A universal definition of telemedicine has not been agreed on, due to the ever-changing landscape of technology and its use by health care professionals.1–3 However, various definitions have a common key concept: providing health care services at physical distances using technology.1–4 Health care services that are provided through telemedicine include prevention, diagnosis, and intervention for injuries and conditions.5–8 Numerous health care settings use telemedicine due to the various services that it can provide.8–13 Currently, health care systems using telemedicine in clinical practice include, but are not limited to, burn centers,9 neonatal units,10 pediatric primary care,13 veterans hospitals,11,12 organizations serving rural areas,14 and prisoner medical units.15 Telemedicine treatment results have been favorable for many conditions, including stroke,16 dermatology,17 and mental health.18 There are multiple benefits for patients and health care providers. Patients report easier access to care, improved communication with providers, and higher quality of medical services received.19,20 Providers have cited increased productivity, improved coordination of care, collaboration with other health care providers, decreased anxiety among family members while building patient care goals, and easier access to direct care.12,21,22
Despite the numerous benefits reported in the literature, multiple barriers exist for implementing and using telemedicine. A systematic review identified barriers existing at the system, clinician, and patient levels.23 Cost and reimbursement were concerns identified by health care organizations, along with liability and confidentiality considerations.23 Other barriers identified were perceived difficulty of training health care providers12 and the technological ability of staff,23 cultural resistance to change,23 patient education level,12,23 equipment issues for patients or clinicians,12,22 and time required to schedule telemedicine visits.22 Additionally, the wide scope of delivery options of telemedicine may make it difficult for clinicians and patients to identify and overcome barriers. The scope of delivery for telemedicine includes telephone calls, text messages, smartphone applications, video conferencing, and remote monitoring through wearable sensors.19
A plethora of options may make telemedicine appealing to the athletic training profession because athletic trainers practice in various settings. Telemedicine could be beneficial to the skillsets of athletic trainers when potential benefits of this health care delivery method are assessed. The Board of Certification's 7th edition of the Practice Analysis lists injury and illness prevention, assessment and diagnosis, immediate and emergency care, therapeutic intervention, and health care administration as the domains of clinical practice.24 With a wide scope of practice, it is reasonable to consider telemedicine as an option of health care delivery for athletic training; however, the concept and delivery are fairly new to the profession. To our knowledge, there are two published reports that investigated telemedicine use by athletic trainers.25,26 However, both of these investigations intended to examine the perceptions of telemedicine after the new delivery method was implemented.25,26 Currently, there is a lack of evidence regarding athletic trainers' experiences with telemedicine for those with a previous and established history of use in clinical practice. Therefore, the purpose of this study was to examine the lived experiences and perceptions of telemedicine in the practice of athletic trainers.
Study Design and Participants
We used a partially mixed sequential dominant status design27 and recruited a convenience sample of credentialed athletic trainers from a national survey. Participants (N = 512) had to self-identify as a user (n = 214) or non-user (n = 298) of telemedicine based on a provided definition in the survey, which was explained as the “use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include video conferencing, the internet, store-and-forward imaging, streaming media, and wireless communications” (p. 2).28 Data from this study are not provided in this article but did influence the sequential order for recruitment. The second phase of the study, the qualitative interview, was guided by interviewing the experiences of athletic trainers who self-identified as users of telemedicine from the provided definition. The telemedicine users were asked to participate in a follow-up interview in which 121 participants consented to do so. From this sample, 11 athletic trainers (females = 6, males = 5; age = 37 ± 12 years) responded to the email to schedule the interview and completed the one-on-one interview. Recruitment of additional participants was discontinued when we reached data saturation. Table 1 provides demographic characteristics for the participants. All participants initially provided electronic consent to participate in the survey and provided follow-up contact information in the first phase of the study for which the study was approved by the institutional review board of Indiana State University. All participants then provided verbal consent during the interview prior to enrollment in the second phase of the study that was approved by the University of South Carolina's institutional review board.
Participant Pseudonym and Descriptive Characteristics
One researcher (ZKW) scheduled and completed one-on-one audio interviews using a web-based platform (Zoom Video Communications, Inc). Scripts were created by an athletic trainer with contemporary expertise in telemedicine (ZKW) and reviewed by a researcher with a background in qualitative methods and telemedicine (KEG). Interviews were recorded and lasted approximately 15 to 30 minutes. The interviews followed an interview protocol (Table A, available in the online version of this article) that sought to obtain demographic information, participants' definition of telemedicine, and their perceptions related to telemedicine use in athletic training. Following the interview, automatic transcription was completed using features provided by Zoom and checked by members of the research team for accuracy. Trustworthiness was established with multiple researchers' analyses, an external auditor, and transcription credibility checks by research team members who did not conduct the interviews.
Data were analyzed using the consensual qualitative research tradition.29 A three-person data analysis team (ZKW, ADM, MMK) convened to analyze data following a multi-phased approach to identify emergent domains and categories. Data analysis included external review by a fourth member of the data analysis team (KEG) with prior experience with consensual qualitative research and telemedicine research.25 Data were analyzed to determine the frequency of the categories within the sample. A category was considered general if it applied to all cases, typical if it applied to more than half of the cases, and variant if it applied to more than one but less than half of the cases.29
The experiences with telemedicine had three emergent domains from the responses: (1) impressionable state, (2) concerns with implementation, and (3) connectedness. The domains and categories and the frequency of the categories are listed in Table 2. Supporting quotations from the interviews are provided for each of the domains and categories in Table 3.
Emergent Category Frequency Count
Participants were in an impressionable state by which their perceptions of telemedicine were influenced by mentors, jobs, and third-party insurance companies. Individuals shared experiences with telemedicine and reflected on how they were introduced to it. Two categories presented during interviews. The first category involved influence via mentors, people, jobs, and past experiences. The second category involved curiosity and desire to know more. Participants' perceptions of telemedicine were influenced by various experiences, including exposure in formal education, discussions with other professionals, and allotments of private health insurance companies. Two participants were influenced by a third-party payer for health insurance related to implementation. Participants expressed a desire to know more about telemedicine, including more training on its use. There was also curiosity regarding telemedicine being an avenue for growth in the profession. The lack of adoption at the current time was perceived to be driven by a social normative culture that is resistant to change.
Concerns With Implementation
Participants noted concerns with implementation of telemedicine in their practice including feasibility, thoughts on the end-user experience, and novice knowledge relative to telemedicine. There was concern with implementation feasibility and telemedicine use in athletic training, citing that it was not feasible for scenarios where hands-on patient care was typical. The lack of physical touch in post-surgical cases was a consistent concern.
The patient's experience in using telemedicine was also a theme across participants (10 of 11). Administrative concerns such as information technology and ancillary staff support to assist with technology were noted. Participants identified needing to have technological support for day-to-day operations and in the event of a disruption of technology operation. The athletic trainers were concerned with privacy and patient preferences and noted their level of experience and access to technology influenced these thoughts. Fees associated with telemedicine and whether third-party payers would reimburse services was a concern, and the idea that patients may be negatively influenced in their decision to use telemedicine if health insurance companies did not reimburse services.
Finally, concerns with implementation also focused on a clinician's skillset. There was a perception that more formal education is needed in all levels of the profession. The athletic trainer's experience level as a health care provider was noted as important, with the perception that telemedicine providers would have to be skilled in interviewing patients to make up for a lack of hands-on patient evaluation. The need for education and training in telemedicine use was noted. There was also a concern about the barrier of time management for the clinician, with a novice user perceiving telemedicine as inefficient.
The connectedness domain incorporated education, collaboration, and immediacy of interactions that were completed using telemedicine. The category of education emerged throughout the interviews. Participants noted the importance of students and clinicians engaging in learning via telemedicine, and some described the use of video communication with expert clinicians performing surgery or lectures on patient care from a distance. Telemedicine was also described as a platform for patient education, and the ability to incorporate telemedicine in practice was thought to benefit the patient. The benefit of collaboration was noted throughout the interviews, in that athletic trainers felt they were able to connect with health care providers, including specialists, easier via telemedicine. Ease of access to care was consistently described as a benefit of telemedicine. It was thought to especially benefit patients with barriers to scheduling traditional medical care. Overall, perceived benefits of telemedicine expressed by participants included the ease of access to health care for patients, the ability to triage, and quicker determination of a care plan.
Telemedicine use in clinical practice dates to 1959, with a surge of recognition in the 1990s.4 Although telemedicine has existed for some time, its use in athletic training is not common. Because telemedicine is new in athletic training, perceptions of clinicians who have self-identified experience with telemedicine have remained unknown. Our study found that athletic trainers who have experience with telemedicine had numerous concerns regarding implementation into athletic training practice.
The feasibility of providing quality care through telemedicine was the participants' main concern. Specifically, respondents questioned the ability to perform orthopedic evaluations and health care services without hands-on care. Scenarios like a catastrophic event or post-surgical cases were given as examples where telemedicine feasibility would struggle. Additionally, accurate diagnosis was called into question due to the lack of physical touch that is common with face-to-face interactions. However, this concern may not hold true for orthopedic injuries. A previous investigation compared diagnostic findings of telemedicine to conventional physical therapy and found an 86% agreement between examination findings.30 The concern of quality of care found in our study appeared to be dependent on the athletic trainers' level of experience. It was noted that newly certified and young professionals may lack clinical interviewing skills needed to be successful when using telemedicine. Previous research reported a barrier of providers not being proficient in facilitating telemedicine consultations.31 Therefore, organizations looking to provide telemedicine services should consider the athletic trainer's competency in subjective assessments. A framework for health care competence involves work experience, in-service training, and education.32 A neurovascular fellowship program provided physicians with telemedicine training for a minimum of 8 weeks.33 Participants were oriented with the telemedicine network while shadowing interactions with stroke patients before conducting telemedicine consultations independently.33 More than 62% of fellows reported that the telemedicine education and training they received was beneficial, and 81% of fellows reported that telemedicine training should be required for the accredited vascular neurology fellowship.33 The current study also found that novice clinicians of telemedicine would be a barrier to implementing the service within a clinical practice. This concern could be addressed by organizations providing training like that of the neurovascular fellowship program.33
There was also a perceived lack of resources for athletic training program educators and a desire to provide students with telemedicine experiences. Two participants stated they had not learned about telemedicine during their professional education or in clinical practice until pursuing a post-professional Doctor of Athletic Training degree. A previous investigation of telemedicine training for athletic training students demonstrated that a 2-week intervention improved the ease of use and perceived attitude toward telemedicine.26 Therefore, we suggest that athletic trainers seek opportunities to learn telemedicine for consideration of use in clinical practice, because it may not be formally offered in continuing education planning or in professional athletic training programs.
Clinicians' willingness to adopt telemedicine may be based on their level of education, training in telemedicine, and comfort level with technology. The perceived ease of use and usefulness of technology are two components in the theoretical framework for the acceptance of technology.34 The current study demonstrated the perception that a younger clinician is comfortable with technology and may use telemedicine as a method to obtain a second opinion on a case. Although our study provided positive perceptions of telemedicine use by young clinicians, differing perceptions were seen in the findings of van Houwelingen et al,35 where nursing students in Generation Z (individuals born between 1996 and 2010) were not interested in becoming trained in telehealth activities. Such findings may be explained because students were polled, and our study examined perceptions of practicing clinicians. It can be argued that students are focused on learning skills necessary for job acquisition, which does not include proficiency in telemedicine at the current time. However, practicing clinicians may be able to demonstrate a positive outlook on telemedicine if they see it as a simple addition to their clinical skillset.
Finally, athletic trainers reported concerns with the feasibility of implementation. Previous research noted the importance of the telecommunication network, including signal quality and reliability of connections, when implementing telemedicine services.4 Evidence from a systematic review listed low network bandwidth of a patient's dwelling as something that would impede implementation.23 Our study supports the notion that a strong network connection is important when considering the feasibility of implementing a telemedicine service.
Our study demonstrated concerns regarding the patient, including privacy, experience, and preferences. Ease of telemedicine use by the patient was also a perceived concern. Participants mentioned the possible difficulty for patients to obtain equipment needed for telemedicine visits and/or understand how to operate the equipment. A patient's understanding of how to operate the technology used in telemedicine is one of the most common barriers discussed in the literature.31 Inability of patients to operate technology may lead to difficulty in clinical diagnosis if visual observation is required (ie, poor image clarity or real-time video31). Our results demonstrated the concern that older patients may not be technologically savvy, which was supported by a systematic review that identified age and computer literacy as factors impeding technology use.23 Additionally, older patients may find decreased value in telemedicine encounters due to a lack of face-to-face interaction.36
Another barrier identified was the potential fees for patients using telemedicine services. Participants reported the concern that telemedicine visits would not be reimbursed by health insurance companies. Therefore, patients may decide against a telemedicine visit if their insurance company declined service reimbursement. The main issue regarding insurance reimbursement is the requirement of a face-to-face consultation that involves the patient and provider physically being in the same room.4 However, in some states the use of real-time consultation between a provider and a patient is acceptable for reimbursement services.4 Third-party payers were found to not only potentially influence a patient's decision to use telemedicine but also influence athletic trainers' perceptions of telemedicine. One participant was involved in a discussion regarding telemedicine implementation at the worksite after a private health insurance company approached the health care organization in hope of providing consumers with lowered price points. Another participant's perception of telemedicine was influenced by a health insurance company after learning that the insurance policy allowed access to care at a discounted rate. Both examples demonstrate the potential benefit of lowered health care costs using telemedicine. A systematic review found that, although there was evidence to support reduced health care costs through telemedicine, the limited amount of cost-effectiveness studies makes it impossible to formulate a conclusion regarding the financial benefit of telemedicine.37
Our study found that participants identified numerous benefits of telemedicine, including being a resource for patients who cannot attend a traditional appointment. Various reasons were given why it would be difficult to have a face-to-face appointment, including a conflicting work schedule, having young children, or being homebound. It has been estimated that for more than 2 million U.S. citizens, a barrier to receiving timely access to primary care was due to not having access to transportation.38 Telemedicine allows for access to health care in patients' homes, which could potentially influence their willingness to schedule appointments.
Our study illustrated the perception that there was increased adherence to follow-up appointments through telemedicine. One participant noted that prior to implementing telemedicine there was low adherence to follow-up appointments at their clinical setting because patients traveled considerable distances for surgery by an orthopedic physician. Although patients were willing to travel for surgery, they were less likely to travel for a follow-up appointment. However, when telemedicine visits were implemented, patients were more likely to attend follow-up appointments. A prior study that investigated telemedicine use in family practice found telemedicine a viable option for routine follow-up appointments.39 Another participant in our study found benefit in time efficiency by scheduling telemedicine visits with a team physician instead of driving long distances for appointments. Telemedicine serves as an access point to health care while alleviating unnecessary emergency department visits and providing appropriate referral and patient education. A previous study highlighted that telemedicine access can potentially cut costs through the reduction of local emergency department visits.40
Limitations and Future Research
The current study had the limitation of recruitment through self-identification as a telemedicine user in a national survey; however, it was unknown how frequently telemedicine was used or participants' experience level with it. The perception that athletic trainers are novice in their education and experience with telemedicine demonstrates the need for future investigations to examine the prevalence of formal educational opportunities of telemedicine use at the professional and post-professional levels and within professional development opportunities specific to athletic training.
Implications for Clinical Practice
Athletic trainers expressed a patient-centered approach to telemedicine with positive thoughts relative to access to and coordination of care. Although numerous benefits of using telemedicine were identified, the feasibility of implementation and the patient experience were concerns. Concerns also included limited access to technology resources and a lack of education related to telemedicine. This study highlights the importance for athletic trainers to seek educational opportunities regarding implementation of a telemedicine service within their setting for the benefit of their patients.
- Sood SP, Bhatia J. Development of telemedicine technology in India: “Sanjeevani–” an integrated telemedicine application. J Postgrad Med. 2005;51(4):308.
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- Holt B, Faraklas I, Theurer L, Cochran A, Saffle JR. Telemedicine use among burn centers in the United States: a survey. J Burn Care Res. 2012;33(1):157–162.
- Armfield NR, Donovan T, Smith AC. Clinicians' perceptions of telemedicine for remote neonatal consultation. Stud Health Technol Inform. 2010;161:1–9.
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- McConnochie K, Wood N, Herendeen N, ten Hoopen C, Denk L, Neuderfer J. Integrating telemedicine in urban pediatric primary care: provider perspectives and performance. Telemed J E Health. 2010;16(3):280–288.
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- Henderson J. The 2015 athletic trainer practice analysis study. Omaha, NE: Board of Certification. 2015.
- Winkelmann ZK, Eberman LE, Games KE. Telemedicine experiences of athletic trainers and orthopaedic physicians for patients with musculoskeletal conditions. J Athl Train. Published online July 21, 2020. doi:10.4085/1062-6050-388-19 [CrossRef].
- Winkelmann ZK. Impressions of Telemedicine in Athletic Training Education. Dissertation. Indiana State University; 2019.
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Participant Pseudonym and Descriptive Characteristics
|Pseudonym||Age (y)||Sex||Experience (y)||Current Job Title||Current Job Setting|
|Carole||25||Female||3||Assistant Athletic Trainer||College/University|
|Charlotte||57||Female||32||Professor & Administration||Academia|
|Christine||27||Female||4||Athletic Trainer||Secondary School & College/University|
|Julianne||40||Female||16||Clinical Education Coordinator||Academia|
|Mike||29||Male||6||Athletic Trainer||Physician Practice|
|Nick||35||Male||14||Wellness Director & Small Business Owner||Clinic & Entrepreneurship|
|Rick||27||Male||5||Assistant Athletic Trainer & Mental Health Liaison||College/University|
Emergent Category Frequency Count
|Domain and Category||Counts||Frequency|
|Concerns with implementation|
| End user||10/11||General|
|Impressionable state–influence||“…I had heard whispers of it in my undergraduate education, but I never really learned much about it until I was in a Doctor of Athletic Training program at XXX, where we actually kind of explored what it really is and how you can use it in your practice in different ways.” (Christine)|
|“. . .We were having a discussion with a NATA representative for third party reimbursement. I know our state organization was behind this meeting and our service line director for orthopedics was on the call that he actually brought up that he was approached by a large private payer in the area for us to come up with a way to deliver an alternative access point for clients of this insurance company.” (Pete)|
|“It was actually offered as a benefit to the employees where I work. It is part of the school's plan. So, the school has a really good health and mental counseling and medicine program, and we have access to it for a very, very discounted rate.” (Julianne)|
|Impressionable state–curiosity||“As an educator, I [would love] resources and how to get them used to doing telemedicine [in a] particular [system or] what it might look like in a larger [health care] system by document[ing] telemedicine with them. So, I don't really know what that would [look] like [but I would love any] resources that can be provided in that way.” (Cecelia)|
|“With athletic training people are too stuck in their ways, they're too old school to look at it as a viable option, but I see it as something that can really, really drive the value of the profession forward.” (Nick)|
|“I feel like there's a lot of untapped potential in it, you know as the I hate to say it, but as the older physicians make their way out.” (Mike)|
|Concerns with implementation–feasibility||“And so, from a barrier standpoint, you know, once we get people to staff it, the access is there. That is one of the barriers is having that ability, but it would be, you know, setting up the communication.” (Tom)|
|“. . .A catastrophic injury or some sort of surgical procedure I would find to be rather difficult because of the hands-on human touch component that's probably necessary for recovery there. So that would be another barrier. If somebody were to try to do [post-surgical] telemedicine, which I don't know how feasible that really is.” (Nick)|
|“Definitely another barrier is obviously the physical touch aspect of it, let us say 3 months [postoperative] that have an ACL. You can really feel and make sure that the graft is intact and really in there. So, you kind of have to go based on what the patients are telling you.” (Rick)|
|Concerns with implementation– end user||“. . .A barrier would be people who don't have access to the internet. I know people who do not really have the internet on their phone. I do not know what packages, they have a plan, but they do not have internet, they can just talk and text. Another barrier would be the older community. They are not technologically savvy.” (Julianne)|
|“. . .I know it's not necessarily HIPAA compliant. So, anybody can have access to my phone. I know my family does, so it definitely doesn't fall within HIPAA which frustrates me as a clinician, but it's also a tradeoff.” (Carole)|
|“The next five years they'll probably be defined by payers when private payers start really reimbursing for telehealth and learn different levels. That's going to help to find things further down the road.” (Pete)|
|“I feel like it is going to take off at some point obviously as soon as insurance companies start to evaluate it as a great tool in medicine. I feel like there is a lot of untapped potential in it. . .as the I hate to say it, but as the older physicians make their way out of practicing and the younger physicians that are coming in [will] initiate that change just because they're so used to [it]. You know, a resident that's in a second year residency right now, maybe a little bit more comfortable with FaceTime. For a wound check. . .they want to get a separate set of eyes on it as opposed to a physician in their 50s and 60s and 70s [who is] still practicing.” (Mike)|
|Concerns with implementation–novice||“I think it's going to take somebody with a certain amount of experience able to facilitate through this, because once again, you got to think differently to think of how you're communicating over a phone [and] or a computer with audio, video. [You have to be] a little bit more in tune with your evaluation process so that you're thinking of what is it you're going to say to them, to get them to do certain things for you to be able to see over the phone that helped guide you better [part in this] processes.” (Pete)|
|“I think that more modes of [practicing] telemedicine could be provided whether the programs that we can simulate telemedicine with students or, you know, maybe trained clinicians on telemedicine…but more systems in which we can orient [them] to what [a telemedicine mode] might look like.” (Cecelia)|
|“So I've found that it can just be a little bit more efficient for everybody's time which you wouldn't thinkthat would be the case, or at least that was one of my perceived barriers when I first was learning abouttelemedicine.” (Christin)|
|“It takes a little bit to get used to. Communication is key if you are not a natural communicator. Or if you are not somebody…I have seen a handful of new grads, try it and really struggle because they don't have the clinical interviewing skills that other people have.” (Pete)|
|Connectedness–education||“It opens up the opportunities for the students to hear people around the country or even around the world.” (Charlotte)|
|“We put this under a patient-centered approach of having the patient have an increased access to information and to have, even if it's just questions, reassurance, and education about what their condition is.” (Tom)|
|“It can be goal setting and it can be giving them an exercise plan, updating [an] exercise [plan], reviewing food journals. A lot of these other things that are more of a follow-up or check-in process, they do not need to be in person.” (Meg)|
|Connectedness–collaboration||“It seems to be quite beneficial, especially if they're talking to a professional that is [staying] on the West Coast and you're on the East Coast and you're trying to work through whatever malady that the patient may have and that physician is experienced and like they are one of the best in their field for that condition.” (Rick)|
|“I've used another one for a staph infection that wasn't being treated correctly. I was able to conference with a doctor in infectious disease, and they were able to kind of order tests that would hopefully lead to a better care plan.” (Christine)|
|“What I do use it for, like I said before, was getting results in our [MRIs] talking with a physician about plan of action or plan of care.” (Carole)|
|Connectedness–immediacy||“Ease of access. Like I said, just as far as scheduling and not having to leave the house, especially for parents with young kids or ultimate work schedules.” (Meg)|
|“…It is allowing access into the medical system and that initial evaluation of, is this something that needs to be responded to very quickly, is this something that can we can wait till the next day or two days, and the other advantages it [gives] the patient, you know, immediate information. . . .” (Tom)|
|“…So that's changed my practice in the sense that I'm able to directly communicate with my physician or head athletic trainers to get answers that are quicker, and that way I can provide better care and go ahead and administer whenever I need to [administer]. So knowing an MRI is negative or knowing the plan of action for a patient gets me to be able to do that in that day as opposed to waiting, maybe days or weeks to see a physician in person. I am able to go ahead and get a jumpstart on treatment and we have. And that's been a huge benefit.” (Carole)|
Please discuss what telemedicine means to you.
How did you first learn about telemedicine?
What type of technology do you use for telemedicine?
Can you describe when and why you decided to start using telemedicine?
What are some advantages to using telemedicine in your current job?
What are some barriers to using telemedicine in your current job?
What do you do to navigate those issues or concerns?
Can you describe how you use telemedicine?
8. Can you describe how telemedicine has changed your clinical practice?
Specific patient cases
Domains of practice
Provider to provider, provider to patient
Use of a facilitator
Has this impacted your patient outcomes?
Has this impacted your interprofessional collaboration?
Can you describe how you changed your clinical practice for telemedicine?