University of Bath

Royal College of Surgeons of Edinburgh

Healthcare Informatics

Crossing the Rough Road and Hot Sands via Telephony:

An Analysis of Telemedicine Utilization at
Shriners Hospitals for Children, Salt Lake City

Jonathan Nicholas Grau

Supervisors:

Alice Breton, MSc

Director of Studies
Royal College of Surgeons of Edinburgh

Kristine Ferguson, MSW

Director of Outpatient/Care Coordination Services
Shriners Hospitals, Salt Lake City

December 2008

This project proposal is submitted in accordance with the requirements for the degree
of Masters of Healthcare Informatics of the Royal College of Surgeons of Edinburgh
and the University of Bath.
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Copyright Notice

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Signature:

Date: December 31, 2008

Disclaimer

The opinions expressed in this work are entirely those of the author except

where indicated in the text.

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Acknowledgements

Thanks to the faculty and administrators of this program at University of Bath

and Royal College of Surgeons of Edinburgh. Thanks, in particular, goes to

Alice Breton and Kris Ferguson and to my fellow students.

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Abstract

The author conducted a qualitative study to explore the factors that have

facilitated and prevented optimal use of an established telemedicine program

at Shriners Hospitals for Children, Salt Lake City. A focus group was carried

out with attending staff to capture data regarding individual and shared

experience working with the technology. A simplified extension of Unified

Theory of Acceptance and Uses of Technology was applied to the data to

identify factors that contributed to staff decision-making regarding how

telemedicine was employed. The study revealed how pediatric orthopedic

physicians were influenced by individual, technical, and managerial factors

and how their individual perception of telemedicine had formed.

The results from this study suggest that individual factors such as self-efficacy

and planned behavior drove physicians to use telemedicine despite significant

technical and managerial barriers. Sensitivity to professional status led them

to alter their use of the technology, however, which led to a precipitous decline

in its effectiveness. Themes that emerged from this study indicate that

physicians require a high level of confidence both in the technology and in the

medical skills of remote-side clinicians in order to deliver quality care and that

patient satisfaction and expected cost benefits represent powerful normative

factors for driving utilization.

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Contents

Abstract.........................................................................................................4
Contents........................................................................................................5
Introduction..................................................................................................6
Statement of Research Problem...............................................................10
Background...............................................................................................10
Research Problem....................................................................................11
Aims and Objectives.................................................................................13
Literature Review.......................................................................................15
Search Terms............................................................................................15
Research Tools.........................................................................................16
Reported Research..................................................................................17
Applied Theory..........................................................................................20
Cost Benefits Analysis..............................................................................23
Research.....................................................................................................25
Consideration of Research Methods........................................................25
Methods....................................................................................................27
Ethical Considerations..............................................................................30
Results......................................................................................................31
Fig. 1 – Focus Group Chart......................................................................34
Evolution of Opinion: Discord and Harmony...........................................34
Stages.......................................................................................................37
Emergent Themes....................................................................................39
Fig. 3 – Themes Chart..............................................................................40
Confidence in Technology and Continuity of Care ..................................40
Patient Satisfaction...................................................................................43
Evident Cost Benefits...............................................................................46
Discussion..................................................................................................48
SLC Staff Physician Perception................................................................50
Individual Factors......................................................................................52
Managerial Factors...................................................................................53
Technical Factors......................................................................................55
Conclusions................................................................................................57
Study Limitations and Areas for Further Study.........................................59
Recommendations....................................................................................60
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Introduction

Healthcare Informatics (HI) is a broad and diverse field of study. At its most

broad, it is the art of communicating health information across large

populations. At its most diverse, it includes the science of minimally-invasive,

unmanned robotic surgery and the promise of improved outcomes through

decision support, data capture, and collaborative treatment technologies.

The challenge for the HI researcher is to derive form, function, and value for a

specific practice area through critical analysis, comparison, and first-hand

experience of a given information system. I chose a study of telemedicine

because I felt the technology had received a lot of attention in recent years yet

had failed to be fully utilized as an efficient and effective care delivery system.

Indeed, as recently as 30 June 2008, Adena Medical Center in Ohio, USA

announced an expansion of its telemedicine services fueled by “an increasing

need for medical specialists, the decreasing cost of technology and the

prospect of lowering health care costs (1).” As I researched this topic I found

that many telemedicine programs had likewise been founded on such lofty

expectations yet rarely had these expectations actually been met (2).

Like HI, telemedicine too has an expansive scope and has evolved rapidly

through the years. Many organizations refer to telemedicine as the clinical or

care delivery aspect of telehealth. The United States Department of Health

and Human Services, Health Resources and Services Administration uses the

term telehealth to describe all aspects of:

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… the use of electronic information and telecommunications

technologies to support long-distance clinical health care, patient and

professional health-related education, public health and health

administration (3).

The Association of Telehealth Service Providers, on the other hand, defines

telemedicine specifically and more narrowly as, “the provisioning of health

care and education over a distance, using telecommunications technology (4).”

Common to both definitions is the concept of distance. Telemedicine

applications, such as videoconferencing, streaming media, and short

message services, have been and will continue to be employed in an effort to

conquer distance by giving physicians a longer virtual reach.

Enabling providers to span time zones and cross over borders has introduced

jurisdictional issues as well. The Joint Commission for the Accreditation of

Healthcare Organizations (JCAHO) has established standards to help sort out

the credentialing and privileging of telemedicine services in the United States

and has set parameters for lawful conduct for licensed independent

practitioners. JCAHO holds that telemedicine does not include interpretive or

consultative services, for example. Consequently, JHACO standards narrow

the definition of telemedicine by limiting it for use by practitioners with total or

shared responsibility for the patient. This definition happens to severely

constrain the real-world use of telemedicine by radiologists and triage

specialists (5). Regardless of the various definitions used to describe or

proscribe telemedicine, as a healthcare delivery mechanism it has changed

little since the advent of phone communications and the “take two aspirin and
 8

call me in the morning” mode of doctoring. Indeed, physicians and nurses

have been providing ad-hoc care over the phones for the good part of the last

century. It was only in the last twenty years, during the building out of the

digital communications infrastructure that many new technologies with

healthcare applications came online. With expanded bandwidth came

additional capacity for digital visual imaging, two-way video, conferencing, and

the like to add to a single voice stream. New telephony technology, for

example, had the potential to transform and drive down costs related to

emergency medicine, health management, and private practice and still do.

Such technology can also help expand the reach of health delivery itself by

making specialized care accessible to needy recipients and making localized

clinical expertise a common weal asset(6,7).

Distance and clinical expertise are therefore the two problems telemedicine is

designed to address and Salt Lake City, Utah USA is an excellent example of

a test bed for telemedicine services. It has a population of approximately one

million yet lies 350 miles in any direction from the next nearest urban center.

Salt Lake’s geographic isolation belies deep integration and connectivity into

the global information system thanks to its high-tech industries. Shriners

Hospitals for Children, Salt Lake City (SLC) benefits from an equally

auspicious situation. It delivers free orthopaedic care to all qualified children

along the western range of the Rocky Mountains of North America, from

Mexico to Canada. It has operated a telemedicine program for nearly ten

years to help support this mission. The six surgeons at SLC represent

primary attending staff with over 100 years of shared experience at the
 9

hospital. Each has at least six years of interaction with the telemedicine suite

installed at the facility.

The conclusions I drew from this study indicate that successful

implementation of any telemedicine system comes with significant investment.

Physicians in this study were overwhelmingly concerned with their ability to

deliver quality care, to diagnose correctly and to treat effectively, across a

virtual network. Barriers to adoption can be overcome by good program

design, ongoing outcomes-based feedback, and constant refinement of and

investment in/upgrades to the technology. Findings from this study have been

drawn using rigorous methodological and theoretical practice and can be used

to inform organizational gap analysis prior to design and investment in

telemedicine technology.
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Statement of Research Problem

Background

Shriners Hospitals for Children, Salt Lake City (SLC) is a regional not-for-profit

40-bed hospital specializing in pediatric orthopaedics. Its operating budget in

2005 was just under $22M. SLC treats children from birth to eighteen years

of age for a variety of orthopaedic diseases, including but not limited to:

scoliosis, clubfoot, and problems caused by disorders like cerebral palsy and

spina bifida. Care is provided at no cost to patients and their families. The

cost burden is shouldered by the Shriners Hospitals system and by local

Shrine temples. In the words of the organization itself: “the Shriners and

Shriners Hospitals are separate but inseparable (8).” All of the cost associated

with inpatient care, from admitting through global period, is typically incurred

by the facility which is funded by the Shriners Hospitals system. The costs

associated with transportation for the patient and her family are incurred by

the local Shriners Temple organization funded by members. It is this cost

structure that defines, for better or worse, the value of the telemedicine

program for the organization as each derives separate and unequal returns on

investment.a

SLC employs a number of ground-breaking technologies to help drive

treatment plans. These include plastic and reconstructive surgery, motion

analysis, innovative prosthetics and orthotics, and, as of 1998, a fully outfitted

a
Families are generally responsible for their own food and lodging save for hardship cases,
where the cost for this is assumed by the local Shrine Temple.
 11

telemedicine suite. SLC serves patients within an area that includes six

states in the U.S. and the Mexican states of Sonora and Chihuahua, covering

approximately 800,000 square miles of North America. Its telemedicine suite

has been in operation since 1998 and is one of the most widely used within

the Shriners Hospitals system. The e-MedSoft telemedicine solution installed

by SLC enables “physicians to deliver remote examination, diagnosis and

treatment to patients via secure, private interactions … as well as allowing for

the maintenance of a [Cerner Millenium] electronic patient record, whereby

each physician can access their patient's file, complete with physician notes,

lab results and X-rays (9).”

Research Problem

SLC Telemedicine clinics have been used most commonly to perform wound

checks, post-op and yearly follow-up, and to assess the use and fit of

prosthetics and braces. Each physician is expected to conduct a single clinic

of at least 3 hours in the telemedicine suite per month and to evaluate at least

15 children during each clinic (10). Patient surveys conducted by the office of

the telemedicine coordinator suggest that families enjoy the time savings and

convenience that local telemedicine clinics afford. Growing demand for more

telemedicine clinics, however, has been met by an ambivalent if not reluctant

SLC physician corps. SLC physicians claim they have struggled with the

technology and have employed it minimally.

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SLC administrators, in turn, believe use of telemedicine technology

suboptimal and have struggled to drive utilization beyond this benchmark of

one clinic per doctor per month. SLC administrators have acknowledged that

through the years SLC physicians blamed telemedicine technology for

negatively impacting their clinical practice which has led to underutilization.

Orthopaedic surgeons, perhaps more than other specialists, are governed by

their sense of touch and their ability to observe range of motion, gate, and

overall movement. The disjunction of video interface and audio delay, staff

claims, has delivered immediate and overwhelming diminishment of good

diagnostic practice not to mention interpersonal communication. Furthermore,

Incompatibility between Picture Archiving and Communications Systems

(PACS) often compounded the already poor image quality of x-rays. In order

for SLC physicians to work with absolute confidence, they would often

schedule subsequent in-person visits to work around the telemedicine clinic.

SLC administration also believes itself to have a distinct disadvantage in

fomenting adoption and utilization among its staff thanks to its culture. Staff

physicians are measured on a more traditional clinical/outcomes-based scale

not solely on their work quotient and ability to contain cost. Additionally,

funding for day-to-day hospital operations comes from the Shriners Hospitals

system, including all overhead for staff, technology, research, inpatient

room/board, etc., while local Shrine temples finance the transportation costs.

This shared cost structure is a product of the Shrine’s overall organizational

structure: one part philanthropy, one part fraternity. This “split shareholder”

arrangement creates indirect operating accountability with unclear

repercussions should technology investment lose traction or fail.

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Consequently, staff physicians appear to enjoy a relatively powerful position in

the facility compared to their counterparts in fee-for-service institutions which

may be a cause for poor program adherence.

Aims and Objectives

There is no question that SLC has a unique operating dynamic thanks to its

not-for-profit status and philanthropic mission. Given the particulars of the

culture and structure of SLC, this study ran the risk of being too narrow and

lacking in resonant, applicable analysis. However, as Dr. Carolyn Clancy,

Director of the Agency for Healthcare Research and Quality, declared, in her

May 2005 presentation to the United States Congress Subcommittee on

Health Committee on Veterans Affairs:

Widespread adoption of individual telemedicine applications in the

private sector will continue to grow slowly … unless creative ways are

found to speed the development of solid, scientifically generalizable

findings of their effectiveness.

She went on to say that:

While there are many promising initiatives underway, there are few

mature telemedicine programs and few good scientific evaluations.

There are, nonetheless, lessons learned that may prove useful to the

VA. However, there is an obvious need to work collaboratively to

identify best practices (11).

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Following Dr. Clancy’s admonishment, my aim was to examine a mature

telemedicine program to better understand drivers of telemedicine utilization

and to identify real or perceived barriers that existed for physicians who

interfaced with the system. In order to achieve this aim, I set out to learn

specifically:

- why SLC physicians were initially impelled to utilize telemedicine;

- how they felt telemedicine impacted their practice;

- what the motivations were for continued utilization;

- and, finally, what they would suggest to reinforce its wider use.
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Literature Review

The strategy employed for literature review was a search for research that has

been conducted worldwide relating to usability and adoption of telemedicine

technology, telemedicine’s impact on professional autonomy and perceived

efficacy, and provider perception of outcomes related to its use. From this

broad systematic search, I attempted to isolate research done within the last

eight to ten years that involved provider acceptance of telemedicine within an

orthopedic and/or pediatric setting. I adhered to this strategy as much as

possible yet I followed a number of circular research paths proffered by

GoogleScholar and PubMed functionality that supported links ranked by

citation statistics, key authors, and other helpful criteria. Overall, this review

of literature provided what I believe to be an exhaustive survey of subject

matter and theory from recent years to help frame this study within

parameters defined by relevance and currency.

Search Terms

The search strategy involved matching combinations of the following topics

and terms in an attempt to fine tune results:

Topics Terms
telemedicine acceptance, adoption, diffusion, efficacy,

orthopedics, pediatrics, provider, satisfaction,

“shriners”, utilization
theory acceptance, adoption, diffusion, efficacy,

qualitative, technology, telemedicine, utilization

cost efficiency acceptance, adoption, efficacy, pediatrics,

provider, technology, telemedicine, utilization

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I performed a standard search followed by an exact-term search on each topic

individually and each topic/term combination. Within telemedicine,

“telemedicine adoption” returned the broadest set of results, followed by

“telemedicine efficacy” and “telemedicine satisfaction”. To generate more

precise results related to provider utilization in pediatrics, I targeted my search

based on specialty, using terms such as “pediatric telemedicine” and

“pediatric orthopedic telemedicine”. Finally, I searched for “shriners

telemedicine adoption” which returned a single reported study. Within the

theory topic, “diffusion theory” and “qualitative theory” had the broadest set of

results while “telemedicine technology acceptance theory” returned three of

the reported studies. The cost efficiency topic required search on

combinations such as “telemedicine cost efficiency” and “telemedicine

provider acceptance cost efficiency” in order to deliver relevant returns.

Research Tools

I employed the search capabilities of Google, PubMed, and IEEE Search to

survey the universe of literature. I also targeted specific peer-reviewed

medical society and professional association Web sites for anything that may

not have turned up in the systematic review. I found that GoogleScholar

results consistently returned papers and articles of consequence and that a

more targeted review and cross-reference using PubMed and IEEE had

excellent results. Accordingly, when an appropriate publication, article, or

dissertation was found via GoogleScholar, I would earmark the author for

targeted searches using PubMed and IEEE. I followed citation and key author
 17

leads as often as I could to ensure that I had not missed a source for relevant

information. Finally, I went outside of the search engine framework and

visited professional associations and medical societies that hosted their own

symposia and member meetings. The American Medical Informatics

Association (AMIA), through its Classic Paper Series, published a “Collection

of Recommended Papers and Information Sources” (12) sourcing a very broad

set of papers related to technology adoption. Additionally, the American

Telemedicine Association (ATA) served as a virtual hub for vast amounts of

research, including unpublished papers presented at ATA’s national and

regional meetings.

Reported Research

Journal articles provided the strongest material for this study. The most

promising research focused on the dynamics of health information systems

adoption and the roles, responsibilities, and level of influence held by various

stakeholders. Lapointe and Rivard, for example, in their Getting Physicians to

Accept New Information Technology (13) posited that individual, professional

and organizational factors directly influence adoption and utilization of hospital

information systems. They confirmed in their study that physicians who resist

using technology held the most power within an institution and that these

resistant physicians were responsible both for taking on the learning curve

and for validating the technology’s efficacy before quitting it. They also

determined that if the technology were implemented correctly, with broad

resources and support, any continued problems associated with its utilization
 18

represented larger organizational and structural issues; “if the implementers

are the object of resistance, the computer system becomes extraneous to the

problem.”

The most recent work I was able to find came out of ATA’s 2007 and 2008

symposia. While not directly related to telemedicine, the subject matter and

applied theory were quite complementary. Whitten et al.’s Provider

Acceptance of a Remote Trauma Consultation Network (14), Reynolds et al.’s

The Role of Provider Perceptions in Deploying an Electronic Medical Record

at Michigan State University (15), and Sanford Melzer et al.’s Experience with

Pediatric Telemedicine Services in a Regional Network (16), for example,

suggested that physicians must be convinced of the full spectrum of expected

benefits and outcomes early in technology adoption and be regularly briefed

on ongoing findings related to such measures in order for perceptions to be

changed and/or reinforced. Reynolds, in particular, found that physicians’

perception of the impact of the technology on their practice had a greater

effect on its utilization than did demographics such as age and sex. The

Reynolds study was the only one of the three that appeared to use a rigorous

quantified approach. This method delivered a broad set of data related to

satisfaction and success rates for EMR adoption but left a number of

important questions unanswered relative to telemedicine, such as: effects on

quality, effects on physician and patient relationships, and finally effects on

clinician autonomy.
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Regarding telemedicine adoption, specifically, the most widely cited study was

published by Gagnon, Lamothe, et al. who performed a quantitative study on

physicians working within the provincial telemedicine network of Quebec.

They found that telemedicine, like other clinical decision support and

computer physician order entry technologies, was a technology that highly

impacted physician perception of professional identity. They found that

“physicians who perceived professional and social responsibilities regarding

adoption of telehealth in their clinical practice had stronger intention to use the

technology.” Their most profound finding was that physicians' intention to use

telemedicine was better predicted if their self-perception as telemedicine

users was considered (17).”

Within orthopaedics, evaluation of provider interfacing and systems utilization

is limited to studies related to clinical decision-making and the use of imaging

technology to support remote diagnosis and treatment (18,19,20). A single study

regarding the telemedicine experience at Shriners Hospitals for Children,

Honolulu was identified. Though similar in nature, the Ono and Lindsey (21)

study at Honolulu, published in 2004, focused primarily on implementation

and adoption within the Hawaii facility with recommendations on operations

and ongoing maintenance for that specific program. Provider interfacing with

and utilization of the system were not within scope. The Ono and Lindsey

study and the findings of the other reported researchers represent a solid but

small body of work in the analysis of physician perceptions of technology with

an emphasis on telemedicine.
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Applied Theory

Prevailing social science in the area of systems adoption is dominated by

Diffusion Theory, Technology Acceptance Model theory, and Social Cognitive

Theory, championed by such researchers as Everett Rogers, F.D. Davis, and

Albert Bandura, respectively. In 2003, a so-called Unified Theory of

Acceptance and Uses of Technology (UTAUT) was proposed as a synthesis of

all previous models of technology acceptance. While UTAUT and all of these

theories separately can be used to analyze technology adoption by

physicians, Mezni and Zeribi’s very recent Determinants of the Individual

Acceptance of the Telemedicine (22) which includes the proposal to merge

UTAUT’s (at least) eight different adoption factors into a simpler model seems

to be most promising. Mezni and Zeribi’s Individual Acceptance model is

especially applicable to this study as it draws from the strengths of studies

using Self Efficacy and Planned Behavior to specifically analyze telemedicine

use among highly autonomous practitioners.

Diffusion Theory, regarded as a benchmark for analyzing technology adoption,

works best at a macro-level thanks to its application-neutral view of the

technology and of its adopters. Though Rogers’s innovation-decision process

focuses on an individual’s acknowledgement of a new technology as a

potentially productive or useful tool, the process through which “an individual

or other decision-making unit” passes first from knowledge of an innovation to

forming an attitude toward the innovation, to making a decision to adopt or

reject, to implementation of the new idea, and finally to confirmation of this

decision does not account for technologies that disrupt or alter significantly
 21

the status-quo, specifically in a healthcare setting. Diffusion Theory therefore

serves as a suitable benchmark but could not be used to analyze in whole or

in part any of the data gathered in this study(23).

Technology Acceptance Model (TAM) theory has been applied to technology

in a healthcare setting but not specifically to telemedicine. Succi et al. in their

1999 Theory of User Acceptance of Information Technologies, discussed how

TAM could be used to analyze physician utilization of disruptive healthcare

technologies such as decision-support and electronic health records. They

found that the addition of specific determinants, such as “the perceived impact

of using the technology on Professional Status,” was a key component to

successful technology adoption by physicians (24). Most recently, Jen-Her Wu

et al. in their Testing the Technology Acceptance Model for Evaluating

Healthcare Professionals' Intention to Use an Adverse Event Reporting

System (25) applied TAM extensions Subjective Norm and Perceived Ease-of-

Use to the study of physician adoption of a medical reporting system.

Interestingly, both sets of researchers suggested that TAM was limited and

required extensions to address the more highly individuated perspective of

end-users in the medical profession. There does not appear to have been

any subsequent research done using TAM or any of its Subjective Norm,

Perceived Ease-of-Use, and Professional Status extensions on telemedicine.

Definitive work using Social Cognitive Theory (SCT) was conducted by a

group of researchers again led by Marie-Pierre Gagnon in Quebec, Canada in

2003. According to Gagnon, et al., “physicians who perceived professional

 22

and social responsibilities regarding adoption of telehealth in their clinical

practice had stronger intention to use [the] technology (26).” Their study

employed a theoretical framework established by Hu and Chau who used

SCT extensions, Planned Behavior and Self Efficacy, to evaluate the

dominant psychosocial drivers of telemedicine adoption. Hu and Chau found

that “technology that could interfere with physicians' traditional practice could

affect their perception of their professional role (27).” The importance of a

physician’s “perception of their professional role” within an equivalent network

of “social responsibilities” begins to describe the challenges associated with

telemedicine studies using TAM. Gagnon’s application of SCT to telemedicine

therefore established a foundation for future research designed to explore the

universe of behavioral factors.

As mentioned, Unified Theory of Acceptance and Uses of Technology

(UTAUT), while exceptionally robust due to its inclusion of such TAM and SCT

extensions as performance expectancy, effort expectancy, social influence

and facilitating conditions, had yet to be applied to telemedicine until earlier

this year. It was not done without significant alteration (28). Mezni and Zeribi’s

very recently introduced Individual Acceptance model, a heavily modified

UTAUT model, was used to analyze telemedicine use in Tunisia.b Areas

Mezni and Zeribi identified as essential to telemedicine analysis, specifically,

the components that comprise a physician’s perception of her capability vis a

vis telemedicine represent three areas of “unified theory”: A) Individual

Factors, B) Managerial Factors, and C) Technical Factors. The following

b
A review of their proposal reveals a quite loose affiliation with UTAUT insofar as it uses the
concept of “unified theory” to rationalize its synthesis of SCT drivers that were already proven
by Hu and Gagnon to be most directly applicable to telemedicine studies.
 23

schema illustrates how those factors combine to contribute to a Physician’s

Perception:

Individual Factors
Self-efficacy
Planned Behavior

Individual
Managerial Factors Physician’s
Acceptance of
Executive-level Champion Perception
Telemedicine
Ongoing Training

Technical Factors
Quality Measurements
Level of Disruption

Individual Factors are composed of SCT factors Self Efficacy and Planned

Behavior which attempt to define how the physician feels technology can

enable him to achieve his ends effectively and efficiently. Managerial Factors

suggest that an executive level champion must enable the use of the

technology and provide training for staff to follow. Finally, Technical Factors

include establishing quality measures that can be used to determine the level

of compatibility with existing processes. All of these factors combine to

influence a Physician’s Perception of a technology’s Ease-of-Use and

Expected Performance. The author believes Individual Acceptance model

correlates with the situation at SLC and can be used to better understand the

captured data.

Cost Benefits Analysis

 24

As of December 2008, The American Telemedicine Association (29)

documented approximately 200 networks operating in the United States,

linking over 2,500 institutions nationwide. Often overlooked in systematic

reviews of telemedicine adoption research are the business drivers that have

justified build-out of such an expansive telemedicine infrastructure. As

mentioned at the outset, fee-for-service providers in the United States

generally arrive at decisions to invest and adopt such technology based

purely on competitive advantage and cost benefit. The same business drivers

can and do exist for non-profits. Indeed budgetary pressures at non-profits

can represent significant risk to their mission-driven operations.

Understanding how telemedicine has been viewed as a business investment,

therefore, and learning whether returns on investment have actually been

realized are important factors in evaluating the adoption cycle.

Douglas Smith’s 2005 article, The Influence of Financial Factors on

the Deployment of Telemedicine, provided a thorough breakdown of the five

financial factors that are most often considered when a telemedicine program

is being evaluated. They include: 1. Initial or capital investment; 2. Operating

or ongoing costs; 3. Profitability or net income; 4. Cash flow; and 5.

Reimbursement. Smith noted that the business case for telemedicine is often

very strong at the outset but, “sustainability … is an issue of concern.

Although governmental or other agencies may provide some funding for initial

deployment, the ongoing operating funds are more uncertain (30).” Broens et

al. leveraged Smith’s study to propose “a layered implementation model in

which the primary focus on individual determinants changes throughout the

 25

development life cycle of the telemedicine implementation (31).” This business

driven adoption model would serve to move pilot studies rapidly into robust

deployment and continued success.

Much of the research in this area indicts the healthcare economy of the United

States which effectively requires the Federal Government to underwrite new

technology by approving reimbursement for such services in its Medicare

Physician Fee Schedule. At the time of this writing, the United States

Congress had just passed into law the first measure for payment of

telemedicine services in skilled nursing facilities, in-hospital dialysis centers

and community mental health centers (32). This legislation comes after nearly

two decades of wide telemedicine utilization in the industry. This legislation

could set the stage for more consistent approval and payment for services

rendered via telephony by commercial health plans to make telemedicine a

viable long-term delivery solution.

Research

Consideration of Research Methods

SLC administrators communicated to me that attending physicians held well

differentiated viewpoints and were willing to speak freely on the topic of

telemedicine. I therefore took advantage of a standing weekly staff meeting to

conduct a focus group, ensuring that I met with the attending staff all at once

and in a familiar setting. The choice of an informal session was based on a

review of prevailing theory in qualitative data capture with specific attention to

 26

Jim Brigsby, Pamela Whitten, and others who found that a “communicative

focus which privileges the role of participatory conversation [should be] used

to examine and explain the invention, diffusion, and reinvention of

telemedicine (33).”

The staff at SLC consisted of six attending physicians each of whom was

obliged to conduct telemedicine outreach clinics. Nearly 1200 hours of

telemedicine practice had been undertaken among them over the previous

eight years. As expert sampling involves the assembly of persons with known

or demonstrable experience and expertise in a particular area, so the choice

of this sample was made by default and not by convenience.

I conducted a 60-minute focus group to allow for plenty of disclosure,

conversation, and potential argument. Every effort was made to capture the

tone of voice, body language, and degree of emotional engagement.

Simultaneous audio and video devices recorded the conversation following

Catterall’s (34) theory that how people talk about a topic and how they respond

in a situation where they are exposed to the views and experiences of others

is as important as what they say in direct respond to a series of questions.

Indeed, the sequence and evolution of the participant responses did seem to

enrich the data.

As well as a form of data collection, the focus group was intended to be used

to identify relevant content for a more formal quantitative approach (35). My

initial proposal involved scaling up this pilot study into an online survey of all
 27

doctors in the Shriners Hospitals system. I met with three of the six

executives at Shriners Hospitals, each an accomplished researcher and

informaticist, who found this proposal promising and generally aligned with the

system’s overall vision for telemedicine. Within weeks, however, external

pressures related to the management of the non-profit system had forced

leadership to effectively close any external research into Shriners Hospitals.

This circumstance, understandable and unfortunate, caused me to reassess

the pilot study at SLC and to reevaluate its methodology and potential

outcomes. Taking into consideration the business drivers and logistical

situation, research design for this study was amended to focus exclusively on

the qualitative phase. In retrospect, I feel that had I extended the study to a

population that had too few telemedicine programs up and running I would

have run the risk of capturing far too much unqualified information (36). As late

as May 2008, only twelve of the system’s twenty-two hospitals had active

programs and of the twelve only Honolulu and Salt Lake City had programs of

relative stability and maturity. Based on this study’s findings, the fact that this

study remained qualitative does not indicate that it was in any way limited.

Recommendations include the possibility for scaling up to include the twelve

Shriners hospitals currently employing telemedicine (a modification of this

study’s original plan) and also the opportunity to do further Individual

Acceptance research on targeted practitioners within the Shriners system

based entirely on the results of this study.

Methods
 28

Self-contained focus groups have been shown to be a good method for

discovering factors or influences that might not be previously known to the

interviewer or to the participants themselves. Joss and Durant (37), for

example, documented how focus groups have been used to help crystallize

individual opinion, heighten group awareness, and strengthen perceptions of

shared experience within the confines of a presumably static research

objective. As Kitzinger (38) observed, focus groups can give participants the

freedom to form and express opinion through interaction and can also help

the interviewer better understand how the observed interaction can be used to

analyze the results. The focus group also allows for participants to experience

and contemplate the group and their role in the group which can precipitate

further reflection on their own experience, potential interaction outside of

established hierarchy or protocol, and even exploration of an argumentative

approach or play “devil’s advocate”. The focus group is by no means a

controlled environment, therefore, and is ultimately unpredictable. It has been

the source of concern for qualitative researchers such as Fern and Bristol (39)

who argued that the group dynamic can suppress or even polarize individual

opinion, can undermine the building up of consensus, and can result in

unclear outcomes. Conversely, many studies have shown how focus group

interaction yields stronger, richer data thanks to unforeseen and spontaneous

“synergism” (40). I chose a focus group because it seemed to be the best way

to capture substantive data about each physician, including his or her

experience with the technology and, especially, the decision-making process

behind its use.

 29

A common concern going into the focus group data capture is how the

moderator can affect the proceedings. “The moderator must be sufficiently

involved in the group to fulfill the role of facilitator, but not so dominant as to

bias or inhibit discussion (41).” Accordingly, an interview script was designed to

support the focus group by encouraging the experts to speak freely about

their experiences on specified topics. Open-ended questions were crafted

along with somewhat more detailed follow-up questions to help focus on

areas of specific interest. The script was tested with the advisors for this study

and reduced to three sets of questions.c

Telemedicine Ease-of-Use

1) What would you rank your knowledge of the telemedicine system?

2) How frequently are you brought up to date on changes to system?

3) Who keeps you informed of and debriefs you on changes to the

system?

4) How much emphasis is placed on the system?

5) How would you compare your experience with the telemedicine

system with other types of electronic systems currently in place

such as medical records, etc.?

Clinical Value

6) Has the system been shown to improve patient outcomes?

7) Has the system been shown to reduce your work quotient?

c
Interestingly, these three sets of questions were finalized prior to a review of UTAUT and the
introduction of Individual Acceptance model to the literature.
 30

8) Is the system always being brought to your attention in staff

meetings or committee forums?

Institutional Value

9) Did you receive formal training on how to use the system?

10) Are you expected to train yourself on use of the system?

11) Does staff stay fully updated on system capabilities?

12) Is ongoing analysis (utilization, outcomes, improvements)

communicated to staff?

13) Is the system easy to use?

14) Do you feel you are expected to use the system?

While every attempt was made to execute the script, the conversation

inevitably followed its own course. Extrapolation, interjection, and reversing-

of-course overwhelmed the scripted questions; only a few were actually

posed. The participants were excited and willing to speak freely. The

conversation itself generally held to the intent of the script and I tried to lead

the conversation according to the agenda set by the script.

Ethical Considerations

This study involved consenting human subjects and took place in the United

States of America. Full consideration was required, therefore, by University of

Bath, School for Health, School Research Ethics Approval Panel (SREAP)

before work could begin. Issues this study addressed in order to gain full
 31

SREAP approval included detailing how sample representatives would be

recruited and assembled and what blinding measures would be adopted to

ensure confidentiality and anonymity. Additionally, I obtained and processed

first-person quotations through recorded interviews. Voice and video files

have been destroyed in compliance with the UK Data Protection Act. Focus

Group participants can gain access to and make requests for alteration of this

study should they find it does not satisfactorily protect them from damage.

Results

Taken as a whole, the focus group conversation followed a predictable

trajectory; one that allowed the most outspoken members to reveal

themselves and to share their well-formed opinions early and the more

reserved to express their opinions in kind. Regardless of whether he or she

volunteered information early in the conversation, it was clear that each

respondent had a particular point of view that may or may not have been

known by other members of the group before hand. This made for a rich

discussion and provided enough data for later analysis.

The study named respondents by the order in which they made their first

remarks. Accordingly, Respondent One (R1) and Respondent Two (R2)

spoke first and second (and did so in an excited manner). Respondent Three

(R3) had a sort of prepared statement and did not engage in further

discussion. Respondent Four (R4) and Respondent Five (R5) were influential

to the conversation’s narrative and made a number of quite poignant

 32

statements. Respondent Six revealed himself to be an outlier. He was not an

orthopaedic doctor but a burn doctor. His contribution was important to the

flow of the conversation but his responses regarding utilization were not

helpful. Respondent Six should not be viewed as a negative result of the

methodology rather as a by-product of the focus group format.

To facilitate subsequent analysis of data, respondent contributions were

recorded on audio and video media and memoed by the interviewer in real-

time. Individual Acceptance theory’s three factor groupings provided the

structure for the interpretive coding that took place during analysis. Its

managerial, technical, and individual factor groupings neatly aligned with the

survey questions and ultimately with the overarching structure of the

conversation. The subtleties of the conversation were memoed and later

recalled after replay of the interview.

For example, as initial viewpoints were communicated, I notated that

subsequent commentary by an individual often grew more reflective and, in at

least one case, softened over time. Such evolution of opinion was an

expected outcome of the grounded semi-structured approach. The group

setting and Time, itself, seemed to function in a normative way. By charting

responses according to factor groupings along a Time axis, I was able to

visualize the affect the group dynamic had on individual opinion, the

conversation’s stages, and ultimately its themes. That is, by displaying each

statement according to its factor grouping over the course of the interview, I

feel I was able to achieve a greater understanding of the narrative structure

 33

(42)
. The following Focus Group Chart (fig.1) illustrates how literal statements

evolved over Time (where the center represents the end of the conversation

and the outer-edge the very beginning). Placement indicates when the

respondent spoke, what he or she spoke about, and what factor grouping they

touched on. If a respondent chose to touch on all three or a synthesis of two,

I plotted that point closer to another grouping. Respondent One, for example,

spoke about all three factor grouping in his first multi-part statement which are

highlighted below:
 34

Fig. 1 – Focus Group Chart

Evolution of Opinion: Discord and Harmony

According to Sim, Fern and Bristol (39,40), focus group study analysis should

include a study of any normative or suppressive factors that may have

 35

affected the data. By analyzing each respondent’s viewpoints over the

course of the focus group we can see how group interaction may have helped

fix or alter the original position and overall sentiment. As mentioned, the first

three respondents commented that they were unenthusiastic about the

technology and cited a number of specific reasons why it could not be used

effectively. They did so in a decidedly pessimistic fashion. Thanks to the

group dynamic, however, R1 and R2 seemed to come around to a more

broadly accepted opinion. While they still held somewhat antagonistic views

their polarized views seemed somewhat neutralized. As previously

mentioned, R3 made a prepared statement, engaged in short dialogue, then

left. R4 and R5 both started and ended the conversation with positive patient

and outcomes-oriented language that did not change over the course of the

conversation. If any normalization of opinion occurred during the focus group

it served to neutralize the somewhat polarized views of R1 and R2. We can

see the evolution of both respondent viewpoints over the course of the

conversation. Each of R1’s initial statements, for example, represented a

negative viewpoint that was reinforced by R2. Each employed words and

phrases like “problem”, “total waste of time,” “ungraceful,” “compromised” to

describe their experience with the technology and its administration. After

nearly sixty minutes of vigorous conversation, there seemed to be softening of

previous held view. Phrases and words like: “It’s better medically,” “more

effective,” “incredibly good” were used to summarize their viewpoints near the

end in accordance with the overall evolution of the conversation.

 36

R1 used a great deal of first-person experience to validate his negative

opinion. It was as if R1 wanted to make sure his displeasure with clinics

administration was documented in order to justify his unease with or distrust

of the technology. After consideration of others, however, and a strong shift to

discussion of patient expectation and perceived outcomes, his initial view

softened.

Such is also the case with Respondent Two, who after an extremely

pessimistic and negative representation of his experience as, “a total waste of

time for us to sit there for four or five hours and see six or seven patients,”

posited a more constructive approach that suggested, ”a better use of time

and effort would be to have a local pediatrician and if he sees a problem to

send them down.” R2 was clearly the most dissatisfied with the technology

yet he likewise acknowledged the benefit to the patient and the opportunity for

improvement.

Respondent Four, on the other hand, began with a clear acknowledgement

that he felt the clinics were, “patient-driven and … valuable for the post-op for

some simple things.” He continued to discuss the benefits of the technology

and concluded by saying, “it’s better than it used to be.” R4 ultimately held to

his original view which seemed to affect R1 and R2.

Finally, R5 began and ended with the most positive statements of the lot:

“I’ve certainly had some great satisfaction out of a number of cases where

you could actually get some things done and the parents were too busy or
 37

whatever to come down and that’s been actually … good,” and, “I think that’s

just the nature of what we do and how try to kind of triage what’s the most

effective use of everybody’s time and telemedicine gets knocked down to a

lower rung because we’ve got other things going on. It’s better than nothing

in many instances.”

Stages

Bales (43) identified that a group goes through a sequence of stages simply as

a result of its existence as a group. Therefore, in order to more easily identify

and sequence the stages that emerged out of this focus group, I used the

respondent chart to pinpoint those contributions that seem to have impacted

the tenor or tempo of the discussion. The resulting map (fig. 2) illustrates how

the conversation progressed as whole. I was also able to identify which

respondents had a transformative affect on the conversation. In effect, I

sought to identify the substantive statements that served to evolve the

narrative and the normative statements that represented the group’s shared

opinion (44). Plotted on a Time axis, these key statements could be used to

identify the transitions and connectors of each stage. I applied Tuckman’s (45)

theory of group development to help identify the stages I had initially identified

and named as expository, interjectory, climactic, and resolving. His concepts

forming – storming – norming - performing aligned neatly with the stages I had

observed as a period of orientation/testing (expository/forming), then of

conflict (interjectory/storming), then of group cohesion (climactic/norming) and

finally settling on functional role-relatedness (resolving/performing). The

 38

organic emergence of these stages convinced me that the data capture had

been effective, that the focus group method was valid and that the data being

captured could be analyzed on a number of different levels.

Fig. 2 – Stages Chart

 39

Emergent Themes

As Catterall and McLaran (46) posited, there is no proven method of analyzing

focus group results. There are however many techniques that have been

used to analyze the observed interaction of focus group participants,

structurally as well as thematically. In addition to reviewing verbatim content

for word repetition and indigenous verbiage, the researcher can look for

potentially important themes by comparing and contrasting what is said during

the course of the conversation, how it is said, and by whom. Further,

sometimes important information is communicated often by what is left unsaid

during the course of a conversation. As previously shown in figure 2, by

plotting the focus group on a factor grouping and Time axis, I had created

both a stages narrative and a preliminary correspondence chart that served to

identify areas of dissonance and concordance within the focus group (47). A

review of these areas of concordance, including the key-words-in-context and

(shared) metaphor allowed me to identify at least three emergent themes that

I believe were consequential to understanding provider acceptance of

telemedicine at SLC. These three themes were identified in figure 3 as:

1. Confidence in Technology and Continuity of Care

2. Patient Satisfaction

3. Evident Cost Benefits

 40

Fig. 3 – Themes Chart

Confidence in Technology and Continuity of Care

The Confidence in Technology and Continuity of Care theme revealed itself

through a series of initial ice-breaking statements by the first four respondents

 41

and vigorous discussion throughout the focus group. As the first and

strongest concordant theme, it revealed shared experience within technical

and individual factor groupings, specifically level of disruption and self-

efficacy. As previously mentioned, R1 and R2 worked aggressively to set the

tone of the conversation from the outset. It was as if R1 and R2 colluded to

bias the conversation at the outset with their negative view on every aspect of

the technology, administration of the technology, and its affect on their

livelihoods. Comments like: “it’s second class,” “it’s a total waste of time,” “it is

sort of not ideal,” and “it is compromised,” set the tone for the theme.

Frustration with the technology itself was communicated with clear language

and emotion in such statements as:

Respondent One

… in these instances you are talking to a treating physician with legal

responsibility for that patient and you are offering suggestions rather

than trying to treat your own patients in a second-class sort of form

where you really don’t have the best information coming in because

you either cant see the x-ray or you cant trust the exam.

Respondent Two

… on the telemedicine side is the communication issue. The

communication sitting in a room is completely different than the

communication over a TV screen where you may or may not even be

able to see the person you are talking to. And I have a very difficult

time keeping a train of thought, keeping … trying to get information.

 42

Respondent Four

Actually, if someone wanted to transmit the x-rays digitally I don’t think

we have any of our systems that do that reproducibly [sic].

Each respondent grappled with technical issues they felt had been working

against them as clinicians, specifically incompatible imaging and

communications systems. This technical discussion precipitated a more

charged discussion surrounding the corresponding concept of Continuity of

Care detailed by R3 in the concise statement that follows:

Respondent Three

It’s completely dependent on the examiner on the other end. You

know, if you have to have someone that you’re talking through how to

do an exam it’s useless … So sometimes I feel an emotional

disconnect from the patient from that and a really important part of your

practice is being able to emotionally connect with the mom and the kid

and, um, I can’t do that as well in telemedicine.

Indeed, each respondent commented first on how the technology failed as a

tool to extend capabilities then talked about how specific personnel issues

undermined their ability to provide quality care by proxy. R1 lamented the fact

that, “we practice medicine face-to-face and when forced to practice it over

the teleconference … you realize it’s not the same level of quality,” and each

respondent agreed that the practitioner at the remote end of the telemedicine
 43

must be experienced to ensure quality could be delivered regardless of

technology.

Patient Satisfaction

As each respondent tried to reconcile their negative experience associated

with technical factors, the theme of Patient Satisfaction revealed itself. In

particular, the physicians shared concern over how they were perceived as

practitioners. Each respondent acknowledged that “it [telemedicine] is better

than nothing for the patient.” This most concordant sentiment of the entire

conversation was a general acceptance that the technology had the potential

to improve outcomes thanks to patient acceptance if nothing else. R5 spoke

up for the first time with a highly charged and positive statement which

included terms like, “effective,” really like,” and “very, very good.” R1 and R2

seemed surprised by this viewpoint. R5’s influence impacted the Patient

Satisfaction theme which remained positive and aspirational throughout.

Indeed, many of the respondents felt patient satisfaction was a high priority

which in some instances trumped apparent efficacy. On the other hand, the

fact that these physicians were pediatric surgeons may reveal a group bias

that weighed patient comfort, psychological and physical, over all other

factors. Accordingly, the perception that the technology allowed them to be

effective as long as the patient was satisfied was shared by the group:
 44

Respondent Five

As kind of a glorified triage mechanism for problems or calls that

parents have, the parents really like it for the main reason that you can

sit down and talk much more effectively … I’ve certainly had some

great satisfaction out of a number of cases where you could actually

get some things done and the parents were too busy or whatever to

come down and that’s been actually … good.

Respondent One

Its more user-friendly for families who are three hundred four hundred

miles away that have questions to say ‘o.k. you go a mile down the

road or maybe even fifteen miles or twenty miles to do that

telemedicine thing’ and whoever is in clinic just looks at a screen just

like they would in the next room you know ‘you’re doing okay’ or

‘maybe you should come in’ or ‘that looks like it’s a wound and needs

to be seen.’

Within the Patient Satisfaction theme we see the aspirational views of the

respondents who are better able to envision the larger possibilities of the

technology on their practice regardless of how they felt individually about the

technology. Given the perceived limitations of the technology and the

frustration with its administration, the respondents did see value in its use and

agreed on an ideal application for the technology thanks to the perception of

the patient:
 45

Respondent Four

… they have tele-gait lab 2-D video which was actually pretty good,

better than just watching the kid walk, but they have a special hallway

with a video from the front and a video form the side where you can

see, you know … and they can actually send the video then they had a

couple of sessions where they correlate the 2-D video analysis with the

3-D gait lab. It was a pretty good correlation … You can see how they

walk and if they look like they are walking great then … They can go

ahead and do their gait lab and send it to you and in your free time.

Respondent Two

… the telemedicine room would simply be one more room and you

would go in there when the light comes on, meaning the patient is

ready to be examined rather than sitting in front of this TV camera

during all of this downtime … and you go to the next room that’s a live

room here with a patient in it and you don’t come back until the next

telemedicine patient is really ready. That makes our time more

effective.

Such constructive statements indicated that the physicians were curious to

learn more about potential outcomes with technical issues resolved. Patient

Satisfaction as a theme also paralleled the Performing/Resolution stage of the

focus group which confirms this as an important contextual area.

 46

Evident Cost Benefits

The final theme to emerge was one that involved discussion of SLC

administration and apparent cost-effectiveness of telemedicine services.

Respondents seemed to feel Administration had over-estimated the value of

the technology yet had built a fragile support system around its use. They

could understand the rationale for initial investment and remained convinced

of its overall value proposition. R1 and R3 articulated the challenge

associated with running a cost-efficient operation thusly:

Respondent One

I think the problem we run into is the panacea that telemedicine seems

to offer. A system like the Shrine generates a huge push to see more

and more and from the medical side we’re saying ‘you know we’re not

… it’s second class to begin with.

Yes, it does, perhaps, save money but the other shoe is that it’s not

state of the art medical care. It is compromised. And you kind of have

to make it as safe as you can within the constraints of the technology.

Respondent Three

Although I completely appreciate the money it saves the Shrine and I

know it’s a lot more convenient for a lot of patients and they’re very

thankful for that. I always sort of feel like I hadn’t done my job as well

as I could have.
 47

Respondent One

Telemedicine is encouraged, particularly, from the board level. They

look at our numbers and they are discouraged when they go down

because they perceive that it saves them money. Whether, in the big

picture, it [does,] depends on which pot the money comes out of in

order to determine whether it really saves or not because as [R2]

pointed out there’s a lot of assets that go into these clinics some of

which is visible to our Board of Trustees but nevertheless there’s cost

involved … It’s better medically. We’re seeing patients that are more

appropriate …

Respondent Four

On the other side of that equation I think you know early on … you look

at the figures, you look at the travel fund and the costs of paying for the

travel and you have to offset that with the cost of running the operation.

While each respondent had frustrating experiences with technology and

generally felt their effectiveness had been compromised as clinicians, they all

continued to be convinced of the cost benefits that made such a compromised

program “better than nothing in many instances.” That telemedicine as a

concept could be viewed as a cost-effective tool that might not significantly

undermine physician autonomy was an opinion shared by each respondent.

That SLC had somehow failed in its delivery and/or support of the technology

and had undermined physician autonomy was also a shared opinion. The

group held a common understanding of the need for appropriate application of

 48

the technology and agreed that while the technology may have been flawed

and the administration of the program may have needed alteration, the

potential for high-yield outcomes yet remained.

Discussion

Given the long history of this group with its telemedicine program, it was not

surprising that one of the themes to emerge from the discussion was one

focused on pragmatism: cost benefits that justified continued telemedicine

use. The emergence of the Evident Cost Benefits theme, therefore, indicates

that the physicians were in agreement on the concept of telemedicine, its

promise and potential. Despite this overarching sentiment, SLC staff

purposefully chose to limit their use of the technology to accomplish the

revised, sub-optimal objectives of:

1. meeting institutional mandates;

2. minimizing risk to themselves; and,

3. satisfying patient expectation.

What drove them to this behavior was a multi-faceted distrust of the

technology. There is no question that technical and interfacing issues

presented problems. Staff physicians knew additional resources could be

applied to fix incompatibility and latent communications. Staff was more than

a bit frustrated this did not happen sooner and had expected upgrades to

occur much more regularly. Yet what was clearly a more ominous component

to the technical problem was the lack of confidence in the clinic-side

 49

doctoring. Each respondent had negative and possibly frightening

experiences with telemedicine. R1 offered an example of his experience,

shared by many in the group, which indicated how fearful he was of making

an incorrect diagnosis due to the technology:

Once a year, a child will come to us with in-toe which is a very simple,

very common pediatric problem that gets better with time … Once a

year you’re going to find a child with spasticity that the physical

therapist examiner on the other end might not actually find. That child

has a brain tumor. It’s not typical in-toeing; it’s actually neurological.

That’s the fear.

In other institutions, this crisis in confidence in technology and in care

continuity may have forced a program to come to a halt. There are no studies

to tell us how incompatibility issues with technology and inconsistency in

remote skills have affected telemedicine programs. We can only assume that

SLC staff physicians continued to work with the technology because they had

the authority to make adjustments they felt were necessary. As discussed,

the Patient Satisfaction theme represented an acknowledgement that the

physicians knew their patients valued the hospital’s use of telemedicine.

Together, these complex themes illustrate why recent research has focus on

uncovering the complexities of physician acceptance and why Mezni and

Zeribi’s model does a good job of isolating the key factors that contribute to

Physician Perception.
 50

SLC Staff Physician Perception

Telemedicine at SLC was perceived by physicians to carry both positive and

negative attributes. Each physician acknowledged that they felt telemedicine

somehow impacted how they were perceived as professionals. Each felt

compelled to use a technology they felt had very low clinical value. Each

believed that their patients and their families felt good about telemedicine

clinics and that hospital administration, not to mention highly visible members

of the local Shrine temples, expected it to be used as much as possible.

These themes had direct, literal correspondence to the factor groupings. By

charting whether the correspondence was positive or negative, we identified

how the factor groupings impacted the situation at SLC. In some cases no

data existed to support a correspondence which hinted at potentially larger

organizational issues. Identifying these particular correspondences allowed

me to produce a thematic overlay to the factor groupings and definitive

explanation for the SLC experience. Expressed as positive, negative or non-

contributing to the physician decision-making process and the creation of

Physician Perception, the key factors are:

 51

Thematic Overlay

Confidence in
Patient
Technology / Evident Cost Benefits
Satisfaction
Continuity of Care

Individual Factors

Self-efficacy + + +
Planned Behavior + + +
Managerial Factors

Executive-level
Champion

Ongoing Training

Technical Factors

Quality
Measurements

Level of Disruption
-

Taken as a whole, the focus group provided three strong areas of thematic

correspondence across the sample. Based on the progression of stages and

the normalization of opinion over the course of the conversation, I determined

there were too few data to suggest that any single theme was dominant.

While individual respondents may have weighted certain factor groupings

differently in developing his or her own Physician Perception, none were

pronounced enough to resonate as themes across the sample.

 52

Individual Factors

Individual factors dominated the discussion. Despite problematic experiences

with telemedicine, SLC physicians persevered with its use. This behavior

indicates that they cared a great deal about how they were perceived as

professionals. There also appeared to be a good deal of solidarity among the

staff which manifested in competitive (peer) pressure, desire for

control/mastery of technology, and concern about professional status within

the group. For example, respondents spoke often about their intention to use

the technology for its best purpose. Statements like, “I think that’s just the

nature of what we do; to try to kind of determine what’s the most effective use

of everybody’s time. Telemedicine gets knocked down to a lower rung

because we’ve got other things going on,” indicated that each had a definite

idea of what that “effective use” should be and over time each acted upon

those instincts

Staff could not deny the importance the technology seemed to hold for

institutional stakeholders, and for each other, so they found ways to work

around the clinics requirements. They viewed the telemedicine program as a

potential liability and therefore made what they felt were necessary, risk-

adjusted changes to its application in order to meet hospital administration,

Shriners, and patient expectations. Such behavior represented the power of

the normative environment within which they operated. Individual factors,

therefore, seemed to have had an overwhelming impact on Physician

Perception of telemedicine at SLC despite evidence to suggest that the

technology and the administration had failed them in many ways.

 53

Managerial Factors

The telemedicine program at SLC impacted a fairly autonomous and highly

professional staff rather profoundly. By 2003, SLC administration had

implemented and held staff physicians accountable for clinics requirements of

one clinic per month. Whether this mandate was a product of the success

hospital administrators believed they were having and a way to capitalize on

the program’s momentum or whether it was a response to early resistance

they were feeling from staff is unknown. The fact that the mandate was put

in place indicates that the hospital was planning to further operationalize the

technology. According to Mezni and Zeribi’s model, hospital administration is

responsible for recruiting a clinical champion and for providing on-going

training/education as they proceed with a telemedicine program. As Peter

Yellowlees discussed in his Successfully Developing a Telemedicine System

(48)
, the physician or “clinical” champion is the peer and advocate who takes

on the burden of the learning-curve, troubleshoots the technology, and fine

tunes its application.

SLC had a clinical champion early in the adoption cycle and this factor may

have contributed to a sense of competitiveness and of obligation among staff

to employ telemedicine early and often, certainly before any clinics

requirements had been communicated by administrators. With Chief Medical

Officer, Peter Armstrong, SLC had a clinical champion who definitively

associated himself with the success or failure of the program. However,

within 24 months of initiating and driving the program, Dr. Armstrong was

selected to become the Shiners Hospitals corporate Director of Medical

 54

Affairs in 2000. His departure unquestionably affected how telemedicine

would be devalued and potentially underused by the staff he left behind.

The decision to invest in a telemedicine suite at SLC was made by the Board

in 1997 and funded by the Shriners Hospitals system and the local Shrine

Temple in 1998. At a symposium in 1999, Dr. Armstrong made the following

remarks:

The Shriner telemedicine initiative set out to provide supplemental

services by reducing the need for travel and lost time away from work

and home for patients and their families, as well as for Intermountain

[SLC] staff. Beyond supplementing outreach clinics, telemedicine is

expected to enable the SHC-Intermountain to reach additional patient

populations and provide patient and provider education. Ultimately

these services will provide a medium by which Shrine hospitals can

exchange information (e.g., outcomes research) (49).

This compelling language shows an activist, internal champion seeking novel

ways to realize the institution’s mission. Like many in the industry at that

time, he believed the material benefits of streaming voice and data to

transform clinical practice were within reach. Yet within six years of the

launch of SLC’s telemedicine initiative the story had reached its denouement.

Despite a mandate by the administration and high patient satisfaction,

utilization plateaued and more and more clinics were being cancelled. Did

Armstong’s leadership as clinical champion really have such a profound affect

 55

on utilization in the first three years? His name wasn’t mentioned once in the

focus group.

Further, SLC administration rarely upgraded the system and seldom provided

training. There was informal surveying of the patient population to support

outcomes research but the findings were never released. For clinicians who

live and die by outcomes research, the dearth of information in support of

telemedicine utilization within SLC and in the Shriners Hospitals system at-

large amounts to conceptual gap between purported benefits and actual

outcomes. Staff physicians had nothing to turn to within their organization or

even their specialty if they wanted to learn more about the technology and its

effects on their clinical practice. This Managerial factors gap represents a

significant area of speculation and should be a focus for further study.

Technical Factors

Some time early in the adoption process, each staff physician came to their

own conclusion about the potential risks associated with use of the

telemedicine system as it was originally installed. Again, the shared belief

that the technology was conceptually sound and afforded cost benefits to the

institution indicates that staff was willing to use an improved technology that

never came.

Orthopaedic surgeons, more so than other specialists, are governed by their

sense of touch and their ability to observe range of motion, gate, and overall

movement. The disjunction of video interface and audio delay presented a

 56

significant barrier. PACS incompatibility often compounded the poor image

quality of x-rays. In order for SLC physicians to work with absolute

confidence, they often eschewed telemedicine as a clinical tool and scheduled

subsequent visits to the facility for an in-person evaluation. Thus,

incompatibility of imaging systems essentially forced postponement of care.

The telemedicine clinic came to be used and perceived as a stop-gap

measure, a time sink, and a major contributor to discontinuity of care.

Staff physicians were unsettled by the lack of dedicated support for the

system and commented that, “We rely on our IT people here to tell us what

they can do. Neither I nor any of my partners have time to go out and figure

out which cameras are the best, I can assure you … there’s no way I have

time for any of that.” As Tulu Bengisu described in his, Internet-based

Telemedicine: An Empirical Investigation of Objective and Subjective Video

Quality (50), new clinical decision-making scales are introduced with virtually

every new application of telemedicine technology released into the market

today. Without these types of measures in place and programmatic ways to

resolve technical issues it is hard to overcome quality concerns. At SLC,

there were no documented measurements put into place at implementation

and subsequently nothing upon which to base future upgrade decisions other

than anecdotal evidence and ad-hoc IT support.

 57

Conclusions

This study was conducted in order to gain a deeper understanding of the

drivers of telemedicine utilization among staff physicians at Shriners Hospitals

for Children, Salt Lake City. The findings illustrate how Physician Perception

of telemedicine at SLC formed over eight years of use. Using Mezni and

Zeribi’s Individual Acceptance model for analysis, we found that Individual

factors dominated the decision-making process of SLC staff and that equally

important Technical and Managerial factors were simply not present or not

sufficiently powerful to influence optimal usage of the technology. This

imbalance manifested itself over the lifespan of the telemedicine program.

Conscious avoidance of many of the technology’s functions and altered

behavior by the attending staff resulted in a precipitous decline in the success

of the program.

Themes that emerged out of the focus group indicate that SLC staff

physicians were highly concerned with their professional status. Each

physician was aware that her mastery of the technology could somehow

impact how she would be viewed by administrators, peers, and patients. This

sensitivity to professional status represented the most potent driver in a

complex decision-making process. However, professional status alone did

not determine how telemedicine would go on to be utilized. SLC staff felt

compelled to use telemedicine to preserve their autonomy. Yet they

capitulated and changed their behavior. This form of self-efficacy was by no

means motivated by pride or obstinacy. On the contrary, the change in

 58

behavior was an attempt to minimize potential risks staff felt telemedicine

introduced to their practice. The tactile nature of orthopedics coupled with the

extreme sensitivity of pediatric care, concerned SLC staff a great deal. On

balance, they felt the technology severely constrained how they diagnosed

and treated their patients. They responded by subverting the process. The

cause for this deviation can be found in the theoretical framework within which

technology adopters operate. According to Mezni and Zeribi’s model, SLC’s

telemedicine program lacked managerial support, in the form of internal

champions and training which could serve as a continual

troubleshooting/feedback loop for the organization. Additionally, SLC’s failure

to establish quality metrics to help baseline and resolve technical issues

plagued the program from its inception.

Over the lifespan of the telemedicine program, enough counter-intuitive and

costly experience had accumulated so that the staff, as a whole and in tacit

acknowledgement of its autonomy, began to change how telemedicine would

be employed. For treating new patients, for example, telemedicine was

changed from a screening technology to a triage mechanism and finally to an

appointment setting tool. Its effectiveness as a simple follow-up and fitments

tool was challenged due to the poor image and voice quality and constant

concern over clinic-side medical skills. Through it all, SLC staff remained

convinced of the program’s cost-effectiveness. Statements were made

suggesting that the Shrine Temples saved money year-over-year on

transportation and that the hospital was able to reallocate budget for other

purposes thanks to cost-savings in the clinics. Yet, there is little evidence to

 59

support these statements. SLC administration never published its operating

results or established cost-benefit metrics to track these operations and any

material cost savings were anecdotal at best.

Study Limitations and Areas for Further Study

There are two limitations that need to be acknowledged and addressed

regarding the present study. The first limitation concerns the sample size of

this research project. As detailed, this study was based on a single focus

group with a small, yet complete expert sample. It did not necessarily reflect

the experience of other physicians within Shriners Hospitals system. Within

the Shriners Hospitals system, telemedicine programs may vary considerably

in terms of the staff expertise and the extent to which telemedicine programs

have been developed and supported by regional leadership. Additionally, I

purposefully excluded the input offered by Respondent Six who did not meet

the criteria for the study yet may have had additional insights into

telemedicine acceptance at SLC. Future research, therefore, should more

fully explore the variety of program practices at different Shriners Hospitals to

include practitioners outside of the orthopedic specialty isolated for this study.

The second limitation has to do with the extent to which the findings can be

generalized beyond this study. While the applied theory and emergent

themes were effective in helping identify universal characteristics found in the

telemedicine experience at SLC, this study was statistically too small for

broad generalizations. However, the provider organizations performing gap

 60

analysis in anticipation of launching telemedicine can benefit from these

findings.

Additionally, while provider acceptance of the technology has been shown to

be an important component to successful telemedicine adoption, in many

respects the patient is an equal and formidable actor in this delivery system.

Future work should be done to introduce qualitative and quantitative studies of

acceptance of telemedicine and it potential impact of outcomes from patient

perspective. The findings from this study certainly suggest that patient

satisfaction drove physician adherence. More research should be done to

understand the subtle influence the patient has on utilization.

Recommendations

Studies show that a great deal of power resides in the technology-resistant

physician (51). SLC administration, therefore, should not take the physician’s

perception of her status within a substantial normative environment for

granted. Indeed, administrators should attempt to channel a physician’s

desire to innovate and improve by introducing technologies that, at least

conceptually, can be shown to enhance clinical capabilities. Further, hospital

administrators should become equal and opposite partners in technology

adoption by supporting:

1. collaborative end-user feedback and internal leadership via a

clinical champion

2. outcome-based research and user-acceptance testing to support

on-going innovation
 61

3. continuous investment in technology upgrades and user training to

overcome process disruption

Without effective training, support, and outcomes research to show that

benefits can indeed be derived from proscribed use of the technology, so

much of the evidence to support investment is lost. SLC’s experience is an

example of how a promising program lost momentum due to a number of

gaps such as the loss of its clinical champion and poor execution in identifying

and resolving technical issues. While not every provider organization will

share the same viewpoints and experiences as found in this study, a thorough

exploration of staff expectations and values could go a long way in

determining how the Individual Acceptance model can be applied to any

organization’s telemedicine program.

 62

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