Table 4.

Exemplary Quotations Representing Sociotechnical Dimensions and Subcodes

SOCIOTECHNICAL DIMENSION	SUBCODE	SUBCODE DEFINITION	EXEMPLARY QUOTE
Hardware and software computing infrastructure	Technical requirements of CVT	Technological issues (e.g., equipment malfunctions and limited bandwidth) can delay setup or inhibit use.	When you get multiple calls, sometimes the bandwidth can't manage all the calls and you'll get interference or you start dropping calls.
	Space	Facilities lack necessary space for conducting appointments over CVT (e.g., a small room makes it difficult for camera to capture whole room).	We have our SCI clinic use the same space as rehab. The room the CVT equipment is in right now is not very big or very private, we can't really do a physical exam in there. It's just not conducive to a true appointment where you're laying hands and looking at all the things you might need to look at.
Clinical content	Establishing correct clinic stop-codes	Establishing correct clinic stop-codes is necessary for accurately tracking telehealth activities.	There was a while where CVT encounters weren't being coded right, they weren't counting the numbers correctly and it was a scheduling/coding thing. We'd get these notes later on, and all these orphaned appointments out there and orphan meaning that one end or the other, they weren't being coded and checked out correctly. […] I think there's still a bunch of appointments that get lost in the system that are never getting counted. I don't know if it's exactly accurate, but that's like anything with the computerized system. There are always glitches here and there.
	Limitation of evaluating physical symptoms over CVT	Degree to which providers feel it is difficult to assess the health condition of the patient over CVT.	The patients with a spinal cord injury are so special with urosepsis and wound care issues, […] so accommodating them was so hard for my nursing staff to wrap their arms around not physically touching that person. It was such a difficult transition to make, but now the other clinics are off and running and they're looking and going, “Wow, that's cool, and that really works.”
	Value of accessing specialists over CVT	CVT increases access to experts and educational resources to facilitate healthcare team decision-making.	I like that with spinal cord injury, we have access to the specialists at the SCI Center because we don't have that here. […] Our patient can show up here and have the conversation with them. That's really great.
Human computer interface	Provider comfort level with CVT	Providers become more comfortable and confident with using CVT the more they are able to interact with it.	The more we worked with [CVT technology], the more confident we've become.
	Patient comfort level with CVT	Some patients are not initially comfortable with having appointments over CVT but can be open to the idea once introduced to the technology.	Whenever the veterans were here for the face-to-face visit and we showed them the equipment, I think that helped them to be a little bit more comfortable […] so that when I did talk to them and said, “Let's do this by telehealth,” they would say, “That's the thing in the corner, right? Okay, well yeah, that's not scary or anything.”
People	Need for knowledgeable staff	Providers need staff with appropriate knowledge about CVT technology and clinical processes.	We know now that sometimes you need more than just a tech. Not doubting the techs, but sometimes you need a clinical person […] It's like with anything, you implement, you reassess, and you change as you go.
	Need for CVT champion	CVT champions play an important role in facilitating CVT use.	I think it would be hard without one person spearheading it. [The CVT champion] really took the reins on it, and has made a lot of connections with [remote sites and leadership]. I really think [the CVT champion] paved the way for telehealth here.
	Value of supplementing online training with in-person training	Supplemental in-person training gives providers a hands-on opportunity to practice with CVT technology.	I think the online training is useful, but I think the negatives with the online training is you sit for an hour or two and you learn via just watching the computer screen and I'm a hands-on person and I have to learn by redundantly doing something over and over again and the problem is that if I'm not doing it while I'm reading or looking at this system, it doesn't really help me.
	Providers training providers	Providers who are comfortable with CVT technology can share their experiences and knowledge with other healthcare team members.	We have a robust telehealth program, so there are lots of experienced providers that are comfortable with telehealth that can mentor newer providers. I think it's important to have some people that are very comfortable with it and experienced with it to help the newer people and model how it can be done.
Workflow and communication	Communication about CVT activities	Communication about CVT activities (e.g., scheduling) facilitates process.	We connect with each other and there's an expectation that the team is there and ready to go, and our team is here and ready to go. I organize our team, I take responsibility for that. She and I have had a lot of communication. We instant message each other, we set it up well. Then we proceed with the patient.
	Communication about patient medical information	Communication about patient's medical history and symptoms ensures that health concerns are addressed effectively.	Their [patients with SCI/D] discharges are very complicated and very complex and trying to set up healthcare and resources for them. It's important that we all talk and we're on the same page.
			I think getting the [patient] information beforehand of what is needed is the key thing and trying to make sure that the visit is focused and to the point […] because if you have a doctor sitting on the other end, you don't want to be going over 50 different things if you're there to talk about one or two things.
	Establishment of healthcare team communication, trust, and rapport	Establishing relationships between healthcare team members at both sites allows for open communication, and builds trust and rapport.	I think that it's really crucial that folks already have that relationship established well with the [distant facility], because if you have that in place, [CVT] is just like icing on the cake. […] If you don't communicate well with them, if you don't have that whole idea of how you're going to co-manage patients, adding this on with the technology, the extra time, is a beast to even attempt because you don't already have that rapport.
			I can see who my counterparts are at the center, I get to actually see them and they see me. I think it establishes a little more rapport and it's more personal. It feels like more like you're interacting with an extension of your own team, just by being able to see them and communicate.
			I don't really know the providers at [the other facility], and they don't really know me that well, so there's an issue of trust there. It's like, “How do we know that her clinical judgment is appropriate? We don't know her as a provider.” So part of it is establishing that relationship and then over time developing that relationship so that they can make a more accurate determination of whether you're making clinically sound judgments.
Internal organizational policies, procedures, and culture	Support and resources from leadership	Receiving support and resources from leadership facilitates the effective implementation of CVT.	We had an executive leadership group that said, “This is the Director's directive and he's right, and we need to reach out to these patients. We're going to develop a department for you. We're going to give you a chief physician and we're going to hire people into those roles and you have our support and it's an expectation said of you, and you will do this,” and we did. You have to have support from the top.
System measurement and monitoring	Efficiency of using CVT technology	CVT technology allows for open communication between multiple healthcare team members to address the patient's needs in a timely manner.	We had two surgeons, one on my end and one on their end communicating face-to-face on the veteran's condition. That just seemed like a better way to have a difficult conversation about a very complex medical issue. It's better than reading the chart note in remote data, better than email because it was real time, and I think it was valuable. […] I think those two surgeons accomplished a weeks-worth of work and consultation in less than an hour by being able to do it that way.
	Value of using CVT technology for preventive healthcare	CVT technology allows for healthcare team to connect and intervene more frequently with patients, which can prevent issues.	The more preventive healthcare we can do, the fewer hospitalizations, wounds, UTIs, and pneumonia they're going to have. They see us four times a year, instead of twice a year. They're going to be healthier.
	Value of using CVT technology to engage patients	CVT technology gives patients the opportunity to interact with their healthcare team as a whole, and participate in their healthcare decisions.	The benefits [of CVT] for being transferred out into the world for the first time if you're a spinal cord injured patient, are comfort, quality, consistency in care, and a more effective and efficient handoff from provider to provider group. It's an opportunity for the veteran to see their whole multidisciplinary team and realize that they're not just alone.