Acceptance of telemedicine by physicians, nurses, and other health personnel was cited by the respondents as being of moderate to high importance in telemedicine evaluation. If clinicians are not comfortable with the technology, or judge that the technology decreases their control over patient care, they may avoid using it, thereby precluding other benefits of telemedicine. Clinical acceptance of a telemedicine application may depend on the degree of confidence the clinician has in his or her clinical findings (e.g., diagnosis) from using the application as well as the clinician's satisfaction with the encounter in the absence of proximate, tactile interaction with the patient.
Evaluation instruments used to measure physician satisfaction with telemedicine have asked questions such as the following: 2
- How would this situation have been handled without telemedicine?
- How was the patient's care affected by this encounter?
- What is the next step for the patient in terms of future care for this problem (e.g., continue with current care, referral, admission)?
- Did current experience make it more or less likely that you would use telemedicine in the future?
- Five-point Likert scales may be used for the following questions:
- Overall, how satisfied were you with this telemedicine session?
- How essential was visual contact with the other site?
- How essential was it to have full-motion video (as opposed to still images) in this encounter?
- How well did the telemedicine equipment work?
Attempts to gauge clinician satisfaction can be confounded by selection bias. Clinicians who are asked about their satisfaction with a telemedicine application are most likely to be those who are currently using it, including those who may have volunteered to participate in a demonstration project. This excludes those clinicians who may have used the application but are no longer doing so, as well as those who did not choose to participate at all. Furthermore, even among clinicians who are current users, those who choose to respond to inquiries about satisfaction may have different perceptions from those that chose not to respond. Evaluations that do not account for selection bias can provide misleading findings. By not tapping the perceptions of clinicians who no longer use the technology or who have decided not to use it at all, evaluators miss out on learning what aspects of acceptance affect the diffusion of the technology into broader, mainstream practice.
Our interviewees stressed that clinician acceptance may depend on factors that extend beyond the clinical aspects of individual patient interactions, to practice patterns and broader delivery and financing issues. For example, the acceptance of telemedicine may depend upon the patient load and capacity of a clinician, and whether the clinician is a generalist or a specialist. For an overextended local GP, it may remain preferable simply to refer a patient to a specialist rather than to take up appointment slots with telemedical consultations with the specialist. Further, the local GP provider may feel less confident performing procedures onsite or otherwise managing a patient when these functions might be better performed by an offsite specialist. On the other hand, a specialist who requires a large population base to stay viable (e.g., a hand surgeon) may welcome the opportunity to expand access to a larger population pool. Other types of users whose acceptance may affect the success of a telemedicine program are administrative and business staff, instructors, and students.
Of course, clinician or institutional acceptance of telemedicine also may be tied to reimbursement status, as well as other financial factors. Hospitals in rural or otherwise isolated areas can be at risk given declining populations or lower occupancy rates. Failure of a hospital can affect the viability of other businesses in a community. With the ability to offer teleconsultations with off-site specialists and other interactions with off-site health care resources, a hospital can increase its attractiveness and utility in the local community. As such, telemedicine can be quite acceptable to clinicians and institutions.
However, as revealed in one of our site visits to a rural telemedicine program, establishing a telemedicine program can have undesirable consequences among clinicians. In this instance, clinicians were being paid a substantial retainer (approximately $100,000 per year) by a hospital in a rural community to be on call during off hours. When a teleconsultation system was implemented successfully, the requirement for local on-call physician coverage decreased, and the hospital lowered the retainer by approximately two-thirds. This was unacceptable to the local physicians, who countered that they would no longer be on-call. Consequently, the telemedicine program was forced to discontinue its use of teleconsultations during off hours.
Clearly, evaluation of clinician satisfaction with telemedicine must account for selection bias and must consider the broader professional, delivery, and financial context of health care. Evaluations may take measures to avoid selection bias in a manner analogous to "intention to treat" analysis used in clinical trials; that is, satisfaction data can be collected from all clinicians who were offered, or who initiated but did not necessarily sustain involvement in a telemedicine program. Evaluation should not be limited to satisfaction derived from individual patient interactions, but should account for factors such as the impact of telemedicine on patient load, adequacy of reimbursement for telemedicine-based services, and the viability of professional practice and institutional status.