Barriers and facilitators of integrating telemedicine services into routine kidney transplant patient care: a scoping review of qualitative research

Abstract

Introduction

Considering recent advances in technology, kidney transplant patients can significantly benefit from telemedicine. Understanding the factors that influence its integration into routine care is essential for optimizing implementation and ensuring equitable access.

Methods

This review was conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. The electronic databases including PubMed, Web of Science, Embase, Scopus and ProQuest were searched. Relevant studies were evaluated and selected by two authors independently. The extracted data were analyzed and synthesized using a thematic approach. Barriers and facilitators of integrating telemedicine services into routine kidney transplant patients care were extracted based on four pre-defined main themes (Human, Organizational, Technological, and economic environments).

Results

From 1,188 records screened, 17 qualitative studies were selected for inclusion. Analysis revealed multiple barriers and facilitators to telemedicine integration in kidney transplant care, categorized into four main areas: human factors, organizational issues, technological challenges, and economic considerations. Key barriers identified included limited technological infrastructure, patient and provider resistance to digital tools, technology literacy gaps, privacy concerns, and increased workload. Facilitators highlighted were comprehensive guidelines, training programs, user-friendly platforms, ongoing technical support, and strong physician-patient relationships. These synthesized insights highlighted a set of 27 facilitators that can support telemedicine implementation.

Conclusion

The integration of telemedicine services into routine kidney transplant patient care faces many challenges but also offers promising facilitators. Addressing these factors is crucial to improving telemedicine implementation and enhancing patient outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41043-025-01061-4.

Introduction

Telemedicine literally refers to “treating at a distance” and is defined as a medical practice that uses internet and related electronic technologies to provide specialized healthcare [1]. It is particularly valuable in regions with limited access to specialists and has proven crucial during exceptional situations, such as during the COVID-19 pandemic, where patients opted to minimize the risk of infection by staying indoors [1, 2]. The major shift to using telemedicine for kidney transplant recipients (KTRs) dates back to the pandemic, when there were significant challenges in donor and recipient evaluation and in post-renal transplant care [3]. As an initial response to the pandemic, the transplant surgeries were paused with nearly 72% of living kidney donation programs in the United States being suspended [3]. Although the technology was quickly incorporated into transplantation practice, transplantation programs did not fully embrace telehealth in all aspects of donation evaluation; however, most programs reported an inclination to use telehealth before and after donation [3].

In remote and undeserved areas, patients face several barriers to receiving adequate renal transplant care [4, 5]. A lack of infrastructures, including a shortage of transplant coordinators and specialists, coupled with high travel costs and limited transplant-related insurance coverage leads to delays in timely patient referrals to transplant centers [4–8]. Additionally, fewer support networks, poor internet connectivity, and lower patient awareness further complicate the process [7, 9, 10]. A recent study has revealed that the highest direct costs incurred by Australian living kidney donors was related to travel and accommodation [11]. Telemedicine represents an opportunity for health care providers to monitor patients and candidates, especially those from remote areas and allows better utilization of transplant center resources [12].

Considering the lifelong need for monitoring after transplantation, KTRs can benefit significantly from remote care options. Some of the existing practices include initial pre-transplant consultations via video calls [13], wearable devices for remotely monitoring vital signs and kidney function [14], home-based online exercise programs designed for KTRs to maintain physical activity [15], health mobile apps for tracking medications and improving adherence [16], virtual visits with dietitians to support a healthier recovery [17].

To successfully implement telehealth for KTRs, incorporating the perspectives of patients and healthcare providers is crucial for evaluating the effectiveness of interventions and designing user-friendly solutions that meet patients’ needs. This scoping review aims to explore the opportunities, barriers, and challenges of current telemedicine practices from the viewpoints of KTRs, healthcare providers, and stakeholders.

Methods

This scoping review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) checklist [18]. This methodology was selected to comprehensively explore the existing literature on the barriers and facilitators to integrating telemedicine services into routine kidney transplant patient care. The review aimed to address the following research question: What are the key challenges and enabling factors in implementing telemedicine in routine care for kidney transplant recipients [19, 20]?

Furthermore, scoping reviews can identify potential gaps in the scientific evidence on a particular topic [21, 22]. This scoping review was done in accordance with the six steps introduced by Mak and Thomas (2022) [23]. The protocol of this study was assessed and approved by Institutional Review Board (IRB) of Shiraz University of Medical Sciences.

Search strategy

In order to develop search strings, three components of SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research Type) framework [24], including Sample (kidney transplant patients), phenomena of interest (telemedicine), and research type (qualitative studies) were considered. Medical Subjects Headings (Mesh) thesaurus, contacting relevant experts, and reviewing the relevant literature were applied to find the potential terms. As a whole, “Kidney Transplantation”, “Renal Transplantation”, Telemedicine, “Virtual Medicine”, Teleconsultation, Telenephrology, “Digital health”, “Qualitative research”, Viewpoints, and Experiences were used to develop the search strategy. First, search strings were created for the PubMed electronic database and then adapted for other desired databases (Supplementary Table 1).

The electronic databases including PubMed, Web of Science, Scopus, Embase and ProQuest were searched from inception to the November 2024. Besides, OpenGrey and Google Scholar were searched to find relevant grey literature. In order to minimize publication bias, reference list of review studies, citations of included studies as well as relevant key-journals (Kidney International, American Journal of Kidney Diseases, Kidney International Reports, Kidney Diseases, and Kidney Research and Clinical Practice) were manually reviewed.

Selection of studies

All search results were entered into Endnote software (Thomson Reuters, New York, NY), and after removing duplicates, the remaining studies were screened independently by two authors based on title and abstract. In the next step, potentially relevant studies were evaluated based on the full text of the article by the same two authors independently based on the study inclusion and exclusion criteria. Any disagreements between the two authors during these stages were resolved through discussion and, when necessary, with the participation of a third expert author.

Inclusion and exclusion criteria

This scoping review includes qualitative studies that explore stakeholders’ perspectives on providing the care services needed by key transplant patients using telemedicine. The inclusion criteria were: (1) scientific studies with qualitative methodology; (2) papers published in peer-reviewed journals; (3) investigating the barriers and facilitators of integrating telemedicine services into routine kidney transplant patient care; (4) in English; and (5) availability of full-text. On the other hand, the exclusion criteria were: (1) quantitative studies; (2) review studies; (3) letters to the editor, protocol studies, abstracts, editorials, and commentaries; (4) non-English language studies; (5) studies without full-text; and (6) qualitative studies that did not focus on the main aim of this scoping review.

Data extraction

The data extraction process from the included studies was carried out independently by two authors. Data extraction was performed using a pre-prepared form that included the following items: (1) first author; (2) publication year; (3) study aim; (4) participants; (5) sampling approach; (6) country of origin; (7) data collection method; (8) interview format; (9) analysis approach; (10) summary of findings; 11) funding source. Two other authors also supervised this process, and any disagreements among the research team were resolved through discussion sessions.

Data synthesis and analysis

The extracted data from included studies were analyzed and synthesized using a thematic approach [25]. In this regard, three authors assessed and reviewed the differences and similarities among retrieved summaries and identified main barriers and facilitators. Then, the identified themes were categorized and assigned to four predefined main themes (Human, Organizational, Technological, and Economic environments) [26]. Any disagreements at this stage were also resolved through discussion and participation of an expert.

Results

The primary search of included databases yielded 1188 records. After removing duplicates, 275 studies were screened. Next, 69 articles were assessed based on availability of their full-texts. And in the end 17 qualitative studies were included in the study. Figure 1 indicates the PRISMA flow chart, demonstrating study selection process and search results. A list of 52 excluded articles along with the reason for exclusion has been indicated in Supplementary Table 2.

Fig. 1.

PRISMA flowchart

This scoping review included 17 qualitative articles conducted in 5 countries: United States of America (58.8%, n = 10) [27–36], Canada (23.5%, n = 4) [33, 37–39], Australia (11.7%, n = 2) [40, 41], Norway (5.9%, n = 1) [42] and United Kingdom (n = 1) [43]. All of the included articles consisted of semi-structured interviews (52.9%), focus group sessions (29.4%) or both of them (11.76%) and nominal group technique (5.8%). In regards with sampling strategy, 76.4% of studies (n = 13) applied a purposive sampling to recruit participants, 17.6% used convenience sampling (n = 3) and one study applied both purposive and convenience sampling (5.8%). The analysis approaches were thematic and content analysis (82.3% and 17.6% respectively). Table 1 shows the characteristics of included articles in detail.

Table 1.

Characteristics of included articles

Author (publication year)	Study aim	Participants (N)	Sampling	Country of origin	Data collection method	Interview format	Analysis approach	Telemedicine tool	Summary of findings	Funding source
John Christopher Sieverdes 1 et al. (2015)	To evaluate the attitudes, acceptance, and preferences of African American kidney transplant recipients, kidney transplant donors, and potential donors who learn about living kidney donation through an mHealth program.	Deceased/living donor KTR and living donors/potential donors	Purposive sampling	United States of America	Focus groups	Face-to-face	Directed content analysis	A future mHealth living donor kidney transplantation program tailored for AA dialysis patients eligible for transplantation.	There was strong support for mobile technology use, with preferences for various media formats and user-friendly designs. Recipients showed more willingness than donors to spend time on education, sought to develop conversation skills, and preferred diverse information sources. Donors prioritized hearing directly from other living donors.	National Institutes of Health (NIH) grant DK 098777 and the South Carolina Clinical and Translational Research Institute, with an academic home at MUSC, through NIH Grant Number UL1 TR000062
John Christopher Sieverdes 2 et al. (2015)	To explore barriers and perceptions of physical activity behaviors and gauge interest in using mHealth in a physical activity wellness program for dialysis patients on the kidney transplant waiting list.	dialysis patients on the kidney transplant waiting list	Purposive sampling	United States of America	Semi-structured in-depth interviews	Face-to-face	Thematic analysis	Mobile health–delivered physical activity program	Study revealed high interest for using mHealth to promote physical activity among patients. Self-monitoring and self-efficacy were related to the perceived benefit of using mobile technology.	No funding
Ajay Israni et al. (2016)	To determine how KTRs remember to take medications and assess perceptions about adherence and willingness to use a mobile app to improve adherence.	KTR	Purposive sampling	United States of America	Semi-structured interviews	Face-to-face	Thematic analysis	Hypothetical, mobile phone app to improve medication adherence	Participants cited avoiding dialysis, staying alive, and preventing rejection as motivations for adherence. Barriers included forgetting, depression, financial concerns, and routine disruptions. Interest in a proposed app was mixed, with concerns about accessibility and alert fatigue.	No funding
Ann K. Eno BSet al. (2019)	To explore transplant providers’ perspectives on using mobile health (mHealth) technology for follow-up care of living kidney donors	HCP	Convenience sampling	United States of America	Semi-structured in-depth interviews	Telephone	Thematic analysis	mHealth technology for living kidney donor follow-up	mHealth was seen as a more convenient way to communicate with the transplant center, improve engagement through lab value tracking, and streamline the donor follow-up process.	No funding
José Côté et al. (2019)	To document how Kidney transplant recipients experienced a web-based tailored nursing intervention and to explore how they self-managed medication intake.	KTR	Convenience sampling	Canada	Focus groups and Semi-structured interviews	Face-to-face and Telephone	Thematic analysis	A web-based tailored nursing Intervention. The intervention consisted of three asynchronous interactive computer sessions, each 10 to 30 min long, hosted by a virtual nurse.	Nearly all participants indicated that they would recommend the web-based tailored nursing intervention to new KTRs. It helped address uncertainties and supported self-management of immunosuppressive therapy.	No funding
Marie-Françoise Malo et al. (2024)	To capture the participants’ experiences of the KEeP ACTIVe Club.	KTR	Purposive sampling	Canada	Semi-structured interviews	Telephone and video conference	Thematic analysis	The KEeP ACTIVe Club intervention consisted of virtual physical activity session and online social support session	The KEeP ACTIVe Club motivated participants to engage in regular physical activity, especially through tailored training for KTRS.	CDTRP Research Innovation Grant
Tara O’Brien et al. (2020)	To explore the perceptions of kidney transplant recipients who use mHealth apps for self-management of care.	KTR	Purposive sampling	United States of America	Semi-structured interviews	Face-to-face	Content analysis	One mHealth app	Most KTRs (78%) had not used mHealth apps. Preferred features included medication tracking, nutrition monitoring, personalized feedback, and a user-friendly interface.	American Nephrology Nurses Association
Christina Nguyen et al. (2020)	To identify the challenges and strategies related to medication adherence in AYA, and to gather stakeholder views on ePillbox features and coaching support.	AYA with Kidney transplant and parents and HCP	Purposive sampling and Convenience sampling	United States of America and Canada	Focus groups	Via telephone or videoconference	Content analysis	ePillbox and a related website for medication monitoring, personal coaching and action plans	Participants suggested improving ePillbox usability through customizable alerts, a companion website, and communication-supporting features.	National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) under the grant number R01 DK110737​
Cecilie Varsi et al. (2021)	To investigate the perceived benefits and challenges of using video consultations in outpatient renal transplant recipient follow-up from the perspectives of patients and health care providers	KTR and HCP	Purposive sampling	Norway	Semi-structured interviews	Face-to-face and Telephone	Thematic analysis	Video consultation using Norwegian Health Network (NHN) Cisco meeting application	The results indicate that the benefits experienced by patients as well as HCP surpassed any technological challenges encountered. Main benefits were less focus on being chronically ill and economic benefits.	No funding
Ellen M. Castle et al. (2021)	To evaluate the usability (functionality, navigation, and interactivity) of the patient-facing ExeRTiOn online resource	KTR and HCP	Purposive sampling	United Kingdom	Semi-structured and think-aloud interviews	Face-to-face	Thematic analysis	ExeRTiOn is a digital resource for weight-gain prevention support	The ExeRTiOn online resource has the potential to provide new KTRs with much needed information to foster self-management and mitigate the fear-avoidance behavior that is often associated with returning to physical activity after kidney transplantation.	No funding
John C. Sieverdes et al. (2021)	To evaluate the acceptability of the LOVED program to help black kidney transplant wait-list patients advocate for a living donor kidney transplant	Black kidney transplant wait-listed patients	Purposive sampling	United States of America	Focus groups	Video conferencing	Inductive analysis Thematic analysis	The LOVED program is a distance-based, mobile health program designed to help Black kidney transplant wait-list patients advocate for a living donor	Participation was overall a positive experience and participants were more willing to ask for a kidney.	NIH grant DK 098777 and the South Carolina Clinical & Translational Research Institute (SCTR), with an academic home at the Medical University of South Carolina, Clinical & Translational Science Award NIH/National Center for Research Resources (NCRR), grant UL1RR029882.
Brooke M Huuskes et al. (2021)	To describe the perspectives of kidney transplant recipients on the benefits, challenges, and risks of telehealth	KTR	Purposive sampling	Australia	Focus groups	ZOOM videoconferencing	Thematic analysis	Telehealth consultations either by a telephone call, or video call between patients and physicians	KTRs found telehealth convenient, time-efficient, and protective against infections, with less disruption to daily life. Trust and familiarity with their nephrologist supported effective communication.	The University of Sydney Robinson Fellowship. N.S.R. is supported by the NHMRC Postgraduate Scholarship (ID1190850)
James Tang et al. (2022)	To describe the perspectives and experiences of eHealth among kidney transplant recipients	KTR	Purposive sampling	Australia	Semi-structured interviews	Face-to-face	Thematic analysis	Multiple eHealth platforms: Websites /Apps/Reminders/social media/forums/Telehealth /Texting /Email	Recipients perceived eHealth as helpful for care and self-management but faced challenges with navigation, privacy, and misinformation. Accessible, personalized, and secure eHealth could enhance satisfaction and outcomes.	No funding
Liise K. Kayler et al. (2022)	To improve understanding of dialysis staff’s transplant education practices, as well as the potential value of video-based interventions.	HCP	Purposive sampling	United States of America	Focus groups	Face-to-face	Thematic analysis	Educational videos designed specifically for dialysis patients	Five key barriers to transplant education were identified, including reliance on a single educator, uninformed dialysis staff despite their availability; and patient disinterest due to poor timing, feeling overwhelmed, and fears about transplantation.	National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1TR001412
Kara Schick-Makaroff et al. (2022)	To explore the essential priorities and preferences of KTR and HCP to inform the development of a smartphone app to improve immunosuppression adherence and communication	KTR and HCP	Convenience sampling	Canada	Focus groups and Semi-structured interviews	Face-to-face and via Skype	Thematic analysis	Mobile health (mHealth) app for medication adherence	HCP prioritized improving communication over immunosuppression adherence. Recipients emphasized the importance of choice, independence, and better access to their health information over monitoring-focused solutions.	CSTAstellasT3 grant
Alexis J. Carter et al. (2023)	To explore the perspectives of participants regarding the potential shift from in-person to virtual LDN.	KTR and advocates	Purposive sampling	United States of America	Nominal group technique	Virtually via Zoom	Inductive Thematic analysis	Real-time video conferencing to deliver transplant education	Individuals prioritized factors concerning program fidelity, accessibility, interpersonal relationships, and knowledge. Overall, when surveyed on program preference, most NGT participants preferred in-person visits to telehealth.	NIH/NIDDK R01DK125509
Ellie Kim et al. (2024)	To explore and understand the experiences and preferences of living kidney donors regarding the use of telemedicine and in-person visits during the donor evaluation process.	Living kidney donor candidates or previous donors	Purposive sampling	United States of America	Semi-structured in-depth interviews	Telephone	Inductive Thematic analysis	Synchronous video visits, used within a hybrid telemedicine/inperson model for evaluating living kidney donors	Reducing financial burdens, enhancing scheduling flexibility, supporting information with technology, visual aids and key role of the coordinator were main items.	Health Resources and Services Administration (HRSA) under grant number R39OT37885

KTR: kidney transplant recipient, HCP: health care provider, AYA: adolescent and young adult, LDN: living donor navigator program, NGT: nominal group technique, AA: African American, LOVED: Living organ video educated donors

Telemedicine tools

A wide variety of telemedicine tools have been explored across different qualitative studies. These tools include: Mobile health application to enhance medication adherence, enable communication with providers, and support self-management tasks like symptom tracking, lab monitoring, and alerts [36, 39, 41]. Real-time video consultations, often used for routine follow-ups, donor evaluations, and virtual educational sessions was another modality [35, 36]. Web-based interventions, including tailored nursing platforms hosted by virtual nurses, online physical activity programs, and educational resources like the ExeRTiOn platform are among other telemedicine tools [37, 38, 43]. Asynchronous educational videos, particularly for dialysis staff and patients [44] and general eHealth platforms, which encompass reminders, social media groups, email communication, and patient forums were also used [41].

Barriers to integrating telemedicine in kidney transplant practice

Table 2 outlines the related barriers to incorporating telemedicine services into kidney transplant practice under the WHO and Pan American Health Organization framework for implementing a telemedicine service. These barriers span multiple dimensions, including human, organizational, technological, and economical challenges. Regarding user experience and human factors, resistance to digital transition [28, 34, 36, 40, 41], technology illiteracy [30, 34–36, 39–42] and language barriers [30, 34, 40, 41] impeded technology use buy participants. Also, some of the participants complained of too much information and digital overload resulting from telemedicine services [28, 38]. Besides, telemedicine was related to increased patient responsibility (due to obtaining their lab data, managing technological difficulties, managing their medication taking and etc. ) [30, 33]39– [41] and sometimes they failed to retain their tasks [28, 33, 37, 39]. Additionally, missed chance for real-time interactions [30, 35, 36] and lack of physical evaluations in telemedicine visits further complicated the use of these services. Also, a study demonstrated that health care providers had different priorities and sought further clarification on the scope of the app [39]. They were concerned that patients would expect communication with HCP outside of clinic hours and wondered whether the app would be limited to immunosuppression medication intake and transplant care or broader health care information [39].

Table 2.

Barriers to integrating telemedicine in kidney transplant practice

Main themes	Barriers	Studies
Human level	Differing priorities of health care providers	Kara Schick-Makaroff (2022)
	Resistance to digital transition	Ann K. Eno BS (2019), Brooke M Huuskes (2021), James Tang (2022), Liise K. Kayler (2022), Ellie Kim (2024)
	Limited in-person physical assessment	Marie-Françoise Malo (2024), Ellie Kim (2024), Alexis J. Carter (2023), Liise K. Kayler (2022), James Tang (2022), Brooke M Huuskes (2021), Cecilie Varsi (2021)
	Language barriers	Ann K. Eno BS (2019), James Tang (2022), Liise K. Kayler (2022), Brooke M Huuskes (2021)
	Increased patient accountability	James Tang (2022), Kara Schick-Makaroff(2022), Brooke M Huuskes (2021), Christina Nguyen (2020), Ann K. Eno BS (2019)
	Technology illiteracy	Alexis J. Carter (2023), Ann K. Eno BS (2019), Brooke M Huuskes (2021), Cecilie Varsi (2021), James Tang (2022), Kara Schick-Makaroff(2022), Liise K. Kayler (2022), Ellie Kim (2024)
	Digital overload (e.g. overwhelming reminders)	Ajay Israni (2016), Marie-Françoise Malo (2024)
	Task retention difficulties	Ajay Israni (2016), Christina Nguyen (2020), José Côté (2019), Kara Schick-Makaroff(2022)
	Missed chance for real-time interaction	Alexis J. Carter (2023), Ellie Kim (2024), Ann K. Eno BS (2019)
Organizational level	Time constraints and scheduling	Alexis J. Carter (2023), Marie-Françoise Malo (2024), Liise K. Kayler (2022), James Tang (2022), Ajay Israni (2016), Brooke M Huuskes (2021), Christina Nguyen (2020)
	Service inaccessibility	Ajay Israni (2016), Alexis J. Carter (2023), Brooke M Huuskes (2021), Ellen M. Castle (2021), Liise K. Kayler (2022), Marie-Françoise Malo (2024)
	Lack of staffing and increased workload	Cecilie Varsi (2021), James Tang (2022), Kara Schick-Makaroff(2022), Liise K. Kayler (2022), Brooke M Huuskes (2021), Ann K. Eno BS (2019)
	Information confidentiality	Brooke M Huuskes (2021), Cecilie Varsi (2021), James Tang (2022), Kara Schick-Makaroff(2022), Ellie Kim (2024)
	Reliability of information	James Tang (2022), Alexis J. Carter (2023), Christina Nguyen (2020), Kara Schick-Makaroff(2022)
	Patient safety	Tara O’Brien(2020), Kara Schick-Makaroff(2022), José Côté (2019), Cecilie Varsi (2021), Brooke M Huuskes (2021), Ann K. Eno BS (2019)
	Patient privacy	Ann K. Eno BS (2019), Brooke M Huuskes (2021), Cecilie Varsi (2021), Ellen M. Castle (2021), Ellie Kim (2024), John Christopher Sieverdes (2015), Kara Schick-Makaroff(2022), Tara O’Brien(2020)
	Data security	Kara Schick-Makaroff (2022), Cecilie Varsi (2021), James Tang (2022), Brooke M Huuskes (2021), Ann K. Eno BS (2019), Christina Nguyen (2020), Ellie Kim (2024), John Christopher Sieverdes (2015)
Technological level	Information overload	Liise K. Kayler (2022), Ellen M. Castle (2021), James Tang (2022)
	Lack of technological infrastructures	Tara O’Brien(2020), Alexis J. Carter (2023), Cecilie Varsi (2021), José Côté (2019), John C. Sieverdes (2021), Ellie Kim (2024), Liise K. Kayler (2022), James Tang (2022), John Christopher Sieverdes (2015), Brooke M Huuskes (2021), Ajay Israni (2016), Marie-Françoise Malo (2024)
Economical level	High cost of implementation	James Tang (2022), Ann K. Eno BS (2019)
	Financial hardship	Ann K. Eno BS (2019), James Tang (2022), Tara O’Brien(2020)

At the organizational level, several concerns regarding confidentiality [36, 39–42], reliability of information [33, 35, 39, 41], patient safety [30, 31, 37, 39, 40, 42], patient privacy [29– [31, 36, 39, 40, 42, 43] and data security [29, 30, 33, 36]39– [42] were repeatedly noted across articles. Participants in the included studies also marked service inaccessibility [28, 34, 35, 38, 40], lack of staffing and increased workload [30, 34]39– [42] and difficulty in scheduling and time constraints [28]33– [35, 38, 40, 41] as possible challenges.

Regarding technological barriers, three studies identified information overload from technology as a challenge [34, 41, 43]. Additionally, the lack of technological infrastructure was repeatedly noted across multiple studies [28, 29, 31, 32]34– [38]40– [42]. In terms of finance, a few studies recognized the high cost of implementation [30, 41] and financial hardship [30, 31, 41] as possible impediment to telemedicine progress.

Facilitators of integrating telemedicine in kidney transplant practice

Table 3 outlines the recommended factors for successfully integrating telemedicine into kidney transplant practice. Regarding human-level facilitators, preserving the interpersonal connections, both with health care staff and other kidney transplant patients was a crucial factor which was replicated in different studies [29, 32]34– [36]38– [41, 43]. Additionally, arranging an in-person visit [29]34– [36, 38]40– [43] and establishing a trust-based physician-patient relationship [28, 33, 36]40– [42] facilitated the use of telemedicine platform for patients. It’s worth noting that being in a stable phase of health [28, 42] was noted as a factor that patients would be more inclined to choose a telemedicine visit over a traditional one. In some of the included articles, however participants were optimistic about using telehealth visits, but they wanted to be ensured that they had access to the transplant center [30, 35, 36, 39] if needed. Ensuring a conducive environment during telehealth visits [36, 40, 42], having social support [28, 29, 32, 33]35– [37, 40, 41] and maintaining cultural safety [32, 40] further eased the use of these services for participants. Participants in the included studies also highlighted the importance of different strategies in increasing patient engagement, such as self-monitoring [28, 30, 33]38– [41, 43], arranging alerts [28– [31, 33]37– [39, 41, 43], providing individualized feedback [31, 33, 35, 37, 39, 43] and designing an effective reward system [31, 33, 43].

Table 3.

Facilitators to integrating telemedicine in kidney transplant practice

Main themes	Facilitators	Studies
Human level	Arranging an in person visit	Alexis J. Carter (2023), Brooke M Huuskes (2021), Ellen M. Castle (2021), Ellie Kim (2024), Cecilie Varsi (2021), John Christopher Sieverdes (2015), Marie-Françoise Malo (2024), Liise K. Kayler (2022), James Tang (2022)
	A trust-based physician-patient relationship	Ajay Israni (2016), Brooke M Huuskes (2021), Cecilie Varsi (2021), Christina Nguyen (2020), Ellie Kim (2024), James Tang (2022)
	Being in a stable phase of health	Cecilie Varsi (2021), Ajay Israni (2016)
	Conducive physical environment	Brooke M Huuskes (2021), Cecilie Varsi (2021), Ellie Kim (2024)
	Social support	Ajay Israni (2016), Alexis J. Carter (2023), Brooke M Huuskes (2021), Christina Nguyen (2020), Ellie Kim (2024), James Tang (2022), John Christopher Sieverdes (2021), John Christopher Sieverdes (2015), José Côté (2019)
	Cultural safety	John Christopher Sieverdes (2021), Brooke M Huuskes (2021)
	Access to the transplant center	Alexis J. Carter (2023), Ann K. Eno BS (2019), Ellie Kim (2024), Kara Schick-Makaroff(2022)
	Preserving the interpersonal connections	Ellie Kim (2024), Alexis J. Carter (2023), Liise K. Kayler (2022), James Tang (2022), John Christopher Sieverdes (2021), Brooke M Huuskes (2021), Ellen M. Castle (2021), Ellie Kim (2024), John Christopher Sieverdes (2015), Kara Schick-Makaroff(2022), Marie-Françoise Malo (2024)
Organizational level	Adherence tracking by doctor/nurses/pharmacy for continuity of care	Brooke M Huuskes (2021), Christina Nguyen (2020), Ellen M. Castle (2021), Ellie Kim (2024), James Tang (2022), John Christopher Sieverdes (2015), José Côté (2019), Kara Schick-Makaroff(2022), Tara O’Brien(2020), Marie-Françoise Malo (2024), Ajay Israni (2016), Alexis J. Carter (2023)
	Establishing collaboration with other organizations	Kara Schick-Makaroff(2022), Ellen M. Castle (2021), Ellie Kim (2024), Alexis J. Carter (2023)
	Establishing training options for the new health care model	Tara O’Brien (2020), José Côté (2019), Christina Nguyen (2020), Liise K. Kayler (2022), Brooke M Huuskes (2021), Cecilie Varsi (2021), Ellie Kim (2024), James Tang (2022), Marie-Françoise Malo (2024)
	Respecting patient care preferences	Brooke M Huuskes (2021), James Tang (2022), John Christopher Sieverdes (2015), Kara Schick-Makaroff(2022), Marie-Françoise Malo (2024)
	Ensuring program fidelity and accountability	Alexis J. Carter (2023), Brooke M Huuskes (2021), Cecilie Varsi (2021), James Tang (2022), Christina Nguyen (2020), Ellen M. Castle (2021)
	Developing comprehensive guidelines	Ellen M. Castle (2021), James Tang (2022), Marie-Françoise Malo (2024)
	Automatic documentation of telehealth visits in EHR (electronic health records)	Kara Schick-Makaroff (2022)
	self-monitoring	Ann K. Eno BS (2019), Ajay Israni (2016), Christina Nguyen (2020), Ellen M. Castle (2021), James Tang (2022), Kara Schick-Makaroff (2022), Marie-Françoise Malo (2024), Brooke M Huuskes (2021), John Christopher Sieverdes 2 (2015)
	Arranging alerts	Ajay Israni (2016), Ann K. Eno BS (2019), Christina Nguyen (2020), Ellen M. Castle (2021), John Christopher Sieverdes (2015), José Côté (2019), Marie-Françoise Malo (2024), Tara O’Brien (2020), James Tang (2022), Kara Schick-Makaroff(2022)
	Providing individualized feedback	Alexis J. Carter (2023), Christina Nguyen (2020), Ellen M. Castle (2021), José Côté (2019), Kara Schick-Makaroff(2022), Tara O’Brien(2020)
	Designing an effective reward system	Ellen M. Castle (2021), Christina Nguyen (2020), Tara O’Brien (2020)
	Using the relevant security guidelines	Kara Schick-Makaroff(2022), Cecilie Varsi (2021), James Tang (2022), Brooke M Huuskes (2021), Ann K. Eno BS (2019), Christina Nguyen (2020), Ellie Kim (2024), John Christopher Sieverdes (2015)
	Warranting information accuracy	Brooke M Huuskes (2021), James Tang (2022)
Technological level	Preparing the necessary technological infrastructures	Kara Schick-Makaroff(2022), Marie-Françoise Malo (2024), Liise K. Kayler (2022)
	Assuring program safety	James Tang (2022), John C. Sieverdes (2021), Cecilie Varsi (2021), Brooke M Huuskes (2021)
	Designing a user-friendly platform	Marie-Françoise Malo (2024), Tara O’Brien (2020), Ellen M. Castle (2021), Liise K. Kayler (2022), James Tang (2022), John Christopher Sieverdes (2015), Ann K. Eno BS (2019), Cecilie Varsi (2021), John Christopher Sieverdes (2021), José Côté (2019)
	Providing technological support and real-time troubleshooting	John Christopher Sieverdes (2015), Kara Schick-Makaroff(2022), Brooke M Huuskes (2021)
	Enhancing the functionality of the mobile health (mHealth) platform	Ann K. Eno BS (2019), Christina Nguyen (2020), Ellie Kim (2024), John Christopher Sieverdes (2021), Kara Schick-Makaroff (2022), Marie-Françoise Malo (2024), Tara O’Brien (2020), James Tang (2022)
Economical level	Insurance coverage	Ann K. Eno BS (2019), Kara Schick-Makaroff (2022)

Regarding organizational level facilitators, several factors were identified such as: adherence tracking by doctor/nurses/pharmacy for continuity of care [28, 29, 31, 33]35– [41, 43], establishing collaboration with other organizations [35, 36, 39, 43] and establishing training options for the new health care model for both patients and health care providers [31, 33, 34]36– [38]40– [42]. Respecting patient care preferences [29, 38–41], adherence to relevant security guidelines [29, 30, 33, 36]39– [42], ensuring program fidelity and accountability [33, 35]40– [43], Information accuracy [40, 41], developing comprehensive guidelines [38, 41, 43] and automatically documenting telehealth visits in EMR (electronic medical records) [39] were suggested in order to improve workflow and documentation.

In terms of technology, several studies emphasized the importance of establishing necessary technological infrastructures [34, 38, 39], developing a user-friendly platform [29– [32, 34, 37, 38]41– [43], providing technological support and real-time troubleshooting [29, 39, 40], ensuring program safety [32, 40–42] and enhancing the functionality of the mobile health (mHealth) platform [30– [33, 36, 38, 39, 41].

Discussion

According to this scoping review, multiple barriers and challenges exist in integrating telemedicine services into kidney transplant care, as outlined within the framework provided by the WHO and the Pan American Health Organization. However, this review also highlights the most critical facilitators that should be leveraged to support effective integration into routine patient care. The main findings of our study are discussed below.

Insufficient technological infrastructures and high cost of implementation are significant barriers that can impede the adoption of telemedicine services [30, 31, 35, 41]. Several studies on kidney transplant recipients reported service inaccessibility, whether due to limited internet connectivity or a lack of digital devices as a key barrier to the effective implementation of telemedicine [28, 30, 34, 35, 40, 43]. These disparities are particularly pronounced in rural regions [45]. According to a recent study, almost 32.29% of American rural households lack a desktop/laptop with high-speed internet, 21.51% lack a smartphone with a data plan, and 14.02% had no digital access at all [45]. To reduce these disparities, several solutions can be implemented. Informing patients that they can access free internet services at public libraries could help them participate in telemedicine appointments, especially if they do not have access at home [46]. Placing computers in dialysis clinic waiting areas gives patients an opportunity to use telemedicine platforms while they wait for their treatments [46]. This can be particularly beneficial for dialysis patients and chronic kidney disease patients who may require routine consultations. Besides, utilizing satellite communication is an immediate solution for high speed connectivity, while gradually developing fiber-optic infrastructure to meet long term need [47]. Satellite internet does not rely on ground-based infrastructure and addresses the connectivity challenge especially in remote or rural areas.

Among others, technology illiteracy and resistance to digital transition were key challenges [30, 34, 35, 40, 41]. A study on chronic kidney disease (CKD) patients revealed that younger and more educated individuals were more inclined to use mHealth services [48]. Similarly, a previous study on kidney transplant recipients found that internet use was influenced by age, gender, ethnicity and education and Black patients were less likely to use internet [49]. Ann Bonner argues that barriers such as a lack of computer knowledge and unwillingness to use technology, although infrequent among chronic kidney disease patients, pose a potential risk for digital divide in this population [48]. Dorian Schatell et al. found that among hemodialysis patients, the main barriers to internet use were more often linked to limited computer access or insufficient knowledge, rather than disinterest [46]. To address these challenges, evaluating patients’ technological literacy before implementing telemedicine and developing a more user-friendly platform can enhance outcomes [31, 38, 41, 48]. Providing training sessions in form of video tutorial, written guides or face to face group sessions to learn basic skills helps patients become more comfortable with technology. Furthermore, it’s essential to provide orientation and skill-development sessions for healthcare providers such as providing a conducive and private environment during visits, making eye contact, having professional appearance, informing patient of other people like students and considering lag time [50]. This can improve overall satisfaction and clinical outcomes. In addition to creating a more user-friendly platform, participants highlighted several key features that could enhance patient engagement, including alert systems, personalized feedback, nutrition and lab value tracking, tailored training sessions for physical activity, adherence tracking by doctors, nurses, or pharmacies for continuity of care, and the design of an effective reward system [28, 30, 31, 33, 37]39– [41, 43].

One of the main challenges identified was the existence of legal gaps, with participants in multiple studies expressing ambiguity regarding data privacy and security [30, 39–41]. Recent research in Iran and India also highlighted legal issues as major obstacles to the implementation of telemedicine [51, 52]. Fawaz Al Ammary et al. recommended adhering to HIPAA (the Health Insurance Portability and Accountability Act) to improve patient privacy in the adoption of telemedicine for kidney transplant patients [53]. Telemedicine services are newly immerged digital era in the medical care system and clear guidelines are required to successfully implement telemedicine for kidney transplant care [41, 54]. Such clarity safeguards not only patients’ rights, but also defines the responsibility of health care providers and patients [41]. Additionally, some studies emphasized that telemedicine should be a patient-centered decision rather than a mandatory form of care [29, 38, 40]. Therefore, obtaining patient consent prior to initiating telemedicine services respects their care preferences and ensures compliance with legal requirements [39–41]. Holding appointments in a private setting and using headphones rather than speakers further enhances patient privacy [50].

Participants of several studies stated that with the rise of telemedicine, kidney transplant patients faced fewer opportunities for face-to-face interactions and limited access to physical assessments [35, 36, 38, 40, 42]. However, Narissa Andrew et al., Joshua Wolf et al. and John O Joerns et al. revealed that most kidney transplant patients agreed that they received the same care via telemedicine for routine follow-up as in-person visits and expressed a total satisfaction [55–57]. In our scoping review, we learned that patient’s solution for improved outcomes and better patient- provider relationship, was to know the doctor from in-person visits [28, 36]40– [42]. The kidney transplant patients also declared that telemedicine was more effective when they were in a stable phase of their health while in-person visits may still be necessary during health fluctuations or complications [28, 42]. Patients also highlighted the importance of maintaining access to transplant centers, ensuring that they can receive in-person care when needed [30, 35, 36, 39]. Among the facilitators identified, maintaining interpersonal connections with fellow patients and having a supportive network were frequently emphasized [35, 40]. These social connections can provide a sense of shared experience and also reduce feelings of isolation.

The telemedicine services are often portrayed as new technology that replaces the previous ways of healthcare; instead, healthcare workers have to work in parallel practices. Notably, some studies identified increased workload for healthcare workers, along with time constraints and scheduling challenges, as possible barriers [30, 34]38– [41]. In a recent study, Susanne Frennert et al. shed light on the less visible ways that eHealth implementation impacts nurse’s life [58]. The study identified increased sedentary work activities, along with the addition of virtual routines to existing tasks—including both overlooked actions like data supervision and more visible work such as editing and data interpretation—as notable challenges [58]. A recent study in New York City reveled a significant impact of telemedicine on physicians’ work-related hours, with specialists dedicating more time to work-outside-work in comparison with primary care physicians [59]. Participants of our included articles mentioned two actions that can facilitate the workflow and documentation. Automatic documentation of telehealth visits in EHR (electronic health records) and providing technological support and real-time troubleshooting were suggested [39, 40]. Instead of relying on manual data entry, automatic documentation can save clinicians time and reduce burnout. During virtual visits, several challenges, such as connectivity issues or software malfunctions, can arise. Real-time troubleshooting means that whenever there is a technical problem, immediate assistance can fix it. Susanne Frennert recommends several solutions to mitigate the increased workload [58]. Recognition of invisible work, addressing sedentary work by increasing physical activities during work-time, reevaluating work distribution and promoting patient engagement were among solutions [58]. Further studies are needed to evaluate the clinician’s workload and possible solutions.

Strengths and limitations

This scoping review indicates new information regarding the common challenges and facilitators of integrating telemedicine services into routine kidney transplant patient care. To the best of our knowledge, no research has been conducted on this topic. In selecting and extracting data, two independent reviewers were involved to minimize the possible biases. However, this study encounters several limitations. First, in our study kidney transplant recipients with ethnic/racial diversity and physicians might be underrepresented. Second, given that many input studies have been conducted in the United States and a few studies in Canada, Norway and Australia, the findings of this study should be interpreted with greater caution in the context of countries with limited resources. Third, we only included English publications which could cause possible publication bias. Additionally, this review focused primarily on identifying challenges and facilitators of telemedicine use in renal transplant care. However, it did not assess the impact of these interventions on clinical outcomes or adherence, which limits our ability to determine their effectiveness. It is worth mentioning that the type of pre-transplant care (e.g., in-center hemodialysis versus home-based peritoneal dialysis) and donor type (living vs. deceased) could shape patients’ expectations for post-transplant follow-up. Despite these theoretical considerations, none of the reviewed studies examined these variables as factors influencing telemedicine engagement. In future studies, it is essential to examine the strategies for integrating telemedicine services into routine kidney transplant patient care from the viewpoint of the different stakeholders. It is also necessary to implement the strategies in larger scales to further investigate the solutions and facilitators.

Conclusion

The integration of telemedicine services into routine kidney transplant patient care faces many challenges, including lack of technological infrastructures, resistance to digital transition, technology illiteracy, limited in-person assessment, service inaccessibility, concerns about patient privacy and data security, lack of staffing and increased workload and high cost of implementation. However, there are several solutions for integrating these services into kidney transplant patient care, including developing comprehensive guidelines, establishing training options for the new health care model, respecting patient care preferences, designing a user-friendly platform, providing technological support and real-time troubleshooting, assuring program safety, building a trust-based physician-patient relationship, adherence tracking by doctor/nurses/pharmacy for continuity of care ensuring program fidelity and accountability and preparing the necessary technological infrastructures.

Abbreviations: HER, electronic medical record; HCP, health care provider; KTR, kidney transplant recipient, AYA: adolescent and young adult.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

F.KH, M.KH, M.A, and SSH contributed to the conception and design of the study. F.KH, M.A, and S.SH conducted the search, and M.B was co-moderator. F.KH, M.KH and SSH conducted most of the analysis, which M.B and M.A discussed regularly. F.KH, M.KH and SSH wrote the initial draft, and N.G, M.B and M.A contributed to manuscript revisions. All authors read and confirmed the final manuscript.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The Research Ethics Committee of the Shiraz University of Medical Sciences provided the ethical approval for this study (IR.SUMS.REC.1403.337) previously. All methods were performed in accordance with the relevant guidelines and regulations such as Declarations of Helsinki. Informed consent for participating in this study was obtained from all the participants before the interview sessions.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.