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