Table 4.

Barriers and facilitators to patient acceptance of the eOR.

Organizational Policies, Procedures, Environment, and Culture: internal structures and policies guiding clinical workflow
Barriers	Privacy concerns	As long as there were security measures in place with regard to my privacy, I don’t see an issue. I think I’d prefer monitoring being conducted by professionals here in this country so that I would know they would be following a standard of care required by law. I would like to know what happens to the data after the surgery. – P133 There is no privacy among [clinicians] in attendance [of my surgery]. – P134 My privacy is being invaded (through eOR use). -P137 [There is a] potential loss of some privacy (during surgery). – P193
	Increased costs to hospitals or patients (e.g., resource wastage, insurance coverage, payment increases)	I just do not understand the theory of what advantage [eOR use during surgery] would provide. It just seems to add cost with no improvement in outcomes. It seems wasteful with more people involved than the job requires. – P2 I’m concerned that even though you said [eOR use] won’t affect the costs of surgery, it really will - because someone will have to pay for the associated computer monitoring costs…I would wonder if my health insurance cost will go up again because of this. – P58 There are several doctors and nurses are involved in a single surgery… maybe [telemedicine use] increases the cost. – P244 Even if [remote monitoring] doesn’t cost me anything, it costs somebody something. Maybe there would also be false alarms [from the eOR] that could interfere with the surgery. – P277
	Resource shortage	The additional tracking [from the eOR] may create a shortage of staff, causing other surgeries to be pushed back or delayed. – P242 [Staffing the eOR] might take doctors away from other patients. – P290
Facilitators	Checks and balances (i.e., between eOR and OR teams)	I feel transparency (between team members to hold each other accountable). – P111 Better checks and balances for the anesthesia teams (to speak up if there are concerns). – P37
Hardware and Software: technology within the OR and eOR required to run the applications (i.e., computer, monitor, data display devices, data entry devices)
Barriers	Technological errors leading to communication and information transfer failures or false alarms	The computer [in the eOR] could malfunction. – P110 Well, I suppose something could happen to the connection, and they’d lose monitoring capability. – P77 Something could get in the way of communication [between eOR and OR clinicians] at a bad time. – P80 [eOR clinicians might have] slower or worse form of communication with the surgical staff. – P113 Maybe there would be false alarms that could interfere with the surgery. – P277 False alarms [from the eOR clinicians could] lead to over-druggings. – P144 [Use of remote monitoring] is a good idea, but what if something goes wrong in the communication. Are there any monitors in the surgery room for the surgeon to look at also, or is it just in a separate room? – P315
Facilitators	Use of advanced technology (i.e., telemedicine)	Technology can be good [for remote] monitoring – P25 Advanced technology (is) very useful (for surgical) patients and doctors – P218 This scenario [using remote monitoring during surgery] looks very realistic, and I am in favor of the new technology used in medicine since it makes surgeries and any medical procedure much safer. – P228
Workflow and Communication: relationships between health information technology, individual clinicians, healthcare teams, and patients to ensure smooth, cohesive patient care
Barriers	Incorrect eOR patient assessments	Potentially [the eOR] not understanding some specifics behind my vitals or levels due to a change in the circumstances at the location of the surgery and perhaps making a wrong emergency call. – P89 Other signs of distress may not show on the computer and may only be seen in person. If there is an emergency, [eOR clinicians] have to come all the way from another room to intervene. – P276
Facilitators	Increased patient safety from real-time monitoring	[Scenarios involving remote monitoring of surgeries] seem quite normal, as this is an everyday practice in healthcare… It is quite a good idea. – P1 I would hope that the staff monitoring me from a different location would be in addition to the monitoring that would be going on in the operating room. – P9 eOR monitoring reduces complications, [resulting in] less blood loss and fewer infections. – P28 Extra people monitoring [patient surgeries] would reduce complications. – P113 The pros [to eOR use] would be the extra people monitoring your health would increase the chance that any complication would be spotted immediately. – P170 The doctors and nurses [in the eOR] keep a check on the medicine [OR clinicians] give me; that way, they could avoid an overdose, and since other doctors and nurses see me from another room, they will inform themselves and help with that. – P164 [Double checking through the eOR] seems like a great idea. – P21 An extra eye [through remote monitoring] can’t be bad at all, given all the mishaps in surgery rooms. – P26
	Improved surgical focus and lack of distraction in OR	(Remote monitoring allows surgical teams in the OR) a better ability to focus on (bedside) data. – P95 (With regards to eOR use, I would like that there is) someone monitoring me who is solely focused on [monitoring my condition] because they are removed from the physical location and the commotion. – P90 [With eOR use, the OR team has] increased awareness of their surrounding environment [and can notice] things… such as noises or movements. – P103
	Improved efficiency	I think [remote monitoring is a] more efficient process. To be able to monitor all screens at once, away from the actual surgery, would be easier to do and more efficient. – P257 [Remote monitoring of surgery] sounds efficient. – P230
	Safeguard for the OR	My first reaction is [having an eOR to monitor surgeries] is a great situation to have. Someone watching right there, but also a “fallback” in a sense. – P11 I feel very good in this very reliable scenario [where the eOR monitors my hypothetical surgery]. – P15 [Remote monitoring] would make [surgery] safer. – P15 It’s nice to have double monitoring [between the OR and eOR]. – P29 Redundant systems are generally good. Perhaps if one set of equipment fails in the OR, [the eOR] would be a wonderful backup system. – P91
People: humans involved in all aspects of the design, development, implementation, and use of health information technology
Barriers	Attention issues within the eOR and OR	[eOR use could lead to] extra distractions/too many spoons in the soup – P273 [Remote monitoring] could interrupt the surgery and cause complications because of this. – P184 The biggest con [to eOR use] is that being apart and aside from the actual surgery makes people less attentive to what is actually going on. I would worry that whoever is monitoring the computer is only doing so intermittently, perhaps getting distracted by other things. – P201 What if [the eOR clinicians] get bored or are not attentive to the computer screen at all times? – P261
	Decision-making conflicts	Having too many people on a [surgical] team could lead to disagreements about treatment options (between the eOR and OR clinicians). – P265 What I mean is that there are sometimes too many [clinical leaders], and they may not always agree. The people in the room may feel the patient is doing well, whereas the people monitoring from another room see it differently, and this could cause some conflict that delays action. – P271 It could end up being a too many cooks situation causing unwarranted tinkering with medications. – P42’ A con would be that there are too many people, so not all of them are paying close attention. – P177 Too many people monitoring can cause confusion. – P319
	Lack of accountability	[eOR use] could create a sense of diminished responsibility if something goes wrong. The level of attention of the [remotely] monitoring doctors and nurses would be difficult to monitor and could mislead the operating nurses and doctors. – P125 I guess the doctors in the room might feel a little less responsible for what is happening and drop their guard a bit. – P168 Shared responsibility [between eOR and OR teams] can reduce the obligation that someone has to pay full attention [to]. – P11 There is no hierarchy of responsibility mentioned, so who is most responsible if something goes wrong - the doctor in the room or the doctor on the screen in another room? – P58 If something [in the surgery] went wrong, could someone be there to bring me back to life? – P181 [Remote care might be] less personable, I guess – P256
	Distrust in eOR	[I am a] little distrustful of eOR clinicians. – P41 I just don’t trust doctors. You can’t fully trust doctors and nurses – P324
Facilitators	Fewer people-related risks in OR (less infection, fewer distractions, commotion)	I think that the fact that [the eOR clinicians] are outside the room is no issue. Things get monitored remotely all the time. – P8 I like the idea of making the room less crowded and providing a separate location where experts can monitor vitals without distraction. – P13 [eOR use] seems like a good way to monitor my condition without crowding the operating room. – P53
	Sense of comfort for surgical patients	I would feel more comfortable with additional sets of trained eyes looking out for me. This scenario [where an eOR team monitors my surgery remotely] parallels telemetry units in hospitals where each patient has a nurse assigned to them, but their heart are also being monitored by a telemetry tech. – P12 [Having an additional team monitoring me] feels more assuring than my normal view of surgery. – P25 I love this idea [of remote monitoring during surgery]. It would make surgery feel much safer that an extra set of eyes are watching. – P6
	Trust in clinicians	Doctors and nurses [are]…. Careful [during surgery]. –P33 Honestly, I’m of the mindset that I just want to get better, and so long as [those operating the eOR are] trained professionals, I trust them. – P302 I really don’t see any cons to [eOR use], especially since it would not increase the cost of care. I don’t see any privacy issues with [eOR use] either, as long as I can trust the [remote] medical team. – P78 I trust that professionals in the field (of surgery) understand and implement best practices. – P95