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.”