Decision-making Factors Associated with Telehealth Adoption by Patients with Heart Failure at Home: A Qualitative Study

Abstract

Telehealth has been reported to be effective in helping patients with heart failure manage their symptoms at home. Despite this, the adoption rate for telehealth among home care patients with heart failure is low and there is limited research on reasons for this. This paper was undertaken to explore factors associated with patients’ decisions to adopt telehealth at home. A qualitative descriptive study underpinned by the Unified Theory of Acceptance Use of Technology model was conducted using semi-structured telephone interviews with patients with heart failure (N=20) referred for telehealth. Interviews were analyzed using a mixture of deductive and inductive coding. Among the theoretical model elements, the perceived usefulness of the technology (performance expectancy), the availability of clinical/technical support (facilitating conditions), and the opinion of other individuals important to the patient (social influence) were associated with telehealth initiation. However, the ease of use (effort expectancy) was not an associated factor. Other factors such as experience, knowledge, confidence, satisfaction, and attitudes, were also associated with the decision. Identification of factors related to higher telehealth initiation rates can be used to inform individualized care planning by nurses. Knowledge of such associations can inform referral process to improve the efficiency and utilization of telehealth.

Introduction

Although telehealth has been shown to be an effective intervention to help patients with heart failure (HF) manage their symptoms at home, patients’ initiation rates across the globe for telehealth care services are still lower than desirable.^1,2 Building on previous studies to identify determinants of telehealth adoption, the aim of this study was to explore the factors associated with decision-making of telehealth initiation in patients with heart failure admitted to a large home care agency in the US.

Background

Previous evidence of use of telehealth

Telehealth is the use of electronic information and telecommunications technologies to support patients and clinicians separated by distance³ and has the potential to assist in monitoring the health of individuals with chronic disease. Telehealth has been reported to reduce re-hospitalization and related expenses among HF patients in several studies.^4,5 However, the rates of initiation of telehealth has been reported to be low in many countries. For example in the UK, the overall uptake of telehealth has been slower than anticipated although the mainstreaming of telehealth is supported by UK government policy.¹ In Germany, up to 70% of eligible HF patients fail to initiate telehealth services.² In the US studies have reported refusal rates around 22–23% from randomized controlled trials.^6,7

HF management remains a key challenge in older adult care in both Europe and the US. HF is one of the leading causes of hospitalization among people above 65 years of age in many European countries, costing almost 2% of the total health care budget.⁸ In the US, the average program payment increased by 8% from 1997 to 2012 related to HF patients in Medicare home care service.⁹ Home health care services are growing to integrate care between acute care settings and the home to mitigate patients’ care burden and assist with disease self-management. In Europe, in an effort to find effective solutions, home-based care has been reported to be associated with a reduction in hospital stay; for example, Stewart et al reported a 37% decrease in cardiovascular-hospitalization days for patients cared for at home, compared with clinic-based management.¹⁰ In the US, home health care is a specific Medicare benefit provided to homebound individuals who are ill or injured and require intermittent (part-time) skilled nursing services or skilled therapy.¹¹ Home health care agencies serve approximately 3.7 million individuals, resulting in $18.2 billion in total Medicare payments in 2015.¹² Of the Medicare beneficiaries discharged from hospital into other care services, 37.4% were sent home and received home health services,¹³ and 69% were older than 65 years.¹⁴ As HF is one of the most frequent primary diagnoses for home health recipients¹⁴ in the US, assisting HF self-management at home can be crucial for this population.

Factors associated with adoption of telehealth

There is little existing research that explores the factors associated with patients’ decision making related to the initiation of telehealth services. The majority of existing studies have focused on patients’ views of the usability of telehealth systems^15,16 or their satisfaction after use of telehealth^17,18 rather than their decision regarding whether to use the service or not in the first place. Furthermore, it is reported that less information is available on those who have refused to use telehealth services.¹⁹ A recent review by Woo & Dowding (2017) found only five studies that have been conducted to explore the factors associated with patients’ decision-making regarding telehealth initiation for HF patients at home. The few studies that do exist that have explored factors associated with telehealth initiation in patients who have a number of chronic conditions such as HF and diabetes or asthma, thus it is difficult to separate out HF patients from other patients who have received telehealth. These studies suggest that concerns over technology or equipment, concerns over service change, or ease of use may impact patients’ decision making.²⁰ However, it is still unclear what factors may influence whether or not patients with HF decide to initiate telehealth services in a home care population. Thus, this research tried to address the question: What factors affect HF patients’ decision-making to adopt or decline telehealth at home?

Conceptual Framework

The theoretical basis for examining barriers and facilitators to telehealth initiation for this study was informed by the Unified Theory of Acceptance Use of Technology (UTAUT) model²¹ (Figure 1). This model is one of the most comprehensive frameworks available for studying decision making related to technology adoption and has been used in several studies.^19,22,23 The UTAUT consists of 4 constructs Venkatesh, Morris, Davis, Davis:²¹

Figure 1.

The Unified Theory of Acceptance Use of Technology (UTAUT) model

Source: Venkatesh V, Morris MG, Davis GB, Davis FD. User Acceptance of Information Technology: Toward a Unified View. MIS Quarterly. 2003;27(3):425–478. Reprinted with permission.

• Performance Expectancy - the extent to which use of a technology is expected to assist in performing particular activities

• Effort Expectancy - the degree of ease expected with the use of the technology/system

• Social Influence – the extent to which important others are believed to think the individual should use the technology/system

• Facilitating Conditions - the extent to which an individual believes that technical support exists to aid their use of the technology/system (Table 1).

Table 1.

Description of the UTAUT elements

Main Element	Root Construct	Definition
Performance Expectancy	Perceived usefulness	The degree to which a person believes that using a particular system would enhance his or her job performance.
	Extrinsic motivation	The perception that users will want to perform an activity because it is perceived to be instrumental in achieving valued outcomes.
	Job-fit	How the capabilities of a system enhance an individual’s job performance.
	Relative advantage	The degree to which using an innovation is perceived as being better than using its precursor.
	Outcome expectations	Outcome expectations related to the consequences of the behavior whether using the system would increase quality and quantity of output.
Effort Expectancy	Perceived ease of use	The degree to which a person believes that using a system would be free of effort.
	Complexity	The degree to which a system is perceived a relatively difficult to understand and use.
	Ease of use	The degree to which using an innovation is perceived as being difficult to use.
Social Influence	Subjective Norm	The individual’s internalization of the reference group’s subjective culture, and specific interpersonal agreements that the individual has made with others, in specific social situations.
	Social Factors	The degree to which use of an innovation is perceived to enhance one’s image or status in one’s social system.
	Image	The degree to which use of an innovation is perceived to enhance one’s image or status in one’s social system.
Facilitating Conditions	Perceived behavioral control	Reflects perceptions of internal and external constraints on behavior and encompasses self-efficacy, resource facilitating conditions, and technology facilitating conditions.
	Facilitating conditions	Objective factors in the environment that observers agree make an act easy to do, including the provision of computer support.
	Compatibility	The degree to which an innovation is perceived as being consistent with existing values, needs, and experiences of potential adopters.

The study

Aim

The aim of this study was to investigate factors that affect HF patients’ decision-making to adopt or decline telehealth at home

Design

A qualitative descriptive study utilizing individual semi-structured telephone interviews.

Participants

The sample population was drawn from patients served by one of the largest not-for-profit home care agencies in the US. The organization provides services to an ethnically diverse patient population across New York City as well as Nassau and Westchester counties. It currently has a Bundled Payment for Care Improvement (BPCI) program for patients with heart failure and heart attack. Patients with a heart failure diagnosis and at risk for hospitalization, who are also functionally able and agreeable to participating in telehealth (see Figure 2 for the full eligibility criteria) are referred by the organization for telehealth services—paid by the BPCI program—to aid in self-monitoring of their condition at home (see Figure 3 for the actual telehealth equipment used for the study). Participants were recruited from those who were referred for telehealth services with HF in their diagnosis between September 2017 and December 2017. The telehealth referral and initiation process is illustrated in Figure 2. Purposive sampling was used to sample HF patients who were categorized as either initiating or non-initiating telehealth services. Maximum-variation sampling was used to ensure the sample had a wide range of perspectives to capture the broadest set of information and experiences.²⁴

Figure 2.

Flow Chart of Home Care Telehealth Referral and Initiation

Figure 3.

Telehealth Equipment

• Wireless equipment
• The Telehealth Monitor is connected to a standard home electrical outlet

As recommended by Elo et al.²⁵ and to make sure data saturation was achieved, a preliminary analysis was started after 2–3 interviews had been conducted and stopped after data saturation was met. Data saturation is often used to judge information adequacy and defined as the point at which no new information, categories, or themes emerge.²⁶

Data collection

Potentially eligible patients, (patients with HF who were referred for telehealth and either initiated or non-initiated the service) were identified from telehealth referral lists and contacted by a research assistant independent of the study investigators. A recruitment grid was constructed that outlined the key variables for sampling (e.g., patient initiation status, age, location), which was used to map patient characteristics to inform the sampling procedure. Once potential participants had been identified, they were contacted by the staff member, who a) conducted a cognitive screening to ensure that the patient was able to consent to participate in the study and in a telephone interview,²⁷ and b) obtained verbal consent from them for the PI to contact them further about the study. The patient’s name and contact details was given to the PI only after eligible patients had passed the cognitive screening and provided verbal consent to be contacted. Recruitment was conducted simultaneously with the interviews and stopped once data saturation had been achieved.

Telephone interviews were conducted with all consenting patients. Many point to logistical conveniences and other practical advantages of telephone interviews, such as enhanced access to geographically dispersed interviewees, reduced costs, increased interviewer safety, and greater flexibility for scheduling.²⁸ Since this research aimed to recruit patients within the home care agency across a geographically diverse region (covering the 5 boroughs of New York, Nassau and Westchester counties) a telephone interview was considered to be a suitable method of data collection within the limited budget and time.

A non-directive style of interviewing using semi-structured and open-ended questions was used allowing the participants the freedom to control pacing and subject matter of the interview. Interview questions and probes were based on the four predictors in the UTAUT (Performance Expectancy, Effort Expectancy, Facilitating Conditions, and Social Influence) (Figure 1). Probes were used for answers that were vague or ambiguous when the researcher felt a need for more specific or in-depth information (Table 2). All interviews were recorded and subsequently transcribed for the purpose of analysis. All participants were given a $20 gift card via mail in appreciation for their time. Interviews were conducted until data saturation was met.

Table 2.

Participant characteristics

		Participants
		N=20
		n (%)
Age (years)
	Mean (SD)	72.6 (13.4)
	Median	72.5
Gender
	Male	9 (45)
	Female	11 (55)
Race/Ethnicity
	Hispanic-other	2 (10)
	Non-Hispanic, African American	9 (45)
	Non-Hispanic, White	9 (45)
Telehealth initiation status
	Initiated	13(65)
	Non-Initiated	7(35)

Ethical considerations

Approval was received from both the home care organization and the University IRB committees prior to recruitment. The participants received an information sheet describing the purpose of the study and the study was also explained verbally before they provided consent prior to the interviews.

Data Analysis

Data were analyzed using a mixture of deductive and inductive coding. As a conceptual framework with four constructs was guiding this study, a deductive approach (categorizing guided by conceptual constructs used) was used for coding. In addition, pertinent data derived from the data that were not explained by the conceptual framework were derived using inductive coding. All records were transcribed and were then be coded by two researchers separately. Codes were grouped using an iterative process in order to identify similar categories and themes, using constant comparative analysis methods.²⁹ A qualitative analysis software program, NVivo V11 (QSR International, Doncaster, Australia), was used to assist the coding process. Once coded and categorized, themes and coded data were compared between the two researchers for any discrepancies and consensus was reached.

Rigor

Trustworthiness of qualitative research is determined by credibility, transferability, dependability, and confirmability^29,30 To achieve credibility in this study, an established theory was used for the interview guide and provided a framework for the data analysis. In addition, two researchers carried out coding independently. Probes were utilized to enhance the production of detailed context during the interview, and interviewer notes were added to the transcribed interview context for transferability. To ensure dependability in this study, the researcher kept detailed documentation of the coding schemes and the data analysis process.^26,29,30 The use of NVivo assisted in clarifying and objectifying these processes. In order to enhance the confirmability of the study, the PI kept a reflective journal to ensure that she reflected on how her personal characteristics, feelings, and biases may be influencing the work.^29,30

Findings

A total of 20 individuals were interviewed, 13 categorized as initiating telehealth and 7 who were identified as non-initiators. The characteristics of participants are shown in Table 3. The mean age of participants was 72.6 (S.D. 13.4) years with a median of 72.5 years. There were slightly more females (55%) than males, and the sample was ethnically diverse; White (45%), African-American (45%), and Hispanic-other (10%). Interviews ranged from 11 to 24 minutes with an average of 15 minutes.

Table 3.

Interview Guide (using the UTAUT model)

Domain	Questions	Probes
Performance Expectancy	Could you tell me about your decision to use telehealth monitoring in more detail? Do you think that using telehealth systems would help to manage your health at home?	Initiated: Why did you decide to use the telehealth monitoring systems? Not-Initiated: Why did you decide not to use the telehealth monitoring systems?
Effort Expectancy	How easy or difficult do you think using the telehealth system is (would be) at home? Why?	Initiated: Can you talk me through how you have learned to use the system? What things have you found easy or difficult about using the system? Not-Initiated: Can you talk me through how or why you think you would learn to use a telehealth system?
Social Influence	Could you tell me what your family/friends/caregivers think about you using the telehealth system?	Initiated: Can you tell me about reactions or opinions of your family/friends/caregivers in using telehealth monitoring? How much does their opinion matter to you in using telehealth system? Not-Initiated: Can you tell me how your family/friends/caregivers react or reacted regarding using the system? How much does their opinion matter to you in using telehealth system?
Facilitating Conditions	How easy or difficult do you think it would be/is to get guidance or support using the telehealth service at home? Why?	Initiated: Can you talk me through your experience of getting necessary support to use the system? Not-Initiated: Can you talk me through how or why you think you would or would not get assistance to use a telehealth system?

Three main constructs from the deductive analysis using the UTAUT were found to influence HF patients’ initiation decisions; Performance Expectancy, Facilitating Conditions, and Social Influence. All patients perceived the telehealth technology to be easy to use, meaning that the expected degree of ease associated with the use of the technology/system, was not identified as factor influencing telehealth initiation. In addition several themes were derived from the inductive analysis; experience using telehealth, knowledge of HF and telehealth, confidence in self-management and use of technology, satisfaction with current visiting nurse services, and attitudes toward life and technology. Experience using telehealth technology, which was previously identified as a moderator in the UTAUT model, appeared to be positively associated with initiation.

UTAUT factors

Overall, three of the four elements of the UTAUT were evident in reasons for initiation or non-initiation of telehealth services. The findings are further described below in terms of the UTAUT elements. Respondents are identified according to the telehealth initiation status for the quote.

Performance Expectancy

Performance expectancy, which is the degree to which using a technology is expected to help in performing certain activities, appeared to be the main factor driving either initiation or non-initiation of telehealth services. Where a participant had positive views of the benefits of the service, such as it being useful to help manage their symptoms and live longer, they were more likely to initiate the service. However, if they had negative perceptions of the service, such as telehealth is for very sick people and would not be useful if only for a few weeks while under home care, then they were less likely to initiate the service.

“If this is going to help, this installation, then I should do it…It will help me, keep me alive a little longer”

(Initiated)

“I told them to go to people who are really sick and need them…”

(Not-Initiated)

Effort Expectancy

All participants regardless of their initiation status reported that they expected the telehealth technology to be easy to use. This finding suggest that ease of use (effort expectancy) was not viewed as necessarily leading to patients’ decision-making regarding initiation of telehealth.

“I don’t think that would be difficult”

(Not-Initiated)

“I don’t have a problem with doing that because it’s just a matter of just putting it on…”

(Initiated)

Facilitating Conditions

The degree to which an individual believes that technical and organizational infrastructure exists to support their use of the technology/system (facilitating conditions), was also found to play a significant part in telehealth initiation. Technical or clinical support for telehealth system use was a facilitator, whereas personal assistance by family or a home health aid were seen to be barriers among patients who didn’t initiate the service.

“They would contact me and you know, have me take it again. They would try to figure out if there was a reason why the blood pressure was going up.”

(Initiated)

“My sister comes everyday to…give me my insulin and stay with me most of the day. I’m not here alone. (when asked “do you mean that you don’t need the help (telehealth) because…you have help around?”) that’s correct.”

(Not-Initiated)

Compatibility, defined as the degree to which the system fits well with the way patients’ like to work is a root construct of facilitating conditions. This also appeared to be an element associated with patient’s initiation of telehealth at home, with some patients discussing how the equipment might fit in their home, and linking this to their decisions regarding initiation.

“I don’t know what it looks like, or how big it is or where I would keep it…”

(Not-Initiated)

“It’s on the floor…because I had it on the floor…I had no place to put it…I did not like the second one…I sent it back”

(Initiated)

Social Influence

Unlike other elements of UTAUT, social influence was found to be the least frequently mentioned factor related to telehealth initiation by interview respondents. Only a few of the interviewees discussed or had an opinion from others regarding telehealth services, so the influence of social influence related to telehealth initiation appeared to be minimal. However, those who talked with others about telehealth services stated the others opinion mattered to their initiation decision.

Most participants either never discussed with others or had seen anyone using the telehealth system. Only one person from initiation group stated that they had discussed using telehealth with others (healthcare professionals) and their opinion mattered to her.

From the not-initiated group, two participants mentioned discussing using telehealth with others and only one was directly related to telehealth initiation.

“My sister. We talked about it…I asked her… and she agreed that I don’t need it”

(Not-Initiated)

The other one reported that everybody who he spoke to had thought telehealth was good when he previously used it but he was not informed of the service this time so did not initiate the service.

“Everybody thought it was a good thing. My family, the nurse, the doctor…no negative feedback. Everything was positive. “

(Not-Initiated)

Themes arising from inductive analysis

Alongside factors associated with the UTAUT a number of other factors appeared to influence whether or not patients initiated telehealth services. Factors that arose from inductive analysis are presented according to themes, with supporting quotes where appropriate (Table 4).

Table 4.

Factors from inductive analysis

Factors	Definition	Quotes
Experience using telehealth	Patients have previously used telehealth offered by home care service.	“I had had it many years ago…then now, we put it back on just for my peace of mind” (Initiated) “As far as my experience is concerned, it was a great experience. I had no, you know, I had no problem with it (telehealth)” (Not-Initiated)
Knowledge of telehealth and heart failure	Patients know what heart failure means and symptoms of heart failure. Patients know what telehealth means and specification of the services.	“I really don’t know too much about it (HF)…hardly anything I know. (When asked by the interviewer: you think that using telehealth would help to manage your health at home?) That’s why I accepted.” (Initiated) “I’m not too acquainted with heart failure. This is first time…my knowledge about what this heart failure is…hardly anything I know…that’s why I accepted (telehealth)” (Initiated) “I’d like to know about what is it. What’s the service?…I don’t know anything about it” (Not-Initiated) “No, I don’t. (when asked whether s/he knows what telehealth is)” (Not-Initiated)
Competency/confidence	Patients express competency in using any technology and in self-managing heart failure symptoms.	“I have my personal iPhone… I would say so (when asked whether s/he thinks technically savvy)…I think it’s a basic feel that most people have today (when asked whether s/he is aware of and using technology daily)” (Initiated) “… I have an iPhone and I use that for my email and things…these smart system with the weight, and that is very, very easy…” (Initiated) “I live in the 20th century, not the 21st. I have no computer. I have no cell phone. I have no connection with any 21st century digitation.” (Not-Initiated) “I don’t do emails. I don’t do none of that. I just still use a regular phone to do what I have to do.” (Not-Initiated) “…I can do it (checking weight and blood pressure) by myself. I do it myself all the time, so far…Like I said, I have my own (weight scale and BP machine)…” (Not-Initiated) “I did not need it (telehealth). I could take care of myself” (Not-Initiated)
Satisfaction with the visiting nurse service	Patients express satisfaction with current service home care services	“I go to seven doctors…they take very good care of me…it’s always being monitored, anyhow, throughout the week, you know by one or the other professionals that come in. I’m always on safe ground.” (Initiated) “I have my own scale, my own blood pressure machine. I’m breathing fairly all right, so I don’t need that oxygen now…(when asked whether s/he has been managing symptoms well so far) Yeah, so far…visiting nurse came to my house, they talk to me about it (telehealth) and I explained to them that I’m fairly well so far, but you know, I don’t need that(telehealth)…(when asked whether she is happy with current services) Yeah, So far.” (Not-Initiated) “The doctor call, the nurse is coming… if I have a problem, I appreciate your services, but I believe any problem I have, my sister will be able to take care of me.” (Not-Initiated) “I enjoy visiting nurse coming… if there was something going wrong with me, I would rather get in touch with the nurse service and have a human being come, rather than depend on the machine” (Not-Initiated)
Attitudes towards life and technology	Patients value independence. Patients express positive or negative attitudes toward use of technology.	“I enjoy visiting nurse coming… if there was something going wrong with me, I would rather get in touch with the nurse service and have a human being come, rather than depend on the machine” (Not-Initiated) “I think it (technology) would cause me more trouble” (Not-Initiated)

Experience using telehealth

Previous experience using telehealth services was identified as a factor related to telehealth initiation. This factor is one of the four moderators in UTAUT model that influences the magnitude of the relationship and appeared to strengthen the initiation activity if participants have used it before.

“I had had it many years ago…then now, we put it back on just for my peace of mind”

(Initiated)

There was also evidence of experience having a positive influence on telehealth initiation even in those patients who had not actively initiated telehealth services. One patient who was not informed about telehealth on this admission to home health care stated he would have accepted it if it were offered based on his positive previous experience with telehealth.

“As far as my experience is concerned, it was a great experience. I had no, you know, I had no problem with it (telehealth)”

(Not-Initiated)

Knowledge of HF or telehealth

Knowledge of HF was identified as a factor related to the initiation of telehealth. Patients who recognized their lack of knowledge on HF initiated telehealth hoping it would help with the management of their symptoms at home.

“I really don’t know too much about it (HF)…hardly anything I know. (When asked by the interviewer: you think that using telehealth would help to manage your health at home?) That’s why I accepted.”

(Initiated)

“I’m not too acquainted with heart failure. This is first time…my knowledge about what this heart failure is…hardly anything I know…that’s why I accepted (telehealth)”

(Initiated)

Knowledge of telehealth was also related to experience, as patients who experienced telehealth knew what using the technology entails. Particularly in this study, the lack of knowledge on telehealth appeared to be related to non-initiation.

“I’d like to know about what is it. What’s the service?…I don’t know anything about it”

(Not-Initiated)

“No, I don’t. (when asked whether s/he knows what telehealth is)”

(Not-Initiated)

Confidence in use of technology and self-management

Personal competency with use of any kind of technology was related to telehealth initiation. Patients who initiated telehealth expressed technology competency, when asked, using smart phones or emails in daily life.

“I have my personal iPhone… I would say so (when asked whether s/he thinks technically savvy)…I think it’s a basic feel that most people have today (when asked whether s/he is aware of and using technology daily)”

(Initiated)

“… I have an iPhone and I use that for my email and things…these smart system with the weight, and that is very, very easy…”

(Initiated)

On the contrary, those who did not initiate telehealth expressed non-familiarity or non-usage of recent technologies.

“I live in the 20^th century, not the 21^st. I have no computer. I have no cell phone. I have no connection with any 21^st century digitation.”

(Not-Initiated)

“I don’t do emails. I don’t do none of that. I just still use a regular phone to do what I have to do.”

(Not-Initiated)

As long as patients recognize telehealth as a ‘technology’ rather than a part of ‘routine service,’ technology competency would affect patients decision-making whether to initiate telehealth or not.

Confidence in self-management of their condition may also be associated with telehealth non-initiation. Patients who expressed that they were confident in taking care of their own health were reluctant to engage with telehealth. However, whether lack of confidence in self-management is a factor in patients’ decisions to initiate telehealth wasn’t identified in interviews with patient’s who initiated the service.

“…I can do it (checking weight and blood pressure) by myself. I do it myself all the time, so far…Like I said, I have my own (weight scale and BP machine)…”

(Not-Initiated)

“I did not need it (telehealth). I could take care of myself”

(Not-Initiated)

Satisfaction with current service with visiting nurses

Expression of satisfaction with current services was reported in both initiated and non-initiated groups. However, the theme was evident in driving forward telehealth non-initiation.

“I go to seven doctors…they take very good care of me…it’s always being monitored,… I’m always on safe ground.”

(Initiated)

“I have my own scale, my own blood pressure machine. I’m breathing fairly all right, so I don’t need that oxygen now…(when asked whether s/he has been managing symptoms well so far) Yeah, so far…visiting nurse came to my house, they talk to me about it (telehealth) and I explained to them that I’m fairly well so far, but you know, I don’t need that(telehealth)…(when asked whether she is happy with current services) Yeah, So far.”

(Not-Initiated)

As a component of their satisfaction with their current service, patients reported a preference for having human contact through the nurse home visits.

“I enjoy visiting nurse coming… if there was something going wrong with me, I would rather get in touch with the nurse service and have a human being come, rather than depend on the machine”

(Not-Initiated)

Attitude toward life and technology

Attitudes towards technology was tested in the original UTAUT model as a potential construct for technology acceptance and determined not to be a direct determinant of intention to use technology.²¹ However, in this study attitudes toward technology appeared to be associated with telehealth initiation. Patients who had not initiated telehealth appeared to have negative attitudes toward technology in general.

“I think it (technology) would cause me more trouble”

(Not-Initiated)

One’s beliefs and values combined with other factors also appeared to be a barrier to telehealth initiation. Patients who viewed themselves and independent were more likely to refuse telehealth services.

“I’ll just die and then it’s over with, but I do not want anyone telling’ me what to do.”

(Not-Initiated)

“I live here by myself… I do everything by myself in my house. I live alone.”

(Not-Initiated)

Discussion

This study aimed to explore factors associated with HF patients’ decisions to initiate telehealth services when discharged from the hospital to home. The study found that patient’s decisions could be in part explained by three main constructs in the UTAUT model; Performance Expectancy (perceived benefits), Facilitating Conditions (perceived control and technical/clinical support), and Social Influences (opinion from important others). The construct Effort Expectancy (perceived ease of use) was found to be unrelated to telehealth initiation, as all patients interviewed in the study perceived the technology to be easy to use. This study has also highlighted how other factors such as previous experience using telehealth, having knowledge of HF and telehealth, showing confidence in self-management and use of any kinds of technology, expressing satisfaction with current visiting nurse services, and valuing independence in life, may also be associated with the decision.

Overall the benefits patients’ perceived to be associated with telehealth were key for telehealth adoption. This finding is very well supported by other studies that have explored HF patients’ telehealth adoption at home.^31–34 One study particularly identified the potential benefits of telehealth perceived by HF patients; increased access to care, the earlier indication of a worsening condition (in other words monitoring conditions well), increased knowledge, saving both nurses’ and patients’ time, and greater convenience.³² In our study, the perceived benefits were expressed as useful managing patients’ HF symptoms and helping them live longer.

While Social Influence is one of the central concepts of the technology acceptance model we employed, very few interviewees discussed telehealth services with others, thus suggesting that social influence had a minimal influence on telehealth initiation for the patients in our study. This finding may be due to the particular circumstances of home HF patients. As described earlier in the sample, the interviewees are primarily homebound, with multiple chronic conditions, and are on average 72 years old, thus limiting their contact and information sharing with other people.

Patients’ perceptions of the ease of use of telehealth technology did not appear to be an influencing factor in this study. Mixed findings have been reported on telehealth usability from various studies depending on the different types and versions of telehealth devices. Some studies have identified telehealth as easy to use^35,36 while others identified usability as a barrier.^31,34 In our study, the patients uniformly expressed perceived ease of use for telehealth. This phenomenon can be explained due to the fact that the telehealth device used in this study is very simple (see Figure 3) involving only three units: a blood pressure cuff, pulse oximeter, and weight scale (with the glucometer only for diabetic patients). Those studies that reported ease of use as a barrier to telehealth adoption used more complex technology, such as ECG monitoring using a mobile phone or a web page.^31,34

Experience previously using telehealth was found to be associated with telehealth adoption in our study. Findings from previous telehealth studies that compared pre- and post-telehealth use also found that experience using telehealth leads to favorable changes in perception.³¹ With consideration of these findings, promoting a trial use of telehealth to HF patients before or when they are discharged from the hospital would possibly increase telehealth adoption.³⁷ Increased telehealth initiation may be in part attributable to patient familiarity with technological features that were preferred by the patients interviewed in the initiation group. For patients without previous experience with telehealth, its system features such as digital voice instruction and reading back results can be described when referring patients to the service to promote knowledge of telehealth. Experience, knowledge, and knowing telehealth features are all closely related and can be important factors that can be considered in advance of referral, boosting initiation.

How the individual feels about using any technology at home was found to be associated with telehealth initiation. These feelings regarding technical competency was also reported in other studies to be related to telehealth acceptance.^{32,33,38–40} Hall, Dodd, Harris, McArthur, Dacso, Colton³² used the term “self-efficacy” and indicated low computer use self-efficacy as a barrier to telehealth use. Sanders, Rogers, Bowen, Bower, Hirani, Cartwright, Fitzpatrick, Knapp, Barlow, Hendy, Chrysanthaki, Bardsley, Newman⁴⁰ identified technical competency as a barrier, describing patients who expressed estrangement from modern technologies who refused telehealth. Confidence in HF symptom self-management was also found to be related to telehealth initiation in the current study. Contrary to Nguyen, Keshavjee, Archer, Patterson, Gwadry-Sridhar, Demers,³⁹ who found in older HF patients high confidence levels in managing their conditions at the time of hospital discharge, in the present study very few patients reported confidence in HF symptom self-management. And those who did express this confidence were less likely to initiate telehealth.

Strengths and Limitations

There are a number of limitations to the study that need to be acknowledged. It was conducted in one home care agency located in New York City, where the population and services available to patients may be different from other areas of the US. In addition, the interview was limited to only for those English speakers, and as with all qualitative studies the sample may not be representative of the broader patient population. However, the study utilized a number of strategies, such as having two researchers conducting data analysis, and the use of a theoretical model to provide conceptual underpinnings to the study findings to increase study credibility. In addition, information regarding the characteristics of the study participants is provided to enable an evaluation of the transferability of the findings to other settings.

Conclusion

This study provides new insights on the factors associated with HF patients’ decisions to initiate telehealth services at home. Employing the UTAUT model, we found that patient perceptions of telehealth benefits, the availability of clinical/technical support, and the opinion of significant others were related to HF patient telehealth initiation in a home care setting. However, patients’ perceived ease of use of telehealth was not a contributing factor. Other factors such as experience using telehealth, knowledge of telehealth, and knowledge of HF also appeared to influence patients’ decision making. Based on the findings, future telehealth policies and implementation strategies can focus on communicating the benefits and specific features of telehealth. This can be done through healthcare professionals reinforcing the benefits of telehealth to patients, providing patients with hands-on experience before discharge, and ensuring necessary clinical and technical support.