Perceived barriers and facilitators to the adoption of telemedicine infectious diseases consultation in southeastern Missouri hospitals

Abstract

Introduction:

Telemedicine infectious diseases consultation (tele-ID consult) improves access to healthcare for underserved/resource-limited communities. However, factors promoting or hindering implementation of tele-ID consults in low-resource settings are understudied. This study sought to fill this gap by describing perceived barriers and facilitators tele-ID consults at three rural hospitals in southeastern Missouri.

Methods:

Twelve in-depth, semi-structured interviews were conducted with a purposively sampled group of information-rich hospital stakeholders from three rural, southeastern Missouri hospitals with partial or no on-site availability of ID physicians. Our literature-informed interview guide elicited participants’ knowledge and experience with tele-ID consults, perceptions on ID consultation needs, and perceived barriers to and facilitators of tele-ID consults. Interview transcripts were coded using an iterative process of inductive analysis to identify core themes related to barriers and facilitators.

Results:

Perceived barriers to adopting and implementing tele-ID consults included logistical challenges, technology and devices, negative emotional responses, patient-related factors, concerns about reduced quality of care when using telemedicine, lack of acceptance or buy-in from physicians or staff, and legal concerns. Key facilitators included perceived need, perceived benefits to patients and physicians, flexibility and openness to change among staff members and patients, telemedicine champions, prior experiences, and enthusiasm.

Discussion:

Our findings demonstrate that rural hospitals need tele-ID consults and have the capacity to implement tele-ID consults, but operational and technical feasibility challenges remain. Adoption and implementation of tele-ID consults may reduce ID-physician shortage-related service gaps by permitting ID physician’s greater geographic reach.

Introduction

Telemedicine infectious diseases consultations (tele-ID consults) use telecommunication and information technologies to provide healthcare to underserved and/or resource-limited communities; they are common and effective means of managing infectious diseases [1–3]. Globally, telemedicine technologies in the management of acute [4–7] and chronic infectious diseases have increased over the last decade [8–12]. Infections managed with telemedicine include community-acquired pneumonia, upper respiratory tract, skin and soft tissue, and urinary tract infections, bacterial endocarditis, tuberculosis, human immunodeficiency virus (HIV), hepatitis C virus (HCV), and HIV/HCV coinfection [1, 8–12]. The potential of tele-ID consults to improve access to care in under-resourced settings is one reason behind an increase in adoption and implementation [2].

A systematic review of 18 studies found clinical outcomes, including mortality, readmission, patient adherence/compliance, patient satisfaction, cost and cost-effectiveness, length of stay, antibiotic use, and/or antibiotic stewardship with tele-ID consults were comparable to in-person ID consultation [13]. Specific to cost-effectiveness, 2012 estimates suggest the Veterans Health Administration (VHA) saved ~$1 billion and $6500 per patient by using telehealth technologies (any specialty) [14,15]. The Infectious Diseases Society of America published two statements supporting appropriate and evidence-based use of telemedicine/telehealth to deliver up-to-date, timely, cost-effective subspecialty care to resource-constrained populations [2,3].

Despite evidence for efficacy, barriers to tele-ID consult implementation exist. A scoping review of 130 studies identified increased provider workload, privacy concerns, and insufficient reimbursement as barriers to adoption and implementation of electronic consultations [16]. Facilitators of telemedicine included remote residence location, timely responses from specialists, utilization of referral coordinators, and incentives for providers [16]. A rapid review of 27 studies on healthcare providers’ perspectives on adoption and implementation of pediatric telemedicine identified several obstacles, including information and communication technology proficiency, lack of confidence in quality/reliability of technology, connectivity issues, legal concerns, administrative burden, and fear of inability to conduct physical examinations [17]. Facilitators included transparent dissemination of the aims of information and communication technology services, staff involvement throughout planning and implementation, sufficient training, and telemedicine champions [17].

However, evidence on barriers to and facilitators of the adoption and implementation of telemedicine for ID consultation is scant, particularly in under-resourced or rural settings, where a lower number of subspecialists practice [16,18 19]. Context-specific pre-implementation research is needed to identify key factors influencing tele-ID consult uptake. This study aimed to identify barriers and facilitators to the adoption and implementation of tele-ID consults at three rural, southeastern Missouri hospitals with partial or no on-site availability of ID physicians. By interviewing a diverse array of stakeholders, including physicians, administrators, nurses, and members of hospital leadership, this study describes potentially transferable lessons about factors hindering or promoting adoption and implementation of tele-ID consults in rural hospitals.

Methods

Study design and setting.

Between July and December 2019, semi-structured telephone interviews were conducted with stakeholders at three rural, southeastern Missouri hospitals with partial or no on-site availability of ID physicians. This study was approved by the Institutional Review Board at Washington University in St. Louis School of Medicine. Verbal consent was obtained for study participation.

Description of study participants

Rural hospitals were recruited based on perceived need for tele-ID consults. Participant recruitment and sampling were conducted through existing contacts at the three hospitals. None of the interviewed persons were ID physicians/specialists.

Data Collection

We developed a semi-structured interview guide which included the following questions: 1) In a perfect world, what would telemedicine ID consultation look like at your hospital? 2) What do you see as barriers to inpatient telemedicine ID consultation at this hospital? 3) What do you see as facilitators of inpatient telemedicine ID consultation at this hospital? 4) What are your ID consultation needs? Specific probes for clarifying information followed questions two and three. Interviews were conducted in English. Audio files were securely transferred to a data storage portal and transcribed verbatim by a commercial transcription service.

Data Management and Analysis

One team member reviewed audio recordings to confirm transcription accuracy. Two research team members with qualitative data analysis experience independently coded the data using an inductive approach (several rounds of naïve coding) followed by a deductive approach (review for predefined categories based on literature review and research objectives) [19]. The two coders resolved discrepancies in coding through discussion to reach a consensus. When consensus could not be reached, a third author was consulted to reach consensus. Auditing of analytical processes and procedures were used to gain perspective and understanding and enhance methodological rigor by increasing confirmability and credibility [20, 21]. The coding process was conducted using a stepwise approach. Coders started with initial independent review of eight transcripts to create a codebook and coding structure. Following a second independent review of the initial eight transcripts, each transcript was assessed for inter-rater agreement leading to a review of the codebook and the coding structure. All eight transcripts were further reviewed and discussed to adjudicate discrepancies in coding until reaching consensus. Finally, coders conducted an independent review of the remaining four transcripts followed by a calculation of Kappa for inter-rater agreement, leading to a second independent review of the same four transcripts, a recalculation of kappa, and final coding. NVivo software (version 12; QSR International, Melbourne, Australia) was used throughout the coding process.

Results

Fifteen participants, including physicians, administrators, nurses, and members of hospital leadership, took part in 12 interviews (Table 1). One interview had three participants (two administrators and one physician) and another had two participants (two administrators, one who was also a nurse). Administrators and leaders included hospitalist managers, chief nursing officers, chief medical officers, business directors, vice presidents, and regional practice administrators. Interviews lasted an average of 17 minutes (range 9 to 26 minutes)

Table 1.

Stakeholders interviewed by their role in hospital

Stakeholder	Numbera
Hospital leadership/administrators	8
Physicians	9
Nurses	2

^aInterviewees could fill more than one role, as there were only a total of 15 interviewees. One interview had three participants (two administrators and one physician) and another had two participants (two administrators, one who was also a nurse). Two physicians reported also having hospital leadership roles. Ten of the 12 interviews were one-on-one.

Several barriers to and facilitators of the adoption and implementation of tele-ID consults were identified and grouped into themes. As shown in Table 2, themes are grouped into seven barriers and six facilitators, including descriptions and illustrative quotes for each. This section describes major themes in detail.

Table 2.

Illustrative quotations of the barriers to and facilitators of telemedicine infectious diseases consultation

Theme	Definition/description and examples	Evidence from the interviews
		Barriers
Logistical challenges	Refers to several logistical challenges to adopting tele-ID consultations including lack of access and availability, longer response time, credentialing/licensure, reimbursement, follow through, follow-up, evolution over time, seasonality, hospital size, staff roles, team dynamics, and training.	“I definitely would need close monitoring and someone available that I could discuss things with on a regular basis. With our ID docs that have been here previously, we’ve had cases where everything looks like it’s headed in the right direction, and things change, and then the whole plan completely changes. I need somebody there and available that when those things change, we’ve got recommendations.” “…and I still had about a three or four-week barrier and that’s a big hospital thing…That’s what we have to go through to get that. We feel like we’ve got everything ready. You still have to get approval from people that only meet once a month.”
Negative emotional response from staff and patients	Indications of nervousness or anxiety, or discomfort due to uncertainty in adopting and implementing tele-ID consults.	“I think that I’m gonna say probably the [ID] provider on the other end was the person that didn’t feel as comfortable with it, maybe. We tried to make the patient feel more comfortable on our end of it, and so if you were not able to really—cuz you can move the camera on your end, and so you can look at everything within the room and the patient. I think the one-piece is knowing if the patient’s feeling nervous or anything like that, or if you need to reeducate something that maybe they didn’t understand or hear.” “I think it’s probably the biggest barrier would be the provider platform to make sure that there’s somebody that if they get started, that they continue with it. The reason I say that is from a resource standpoint from a provider, we’ve had lots of issues with our psychiatry side. They were tryin’ to fill gaps and things, and so it was very difficult to have patients on the books and then they would cancel.”
Lack of acceptance or buy-in from physicians or staff	The absence of staff/physician interest, eargerness and/or acceptance of the need to adopt tele-ID consults	“…there has to be physician and nursing buy-in as well… especially the physician buy-in, because we’re gonna be talking directly to the ID specialists, and more likely than not, we may even be putting in the orders as recommended by the EID [electronic infectious diseases] specialist.” “I guess one of the barriers which comes to mind—because I also did Tele-ICU for several years even before coming to [Hospital]—it was a mixed program, bedside to Tele-ICU. One of the roadblocks was acceptance by staff…Especially the physicians. We noticed that, as you may know, physicians tend to set the tone on whatever unit they’re working in. So, if they don’t accept you and they act in an adverse way to your service, many of the nurses might follow suit.”
Patient-related factors	Perceived patient-related barriers to the use of tele-ID consultations including first-time visit, older age, the severity of illness and transportability. Participants described older age for patient as a barrier to Tele-ID. For instance, they felt that it may be harder for older patients because they may not be experienced in connecting or communicating through tele-ID related technologies.	“I think it was harder for them. That’s why we were tryin’ to explain on the other end, ‘well, here’s what the patient’s doing’. They’re feeling kind of uncomfortable. That was just some communication, loud, that we would take out loud as we were doing it… Then of course, if we had a patient that came in that was very ill, we also have protocols in place on what needs to happen from a rapid response and those types of things, and who do you call.” “I think that the older population is probably a little bit harder for them. When I say that, I’m talkin’ about maybe your more geriatric population because that’s just not how they’ve ever connected.” “Preferably, I’d want something that wheels to the patient, just ‘cause if they’re infected patients, and, you don’t really want them moving around the place. And a lot of times they’re in a brace, or they’ve had something done pretty invasive, at least from the standpoint of joint replacements. Like a temporarily fused knee, or they’ve got a vac [wound-vacuum] on, or something. The less transport involved for the patient, probably the better.”
Challenges in managing, using and sharing Technology and devices	Descriptions of several technology and device-related challenges, including lack of compatibility, device distribution, connection, and the types of technology needed.	“Just I think making sure that there’s connections between EPIC, so that you all are able to document, the physicians are able to see that type of consult. I’m sure you have that process all worked through based on your experience with it already. That would be a concern on our end as far as an operational process.” “We’ve had issues in the past. We’ve got our translation software in the iPad, and some of the nursing staff is a little unfamiliar. I had caught wind that it would be a case where they’d have things set up in our [facility], and we’d bring the patients down. That would be like a dedicated nurse, or someone to help with the technology. Is the way I understood it. I didn’t know if there was any other information regarding that that you know, and what you’ve got there.” “Making sure that we have probably adequate number of devices, so that you don’t have to go seek and search for them would be good to have, so that maybe each tower had its own resource. As far as functional layout, again, it goes back to who’s gonna be responsible for getting the device to people. I think that’s gonna be the biggest challenge that I foresee.
Legal concerns	Descriptions of how aspects of tele-ID consultations may lend themselves to legal challenges or issues	“Then even without his consult note on the chart, it’s like we are doing it, and then under his direction, but it’s like legal aspects of that, too. If something went bad, then okay, why did you do what did you do and stuff like that?”
Concerns about reduced quality of care when using telemedicine	Concerns that telemedicine cannot provide the same quality of care as traditional consultations.	“Well, there’s a couple. One is we happen to be at a tertiary care center that has always had—essentially always had boots on the ground ID. Our staff expect it. Our staff are used to it. They have relied on it, and there is just—I think there is a provider barrier to is telemedicine gonna be good enough? Is it gonna give me what I need from a provider standpoint? However, I think in a smaller hospital, the idea of telemedicine is out there and it’s been done, and they know they can get the help they need; but it’s very foreign to Boone hospital who’s never had to use any kind of telemedicine service.”
Theme	Definition/description and examples	Evidence from the interviews
		Facilitators
Perceived need.	The expressed need for tele-ID consults described in terms of the unmet patient and practitioner needs or service gaps that are likely to be addressed. It also includes descriptions of when an ID consultation would be sought including types of medical procedures or outcomes that might lead to ID consult, whether a consultation is formal or informal, care delivery setting, and volume/frequency of ID consults needed.	“Right now, our ID [Doctor] who we have, apparently, he has to cover so many hospitals right now, technically. There are a lot of patients we have here, like patients with multiple wounds and stuff. Patients with bad pneumonia and stuff. For us, we need someone to guide us…Sometimes a certain patient is on IV antibiotics, PICC lines for the workup and stuff. That’s where we mainly needed ID support.” “There’s a lot of situations where a formal consult really isn’t required, but as long as you have access to the EMR, and as long as you have access to the hospitalist or the attending’s notes and medical records and so forth…” “Do you guys do text messages as well? Like just for quick questions or something? The phone call, like when we call him on the days he’s not here, it’s more of an informal conference. It’s just getting his opinion. He’s not actually viewing the chart and doing all the work.” “Well, I personally think that ID is very amenable to the telemedicine platform. I consider that because I think it’s an intellectual subspecialty that honestly, you can get the majority of your information from reviewing a chart, reviewing lab work, etc., and then having a conversation with either the patient or the referring physician or both. I don’t wanna downplay the ability to examine a patient, but if you can’t lay hands-on, I think is a good specialty for that.” “Tele-ID, I think—ID is one of the specialties for the most part, you don’t actually have to see the patient that much. That kind of works out.” “Usually, in my practice that’s not a lot a year. It’s probably only, I don’t know, five or six times a year that I would be consulting to infectious disease. Consultation is for antibiotic management on infected joint. Usually, we had cultures and things already.”
Perceived benefits to patients and physicians	Describes several ways in which tele-ID consults could be beneficial to patients and physicians. For patients, benefits may include improved patient-provider communication, reduced transportation costs, better patient outcomes and reduced transfers.	“I think it’s a great service for our patients and the community here, especially for these patients that can’t drive or can’t get transportation and things like that. I do think it’s a great service for us actually to be able to provide. It’s just truly, like I said, the resources from a provider standpoint on your end. “ “I will tell you for children, it really, really works well… I mean, for the most part I think that this is the direction that we’re going, and I think that your millennials and all of those, they’re ready for that. I don’t see that that would be a barrier for that age range.” “…sometimes if the patient comes around the weekend if you don’t have ID here for whatever reason, either he’s stuck at different—you know, because ID patients he has to go to two to three hospitals and has to work—the sense is if they’re as busy, sometimes he just won’t even be available on the phone. If we need to have something looked at or something like that, then we need to wait for an extra day or so, which is not ideal. That’s where I think this [tele-ID consult] would really help us and put us in pretty good [shape].”
Flexibility or openness to change.	The expressed willingness to make workplace adjustments related to the use of tele-ID, including the change to new technology or equipment as may be required. Flexibility was linked to openness to new ideas of patient care, younger age, familiarity with technology. The willingness of younger patients use tele-ID consult was considered a facilitator.	“I don’t suspect that with the hospitalist team there would be many barriers either. We tend to be more open to that sort of thing, and new ideas, and ways of doing things that might benefit patients”. “From our standpoint, yeah, we’re ready. Let’s do it. Whatever we gotta do if we’ve got—as long as our patients are taken care of, we’re happy”. “I will tell you for children, it really, really works well…. I mean, for the most part I think that this is the direction that we’re going, and I think that your millennials and all of those, they’re ready for that. I don’t see that that would be a barrier for that age range.” “One other thing, I know that a lot of times we tend to focus on the adult population. I think our pediatrics would appreciate some ID support.”
Telemedicine champions	The presence or availability of staff members who are resourceful, motivated, and able to facilitate the setting up and maintenance of tele-ID consults.	“Like I said, we have not done this really before. I probably don’t have any champions that come to mind. Other than we have CIS, or clinical information services, that are clinical IS people. I think that would be a great champion group of this process as well.” “You talked about champions. We actually have through pharmacy an antimicrobial specialist. I look at that as a partnership between ID and pharmacy…maybe we would have a champion there to really help facilitate the ID consult or infection prevention team… All of those are very integrated services that go hand-in-hand. They would definitely be champions.”
Prior experiences	Prior experiences with traditional ID consults or other types of telemedicine that were perceived to help or inform the adoption and implementation of tele-ID. Prior facilitating experiences could include in-person ID consultations, working with iPad for Interpreters, using mobile EMR equipment, and other tele-ID consults.	“We might be doing certain things. We know how our ID doctors here like things to be done, so we do it in that way. Sometimes as patients change, everyone has their own preference in the way they need things to be done and stuff like that. That’s where we were thinking if this can come in soon, hopefully that would really help us. Help us get people taken care of more efficiently, is what I’m—yeah, we haven’t seen anything bad.” “One thing that we do, we have iPads for interpreters. This is kind of simple, but they are on stands. They are very mobile. They don’t walk away as easily as something that’s just a freestanding iPad, if you will. We also have a process set up for that where they’re placed in one specific location. They’re locked up. The house supervisors are able to sign them out. A process like that works very well. That kind of keeps everything in one location instead of being spread out.”
Enthusiasm	Expressions of eagerness/excitement by participants to utilize Tele-ID consults.	“I think everybody I’ve talked to is, at this point, just thrilled to have any kind of ID availabilities, since we’ve been out of ID now for almost a month, I think.. From our standpoint, yeah, we’re ready. Let’s do it. Whatever we gotta do if we’ve got—as long as our patients are taken care of, we’re happy.” “I think you should start tomorrow.”

Barriers

Barrier: Logistical challenges

Study participants raised concerns about logistical challenges associated with setting up and implementing tele-ID consults. Perceived obstacles included lack of access and availability of tele-ID, longer response times compared to in-person ID, credentialing/licensure, reimbursement, follow-through, follow-up, evolution over time, seasonality, hospital size, staff roles, team dynamics, training, tele-ID physical exam, and informal support. Access and availability were major logistical challenges, encompassing tele-ID provider working hours, the commitment to scheduled consults, ability to answer emergent questions, and consult turnaround time. One participant worried access and availability of tele-ID consults would be inconsistent given their prior telemedicine experiences. Another concern was whether tele-ID consults provide 24/7 coverage. Other concerns included perceived potential conflicts in scheduling tele-ID consults, such as staff and tele-ID provider availability misalignment. Another perceived obstacle was completion of tele-ID consults, referring to situations where appointments may be agreed upon, only to be canceled later. See Table 2 for illustrative quotes.

Hospital credentialing is one of the earliest and biggest logistical barriers [22]. One participant expressed frustrations with licensing application turnaround time, which they perceived could take over six months. Hospital size and institutional review approval bottlenecks were other perceived logistical barriers.

Barrier: Negative emotional responses from staff and patients

During interviews, staff said uncertainty associated with implementing tele-ID consults made them nervous, anxious, or uncomfortable. Staff members with prior telemedicine experience mentioned observing similar negative emotional responses from patients using telemedicine. One participant reported patients and providers expressed discomfort or nervousness using telemedicine because of lack of experience or familiarity with technology. Even staff with prior knowledge or familiarity with telemedicine consults expressed nervousness or uneasiness. Nervousness or uneasiness were linked to logistical issues including finding it “hard to get the camera close enough” or “harder for them to assess the patient or feeling of the room” or achieving smooth communication between provider and patient. Participants with no prior telemedicine experience doubted their collective ability to cope with the additional demands of a new service model.

Barrier: Lack of acceptance or buy-in from physicians or staff

Acceptance or buy-in describes the presence or absence of staff/physician approval or eagerness to practice tele-ID consults. Several participants identified the lack of acceptance or buy-in as a potential barrier to the implementation on tele-ID consults (Table 2).

Some participants felt getting physicians to buy in to tele-ID consults was more important because physicians tend to influence whether nurses are open to change or not (Table 2).

The two quotes (Table 2) suggest that a lack of buy-in or acceptance from physicians and healthcare staff could be a major stumbling block that delays or renders the adoption and implementation ineffective or unsuccessful.

Barrier: Patient-related factors

Perceived patient-related barriers to use of tele-ID consults included first-time visits, older age, severity of illness, and transportability. Participants felt that a patient’s first visit as a tele-ID consult would not always work well, because it would be their first time meeting their physician and there may be a “disconnect” associated with that. There may also be a greater need for “hands on” at a first visit, although overall this may be less of an issue for ID than for some other specialties. Other participants thought older patients might struggle to appreciate or use tele-ID consults because they have less experience connecting or communicating through the requisite technology.

Severity of illness was perceived as another barrier to tele-ID consults. Providing tele-ID consults may be complicated if the patient is not transportable due to isolation precautions, being in a brace, or other situations that inhibit their mobility (Table 2).

Barrier: Challenges in managing, using, and sharing Technology and devices.

Most participants identified challenges related to equipment or technology including software (i.e., InTouch Remote Device, Polycom, Telecart, Translation Software) and devices such as iPads, video cameras, and room setup. Technology or device-related challenges included incompatibility, device distribution, stable Wi-Fi connection, and the types of technology needed. For instance, one participant was concerned about equipment compatibility between facilities of the consult provider versus recipient (Table 2). Another participant raised concerns about adequacy, management, and distribution of devices (Table 2).

The quotes in Table 2 illustrate that medical staff members felt equipment compatibility, stable internet connection, and adequacy, effective management, and distribution of devices were potential barriers to tele-ID consults. To address some of these challenges, one participant suggested a staff member be assigned the responsibility of “getting the device to people.” Participants also said delivering tele-ID consults requires specific technology, devices, and software that may be challenging to set up and maintain.

Barrier: Legal concerns

Legal concerns refer to participants’ descriptions of how tele-ID consults may lead to legal challenges. One participant felt legal considerations could be frustrating to medical staff, because they slow down telemedicine implementation.

One participant identified fears that providing tele-ID consults without proper documentation might result in lawsuits if ID-related care was provided by non-ID providers at the rural hospitals (Table 2).

Barrier: Concerns about reduced quality of care when using telemedicine

Several participants were concerned tele-ID consults might not provide the same quality of care as traditional model of consultations (Table 2). As illustrated in the quote in Table 2, for hospitals and medical staff without prior tele-ID experience, there were concerns about whether tele-ID consults could maintain quality of care.

Facilitators

Facilitator: Perceived need.

Perceived need is the expressed tele-ID consult need, including unmet patient and practitioner needs and service gaps. Interviewees mentioned high numbers of patients with infectious diseases needing treatment/care from overburdened specialists, resulting in service gaps in ID consultation and antibiotic management. Another example of tele-ID consult need was ID physician shortages, which resulted in nurses/physicians feeling poorly supported in providing treatment (Table 2). The prospect of having tele-ID availability was intriguing to several participants, “Whatever help we can get would be great.” Another participant said their hospital had been without ID availability for a month, and they were “thrilled to have any kind of ID availabilities.”

Participants described situations where tele-ID consults might be sought, including for certain types of procedures, whether consults were formal or informal, and different care delivery settings. One indicator of tele-ID consult need was the volume or frequency of consults, i.e. the average number of ID consultations needed per day or month. For example, one participant said, “Right now, Dr. [name, ID specialist] was talkin’ to me. He said that he sees about 20 to 30 patients a day here…”. Participants also described tele-ID consult needs in terms of flexibility; consultations could be provided formally or informally, as an inpatient or outpatient service, in rural or suburban settings (Table 2). Participants did express concern on reaching ID providers informally, wondering how this would work in a telemedicine model (Table 2).

Participants also expressed tele-ID consult need in terms of suitability; interviewees felt not all ID consults needed in-person exams (Table 2). Participants felt ID consults were amenable to telemedicine platforms, which improved perceived acceptability of tele-ID consults, especially with ID physician shortages.

Facilitator: Perceived benefits to patients and physicians.

Participants felt tele-ID consult availability would benefit patients and physicians. Patient-related benefits included access to care and better care experiences, including better patient-physician communication, reduced need for transportation to healthcare facilities, and reductions in transfers to facilities far from where the patients live. Providing tele-ID consults were felt to potentially help patients avoid transportation barriers related to accessing treatment and care in rural hospitals (Table 2). Physicians’ perceived benefits included increased access to ID resources, including technical and informational support, and physicians and nurses’ enhanced ability to provide patient care (Table 2).

Tele-ID consults’ potential to reduce barriers like transportation and hospital transfers were perceived to reduce delays and frustrations experienced by physicians and patients as they await ID’s recommendations.

Facilitator: Flexibility or openness to change.

Participants identified flexibility or openness to change by staff and patients as facilitators to tele-ID consults. Staff flexibility or openness to change was an expressed willingness to make workplace adjustments related to telemedicine, including changing to new technology or equipment (Table 2). The required telemedicine workplace adjustments identified included taking on more or different responsibilities and being open to encountering problems and resolving them.

Participants connected flexibility to change as a facilitator to the adoption and use of tele-ID consults with younger age of providers and patients. One nurse felt tele-ID consults could work well for children and younger adults because of technological familiarity (Table 2). Participants felt younger patients would be more accepting of telemedicine (versus in-person) for healthcare delivery because they are familiar with using technology and are used to communicating using devices. Concerning providers, participants felt younger providers are more open to change and doing things in new ways, like adopting tele-ID consults. For instance, one physician said, “All of our group—in general, hospitalist group, we’re fairly young, we’re more open to change, I guess, than some of the other groups from the hospital”. This quote illustrates a perception that a younger staff is linked with greater willingness to use and adapt to technological changes.

Facilitator: Telemedicine champions

Telemedicine champions were reported to be staff members who are resourceful, motivated, and able to facilitate set-up and maintenance of tele-ID consults. Participants felt introducing tele-ID consults would be a process of change requiring advocates or champions (Table 2). This response suggests expertise, responsibility, and current role can be enablers for an effective role as a tele-ID champion. The same sentiments were echoed regarding the roles of pharmacists and the infection preventionists as champions.

Facilitator: Prior experiences

Participants thought previous experiences with traditional consults (ID or other specialties) and other types of telemedicine (e.g., tele-ICU, tele-stroke) could facilitate adoption and implementation of tele-ID consults. Previous experiences included having provided telemedicine consultation, familiarity with telemedicine technology, mobile EMR equipment, and iPad use for interpreter services. As illustrated in Table 2, One participant explained their familiarity with technology and devices, including having and understanding requisite protocols and procedures to support a smooth tele-ID consult process. Overall, participants’ responses indicated any prior understanding, familiarity, or knowledge of telemedicine provided confidence in the adoption and implementation of tele-ID consults.

Facilitator: Enthusiasm

Enthusiasm describes participants’ expressions of eagerness or excitement to set up and use tele-ID consults (Table 2). The quotes in Table 2 suggest staff interest in ensuring “patients are taken care of” after having been without ID consult availability could facilitate adoption of tele-ID consults.

Discussion

Our qualitative study utilized interview responses from key stakeholders, including physicians, administrators, health practitioners, nurses, and hospital leadership, to identify barriers and facilitators to the adoption and implementation of tele-ID consultations at three rural southeastern Missouri hospitals. Overall, participants described several factors related to adoption and implementation of telemedicine ID consultations, including seven barriers and six facilitators.

Barriers

The current analysis identified seven major barriers to adopting and implementing tele-ID consults. Barriers included logistical challenges such as credentialing/licensure, reimbursement, hospital size and staff roles, and other barriers related to management, distribution and effective utilization of technology and devices, and legal issues. Taken together, this highlights the significant operational and technical feasibility challenges related to adoption and implementation of tele-ID consults. The other four barriers included negative emotional responses from staff and patients, lack of acceptance or buy-in from physicians or staff, patient-related factors, and concerns about reduced quality of care when using telemedicine. These barriers point to the complexities and difficulties around utilization and concerns about the burden to patients, physicians, and other medical staff.

Most identified barriers were consistent with research findings from prior studies conducted across different specialties and geographic regions in the United States. For example, two studies focusing on pediatric programs, and another targeting tele-stroke programs in rural areas both identified licensing and credentialing, reimbursement, usability of technology, lack of physician buy-in as the major barriers to telemedicine practice [22, 23, 24]. Worldwide, technological challenges, reimbursement, and patient specific factors have been previously identified as barriers to telemedicine use. [25]

Though data specific to the use of telemedicine in infectious diseases practice are limited, other disciplines using telemedicine are informative. In the setting of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, barriers to telemedicine adoption were similar to our study, including logistical challenges, quality of care, negative emotional responses, legal concerns, and patient-related factors.[26] In a systematic review of telemedicine for dementia care, logistical challenges and patient-related factors were significant barrier to implementation.[27] A study of telemedicine in pediatrics found that logistical challenges, patient-related factors, buy-in, technology, and legal concerns were all barriers to implementation.[28] A study specific to pediatric care in emergency departments also found legal concerns, logistical challenges, and technology were barriers.[29] In a systematic review of home online health consultations, barriers included logistical challenges, technology, patient-related factors, and legal concerns.[30]

Facilitators

We identified six main facilitators including perceived need, perceived benefits to patients and physicians, flexibility and openness to change among staff and patients, telemedicine champions, prior experiences, and enthusiasm. Healthcare professionals pointed to service gaps, including physician shortages to illustrate need for tele-ID consults, suggesting widespread acceptance among participants of tele-ID as an alternative service delivery model. Additionally, suitability, flexibility, and amenability of tele-ID consults to ID physicians’ everyday practice demands (i.e., precludes driving to remote/rural facilities) was perceived to make it relatively advantageous compared to in-person consults.

Prior studies found that perceived need and having champions, the perceived benefits or relative advantage of telemedicine to patients and physicians, and prior individual experience were key facilitators to implementation of tele-ID consults [22, 23, 31].

In a study on telemedicine for dementia, caregiver prior experience was found to be a facilitator for use.[32] In the setting of the severe acute respiratory syndrome coronavirus 2 pandemic, facilitators of telemedicine adoption that overlapped with our study included perceived benefits to patients and staff and prior experiences.[26] In a systematic review of telemedicine for dementia care, prior experiences with telemedicine was a significant facilitator of implementation.[27] A study of telemedicine in pediatrics found that benefits to patients and staff, prior experiences, and telemedicine champions were facilitators of implementation.[28] A study specific to pediatric care in emergency departments found that benefits to patients and staff, telemedicine champions, and prior experience were facilitators of telemedicine use.[29] In a study of obesity services provided in a rural clinic, facilitators included benefits to patients.[33] In a systematic review of home online health consultations, facilitators included benefits to patients and staff and prior experiences.[30]

Our findings suggest health care practitioners’ enthusiasm and flexibility to implement tele-ID consults are linked to perceived patient/physician benefits, which include convenience, reduced workload, and greater ID physician availability. In addition, perceived need and enthusiasm seem to be unique facilitators to tele-ID consults.

Implications for practice

For clinical practice, our study suggests there is a great need for tele-ID consultation in rural southeastern Missouri, which may be analogous to needs in other parts of the U.S. and abroad. With up to 80% of U.S. counties without an ID physician [34], there is a great demand for ID expertise. Our study suggests rural/underserved hospitals are ready and willing to overcome the barriers of tele-ID consult implementation to best serve their patients.

The SARS-CoV-2 pandemic has led to wide uptake of telemedicine, and there have been several calls to action to maintain telemedicine use beyond the pandemic. Authors have suggested improving training and accreditation of telemedicine, changes to the structure of funding of telemedicine encounters, integration of telemedicine into routine care, improving digital ecosystems, empowering consumers, and using a multi-stakeholder approach, as we have done in our surveys.[35–37] These recommendations are supported by systematic reviews showing that telemedicine did not lead to increases in mortality and its general good clinical effectiveness. [38–39]

Strengths and limitations

One limitation of our study is its small size (n=15 participants), though our interviews represented diverse stakeholders from three unique facilities. Without established relationships with patients at the three facilities, we were unable to gain their insights, which remains an area for future research. However, our results are potentially transferable to situations having similar contextual dynamics, i.e. rural hospitals with partial or no on-site ID physician availability.

Our study has several strengths. We provide necessary evidence of barriers and facilitators to adopting and implementing tele-ID consults in three rural, southeastern Missouri hospitals. Team coding of transcripts provided an additional perspective and enhanced methodological rigor and credibility of study findings. In addition, a unique aspect of telemedicine ID consultation, is the critical shortage of ID physicians in the United States, which is a strong facilitator to telemedicine adoption from our stakeholder surveys.

This study identified seven barriers to adopting and implementing telemedicine ID consultations in three rural hospitals: logistical challenges, technology and devices, negative emotional responses, patient-related factors, concerns about reduced quality of care when using telemedicine, lack of acceptance or buy-in from physicians or staff, and legal concerns. Six major themes were identified as facilitators: perceived need, perceived benefits to patients and physicians, flexibility and openness to change among staff members and patients, telemedicine champions, prior experiences, and enthusiasm. Our findings demonstrate rural hospitals in southeast Missouri have the resources and capacity to implement tele-ID consultations and are keen to do so. Significant challenges related to operational and technical feasibility must be addressed to ensure smooth adoption and implementation. Overall, our study suggests stakeholders in these rural hospitals believe adopting and implementing tele-ID consultations could improve healthcare access, provider effectiveness, and patient experiences.

List of abbreviations

EID

electronic infectious diseases

EMR

Electronic Medical Records

HIV

Human Immunodeficiency Virus

HCV

Hepatitis C Virus

ICT

Information and Communication Technology

ID

Infectious Diseases

Tele-ID

consult- Telemedicine Infectious Diseases Consultation

VHA

Veterans Health Administration