internet technology hasn’t broken the barrier between doctors & computers. Hosp Health Netw 1997;71:30-31.
33. Keoun B. At last, doctors begin to jump online. J Natl Cancer Inst 1996;88:1610-12.
34. Chi-Lum BI, Lundberg GD, Silberg WM. Physicians accessing the Internet, the PAI Project. An educational initiative. JAMA 1996;275:1361-62.
35. Bergman R. The computer revolution snags some physicians in & out of the office: it’s time to recognize the new era of the techno docs. Hosp Health Netw 1995;69:68-70.
36. Gleiner JA. Information technology: the next wave. Clinician acceptance of information technology. Physician Exec 1996;22:4-8.
37. Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med 1993;329:1271-73.
38. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-05.
39. Robertson N, Baker R, Hearnshaw H. Changing the clinical behavior of doctors: a psychological framework. Qual Health Care 1996;5:51-54.
40. Nobel J. Influence of physician perceptions on putting knowledge into practice. Lancet 1996;347:1571.-
41. Crabtree BF, Miller WL, eds. Doing qualitative research. 2nd ed. Thousand Oaks, Calif: Sage Publications; 1999.
42. The ethnograph Version 4.0. Amherst, Mass: Qualis Research Associates; 1994.
43. Crabtree BF, Miller WL. A template approach to text analysis: developing and using codebooks. In: Crabtree BF, Miller WL, eds. Doing qualitative research. Newbury Park, Calif: Sage Publications; 1992;93-109
44. Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. 2nd ed. Thousand Oaks, Calif: Sage Publications; 1994.
45. Boyatzis RE. Transforming qualitative information: thematic analysis and code development. Thousand Oaks, Calif: Sage Publications; 1998.
46. Yellowlees P. Successful development of telemedicine systems—seven core principles. J Telemed Telecare 1997;3:215-22.
47. Carlson B. Telemedicine changing practice of medicine. Indiana Med 1994;87:352-59.
48. Leckie GJ, Pettigrew KE, Sylvain C. Modeling the information seeking of professionals: a general model derived from research on engineers, health care professionals, and lawyers. Library Q 1996;66:161-93.
49. Gibbons B. How do we make managed care work for us? Tate Rural Health Watch 1998;2-3,8-9,12.-
50. Kanter RM. The new managerial work. Harv Bus Rev 1989;67:85-92.
51. Beer M, Eisenstat RA, Spector B. Why change programs don’t produce change. Harv Bus Rev 1990;68:158-66.
52. Kotter JP. Leading change: why transformation efforts fail. Harv Bus Rev 1995;73:59-67.
53. Heydt S. Helping physicians cope with change. Physician Exec 1999;25:40-45.
54. Schneider B, Gunnarson SK, Nilesjolly K. Creating the climate and culture of success. Organizational Dynamics 1994;23:17-22.