OBJECTIVE: We investigated rural health providers’ perceptions of telemedicine, developed a framework for assessing their readiness to adopt this type of technology, and offered a guide for its implementation.
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.