dr s cooper dissertation
TRANSCRIPT
Opinion Leaders’ Perspective of the Benefits and Barriers in Telemedicine:
A Grounded Theory Study of Telehealth in the Midwest
by
Shelley Brown Cooper
An Applied Dissertation Submitted to the
Abraham S. Fischler School of Education
in Partial Fulfillment of the Requirements
for the Degree of Doctor of Education
Nova Southeastern University
2014
ii
Approval Page
This applied dissertation was submitted by Shelley Brown Cooper under the direction of
the persons listed below. It was submitted to the Abraham S. Fischler School of
Education and approved in partial fulfillment of the requirements for the degree of
Doctor of Education at Nova Southeastern University.
Michael Simonson, PhD Date
Committee Chair
Linda Yopp, PhD Date
Committee Member
Ronald J. Chenail, PhD Date
Interim Dean
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Statement of Original Work
I declare the following:
I have read the Code of Student Conduct and Academic Responsibility as described in the
Student Handbook of Nova Southeastern University. This applied dissertation represents
my original work, except where I have acknowledged the ideas, words, or material of
other authors.
Where another author’s ideas have been presented in this applied dissertation, I have
acknowledged the author’s ideas by citing them in the required style.
Where another author’s words have been presented in this applied dissertation, I have
acknowledged the author’s words by using appropriate quotation devices and citations in
the required style.
I have obtained permission from the author or publisher—in accordance with the required
guidelines—to include any copyrighted material (e.g., tables, figures, survey instruments,
large portions of text) in this applied dissertation manuscript.
Signature
Shelley Brown Cooper
Name
Date
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Acknowledgments
Thanks to my dissertation chair Michael Simonson, PhD, and committee member
Linda Yopp, PhD, for their guidance and expertise. A special note of appreciation to Dr.
Simonson for his encouragement and no-nonsense advice: It helped me “get off my duff
and finish this thing.”
To my friends, thank you for your continued support. Thanks also for your
understanding when I was AWOL at numerous gatherings. To my family, thank you for
allowing me to disappear into my office night after night. I am grateful to you for
withholding your complaints to fast food and backed-up laundry.
Most important, thank you to my husband, Mitch. You listened to my ideas,
wiped away my tears, quelled my anxiety attacks, and shared my excitement during this
life-changing journey.
In Memoriam
Gloria McShann-Blue
Carl Vernon Hubbell
William Miles Brown, Jr.
Silla
Philippians 4:13 I can do all things through Christ who strengthens me.
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Abstract
Opinion Leaders’ Perspective of the Benefits and Barriers in Telemedicine: A Grounded
Theory Study of Telehealth in the Midwest. Shelley Brown Cooper, 2014: Applied
Dissertation, Nova Southeastern University, Abraham S. Fischler School of Education.
ERIC Descriptors: Diffusion of Innovations Theory, Telemedicine, Opinion Leaders,
Grounded Theory, Hospitals
This applied dissertation provided a better understanding of how opinion leaders
influence the adoption of innovative programming, such as telemedicine, among hospital
administrators in the Midwestern region of the United States. Rogers’ (2003) Diffusion of
Innovations theory was applied to gather a better understanding of the adoption of
telemedicine at the Midwest hospitals. An exploration into the effects of opinion leaders’
influence on administrators provided a focus into this process. As a result of providing a
better understanding of this adoption process, additional innovative medical methods
such as electronic health records, mobile devices, and other forms of medical technology
might be more easily accepted by hospitals.
A demographic protocol instrument gathered personal data on the chief executive officers
and other administrators at 18 hospitals and health care organizations within the Greater
Kansas City Area. In addition, the Innovativeness Scale and Perceived Organizational
Innovativeness Survey (PORGI) were administered to measure individual and
organizational innovativeness. Face-to-face interviews and telephone interviews with the
chief administrative officers using open-ended questions provided rich data regarding the
origins of telemedicine development within each organization. Advantages and
challenges of telemedicine efforts were explored.
An analysis of the data revealed that a modest relationship exists between the key
telemedicine leaders’ level of innovativeness and the perceived level of organizational
innovativeness. The most successful activities were those that involved interviews with
hospital administrators. These interviews resulted in five themes related to Rogers’
(2003) Diffusion of Innovations theory: financial feasibility; resistance to change and
acceptance of new technology; access to specialists or subspecialists; collaborative
governance; and champion or opinion leader roles in the adoption process. Drawbacks
from this study included limited sample size and narrow geographical area. As a result of
this study, it was discovered that additional research on this topic is needed that should
include interviews and focus groups consisting of legislative bodies, vendors, and a
variety of health care professionals to obtain a deeper understanding of external factors
related to telemedicine adoption.
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Table of Contents
Page
Chapter 1: Introduction ........................................................................................................1
Phenomenon of Interest ...........................................................................................2
Background and Justification ...................................................................................3
Deficiencies in the Evidence ....................................................................................6
Audience ..................................................................................................................7
Definition of Terms..................................................................................................7
Purpose of the Study ..............................................................................................10
Chapter Summary ..................................................................................................13
Chapter 2: Literature Review .............................................................................................14
Purpose Statement ..................................................................................................14
Distance Education ................................................................................................15
History of Telemedicine ........................................................................................17
Factors That Contribute to Telemedicine Implementation ....................................17
Needs for Telemedicine .........................................................................................17
Barriers to Telemedicine in the United States .......................................................20
Telemedicine in the Midwest .................................................................................22
Kansas ....................................................................................................................23
Diffusion of Innovations ........................................................................................27
International Telemedicine ....................................................................................33
Benefits and Barriers Identified by Literature (International) ...............................42
Theoretical Framework–Diffusion of Innovations ................................................45
Additional Diffusion Literature .............................................................................47
Importance of Opinion Leaders .............................................................................54
Characteristics of Opinion Leaders ........................................................................56
Research Questions ................................................................................................64
Limitations .............................................................................................................65
Chapter 3: Methodology ....................................................................................................67
Aim of the Study ....................................................................................................67
Qualitative Research Approach .............................................................................67
Rationale for Grounded Theory Study ...................................................................68
Participants .............................................................................................................69
Data Collection Tools ............................................................................................71
The Innovative Survey ...........................................................................................72
The Perceived Organizational Innovativeness Survey ..........................................72
Procedures ..............................................................................................................73
Data Analysis .........................................................................................................74
Conducting the Interview .......................................................................................74
Ethical Considerations ...........................................................................................75
Trustworthiness ......................................................................................................76
Data Collection ......................................................................................................80
Potential Research Bias..........................................................................................82
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Limitations .............................................................................................................82
Chapter Summary ..................................................................................................82
Chapter 4: Findings ............................................................................................................84
Overview ................................................................................................................84
Participants .............................................................................................................84
Interviews ...............................................................................................................86
Interview Questions ...............................................................................................86
Data Collection Instruments and Reliability ..........................................................88
Results of Data Collection Instruments .................................................................91
Normative Group Innovativeness Scale.................................................................93
IS ............................................................................................................................94
PORGI Scale ..........................................................................................................95
Comparison of Normative Group PORGI and IS Results to Participants’
Results ....................................................................................................................96
Qualitative Data .....................................................................................................99
Grouping by Question ............................................................................................99
Data Analysis .......................................................................................................104
Discussion ............................................................................................................106
Chapter 5: Discussion ......................................................................................................107
Approach ..............................................................................................................107
Meanings and Understandings .............................................................................110
Implications of the Study .....................................................................................112
Relevance of the Study ........................................................................................117
Recommendations Based on the Results of the Study ........................................118
Conclusions and Recommendations for Further Research ..................................119
References ........................................................................................................................121
Appendices
A Interview Protocol for Hospital Administrators ...........................................141
B Demographic Information Document ..........................................................143
C Innovativeness Scale .....................................................................................146
D Organizational Innovativeness Scale ............................................................148
E Interview Questions ......................................................................................150
F Telephone Interview Guide ..........................................................................152
Tables
1 Methods, Techniques, Advantages, Disadvantages, and Instruments Used for
Identifying Opinion Leaders ...........................................................................39
2 Key Leaders’ Age Descriptions ......................................................................92
3 Key Leaders’ Gender Classifications .............................................................92
4 Key Leaders’ Ethnic Descriptions ..................................................................92
5 Key Leaders’ Educational Attainment ............................................................92
6 Key Leaders’ Professional Status Descriptions ..............................................94
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7 IS Scores .........................................................................................................98
8 PORGI Scale Scores .......................................................................................98
9 Pearson Correlation Matrix Among PORGI, IS, and Age ..............................98
10 Top Five Themes in Order of Frequency .....................................................118
Figures
1 Adopter Categorization on the Basis of Innovativeness ................................94
2 Distribution of Normative Population Scores: Individual Innovativeness
Scale Scores for the Normative Group ...........................................................95
3 Telemedicine Leaders’ Distribution of IS Scores ...........................................96
4 Distribution of Normative PORGI Scale Scores ............................................97
5 Telemedicine Leaders’ Distribution of PORGI Scale Scores .........................97
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Chapter 1: Introduction
Statement of the Problem
Should your address determine whether you live or die (Christopher, 2013)? Even
though medical innovations have had an enormous effect on society, there continue to be
areas where health care is not readily available. When a Nigerian mother of four dies
shortly after giving birth because postpartum medical care and education were
unavailable to her, it is a tragedy for her family and friends (Oyedepo Olukayode,
personal communication, July 20, 2014). Telemedicine provides a needed service by
connecting patients and health care providers who are separated by distance, time and
accessibility. Miller (2001) detailed, “the advantages of telemedicine in improving rural
access to high quality specialist care” (p. 1). It will provide health care education,
increase doctor-patient interactions, and bring specialty services to underserved areas. It
is clear: telemedicine can save lives.
Meanwhile, when on the other side of the world, elderly patients in rural towns
vie for access to physicians who are scarce and specialists who are seldom obtainable,
unnecessary medical conditions often result (Craig, 2013). The medically unserved,
underserved, and technologically disenfranchised do not have equal access to equitable
medical attention. Providing health care services and medical education from a distance
could decrease the gap in services among populations. The purpose of this qualitative
study was to explore the opinion leaders’ perspective of the benefits and barriers in
telemedicine and their influence on the adoption of such innovative medical processes by
administrators at hospitals and health care facilities within the Greater Metropolitan
Kansas City area (GMKCA).
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Phenomenon of Interest
Telemedicine is a promising technology that can reduce physical and monetary
burdens of patients traveling to distant hospitals in order to have medical consultations
and increase educational sessions in a local area. Telemedicine consists of medical
services delivered from a distance. Specifically, it is the “delivery of health care and the
exchange of health care information across distances, including tele-education and
distance treatment” (Wootton, Craig, & Patterson, 2011, p. 4). Early uses of telemedicine
occurred over 50 years ago; one involved distance and the second concerned traveling
through city traffic. The first took place in 1959 between the Nebraska Psychiatric
Institute in Omaha and the state mental hospital in Norfolk, 112 miles away.
Telepsychiatry was achieved when consultations between general practitioners and
consultants used closed circuit television to care for psychiatric patients (Norris, 2002).
Another example occurred in Boston, Massachusetts between Massachusetts General
Hospital and Logan International Airport Medical Station in 1968. Air passengers
received emergency care and air employees got occupational health services using
telemedicine (Norris, 2002). In addition, telemedicine has benefited isolated, underserved
populations that do not routinely attract medical service providers, such as rural
inhabitants, Native Americans, and prison inmates. Teleradiology took place during the
same timeframe in a collaborative effort between Lockheed, the U.S. Public Health
Service, and the National Aeronautics and Space administration (NASA). Medical care
was given to Papago Indian in Arizona through a project called Space Technology
Applied to Rural Papago Advanced Health Care (STARPAHAC). Specialists provided
assistance by interpreting electrocardiographs and X-ray (Norris, 2002). The military has
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been another frequent user as telemedicine has been a part of large-scale coordination
efforts required for international disaster relief.
Background and Justification
According to the U.S. Census Bureau, the GMKCA, also known as delineation
number 28140, Kansas City, MO-KS Metropolitan Statistical Area, includes the
following cities: Kansas City, Missouri; Overland Park, Kansas; and Kansas City,
Kansas. It is comprised of six counties in Kansas (Franklin, Johnson, Leavenworth, Linn,
Miami, and Wyandotte) and nine counties in Missouri (Bates, Caldwell, Cass, Clay,
Clinton, Jackson, Lafayette, Platte, and Ray) (U.S. Census Bureau, 2013, p. 36). This
area covers approximately 5,506 square miles with an average of 329 people per square
mile and a population of approximately 2,035,334, 0.7% of the total U.S. population. The
median age is between 35 and 39 years old. There are 96.7 to 99.9 males for every 100
females. The racial composition of Kansas City is as follows: 76.9% White; 12.7%
African American; 7.0% of Hispanic or Latino origin; and 3.4% from other minority
groups. The median household income is $53,508, which is above the national average of
$50,740. The percentage of people living in poverty is 10.2%. The percentage of the
population who graduated from high school is 90.1%, while only 31.5% have a
bachelor’s degree or higher (U.S. Census Bureau, 2012).
There are 52 hospitals and health care facilities in the GMKCA. Of these 52, five
have been ranked on the U.S. News and World Reports “Best Hospitals” list. The
rankings are based on number of specialties, patient satisfaction, latest advances in
innovative medical procedures, and accreditation. Hospitals are both privately and
publicly funded (U.S. News and World Reports, 2013).
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While innovative medical processes such as telemedicine and telehealth services
can bring national attention to hospitals, several barriers to developing and accepting
telemedicine have been noted in the literature. Yellowlees (1997) examined 11 reasons
why clinicians fail to accept new information systems such as telemedicine. These
barriers can impede successful implementation of telemedicine programming:
1. Too much change (‘change toxicity’)
2. Failure to begin with an adequate physician base of support
3. Lack of a user-friendly interface
4. Concern regarding the information collected
5. Failure to collect the most important information
6. Physician technophobia
7. Excluding physician involvement from the financial analysis
8. Failure to include marketing to physicians in the implementation plan
9. Inadequate training of physicians to use the system
10. Lack of strong, centralized information systems leadership respected by
physicians
11. Lack of control by the organization over physician practices. (pp. 20–24)
In addition, Yellowlees (1997) provided seven core principles to developing a successful
telemedicine program:
1. Telemedicine applications and sites should be selected pragmatically, rather
than philosophically
2. Clinician drivers and telemedicine users must own the systems
3. Telemedicine management and support should follow best-practice business
principles
4. The technology should be as user-friendly as possible
5. Telemedicine users must be well trained and supported, both technically and
professionally
6. Telemedicine applications should be evaluated and sustained in a clinically
appropriate and user-friendly manner
7. Information about the development of telemedicine must be shared. (pp. 215–
22)
Telemedicine affects current caregivers, underserved populations in the city and
surrounding areas, along with patients needing specialized services not available in their
local areas (Maheu, Whitten, & Allen, 2001; Norris, 2002; Spaulding, Russo, Cook, &
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Doolittle, 2005; Stanberry, 1998; Wootton et al., 2011). Hospitals have commonalities in
designing telemedicine/telehealth and health care learning programming based on
demographics, location, Health Insurance Portability and Accountability Act (HIPAA)
requirements, budget constraints, and state technology goals. The intent of this study was
to provide guidance in developing a set of best practices or an established body of
knowledge in overcoming barriers leading toward implementing a telehealth or health
care distance education program in hospitals or health care organizations. The results of
this study will be of assistance to future efforts of hospitals and health care organizations
implementing a telemedicine programs.
The benefits of telemedicine are numerous. Darkins and Cary (2000) reported
several of the benefits, including (a) reduced cost of health care delivery; and (b) greater
access to health care services and education for the general, rural, prison, and
underserved populations. Military settings, tribal communities, and space research
operations such as NASA’s Telemedicine Spacebridge have benefitted from the
advantages of telehealth (Karinch, 1994; Maheu et al., 2001). Pozgar (2007) noted that
worldwide telemedicine offers several health-related solutions that enable establishing
nations around the world the opportunity to perform tele-consultations, patient studies,
and constant access to up-to-date professional medical information along with decreased
travelling challenges for its affected individuals.
Lastly, telehealth allows health care-related distance education to take place in
areas not readily available to its inhabitants (Bauer & Ringel, 1999). Moore (2007) noted
that distance education facilitates continuous medical education allowing for medical
professionals to stay current with changing profession-specific information and expertise.
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In addition, distance education provides the platform for medical professionals to retain
and enhance their particular specialized skills from amateur to expert specialist, while
advancing their employment opportunities.
However, barriers exist that impede the successful implementation of
telemedicine operations. Many of the obstacles are related to professional licensure,
malpractice liability, and “privacy, confidentiality and security issues” (Simonson,
Smaldino, Albright, & Zvacek, 2012, p. 21), as well as payment policies, and “regulation
of medical devices” (Simonson et al., 2012, p. 21). Grigsby and Allen (1997) noted
additional barriers to sustainability including (a) reimbursement, (b) cost, (c) providers’
acceptance, (d) operating revenue, (e) organizational issues, (f) remote site commitment,
and (g) legal/regulatory issue. Also, public policy issues were considered to be the key
barriers to innovation, demand, and investment in telehealth.
Deficiencies in the Evidence
Several studies have examined the perceptions of hospital employees in relation
to telemedicine initiatives (Cusack et al., 2008; Doolittle & Spaulding, 2006; Hopp et al.,
2006; Levy, Jack, Bradley, Morison, & Swanston, 2003). In addition, a number of
professors and telemedicine program directors have explored barriers encountered during
telemedicine implementation (Brown, 2005; Cox, 2001; Davis, 2001; Doolittle, 2001;
Karp, Bogan, Mohanty, & Karp, 1999; Strode, 2001; Tang, 2001; Yellowlees, 2001).
Additional studies have reported on barriers to distance education from various
organizational perspectives (Berge & Muilenburg, 2000; Levine & Sun, 2002; Oblinger,
Barone, & Hawkins, 2001). Similar strategies were utilized to discover the benefits and
potential barriers present in 15–20 hospitals in the GMKCA. However, this study
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concentrated exclusively on the perceptions of opinion leaders and lead administrative
decision makers.
Audience
Participants in the study consisted of a purposeful sampling of members of
Kansas City hospital’s strategic leadership and planning team including, but not limited
to, the chief executive officer, chief operating officer, director, or president of the
organization.
Data collection methods and forms of triangulation included in-depth interviews,
extensive observations, and surveys of the Strategic Leadership Team and other critical
community stakeholders involved in the telemedicine planning initiative. The site of the
grounded theory study was 18 hospitals located within the GMKCA where leadership
decisions are made. Interviews also provided invaluable information regarding the
leadership styles of the Strategic Planning Team. An extended observation of the
unoccupied, fully-equipped consultation rooms, and tele-video conference laboratories
located within the respective hospitals allowed additional methods of gathering visual
and kinesthetic data on the videoconferencing and distance learning facilities, while
adhering to the HIPAA guidelines.
Definition of Terms
Definitions of major concepts: asynchronous, change agents, CODEC, computer-
based patient records, diffusion, distance education, grounded theory study, HIPAA,
opinion leaders, store and forward, strategic planning, synchronous education, tele-
consulting, telehealth, telemedicine, video conferencing.
Asynchronous is “interaction between people that is separated by time and
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independence: A type of two-way communication that occurs with a time delay,
allowing participants to respond at their own convenience” (Schlosser & Simonson,
2010, p. 92).
Change agents are “individuals who influence clients’ innovation-decisions in a
direction deemed desirable by a change agency” (Rogers, 2003, p. 473).
CODEC is “a coder-decoder of video and audio signals that converts analog
signals to digital signals, and then compresses digital signals for outgoing information,
then decompresses incoming information and converts digital signals to analog signals”
(Porter, 1997, p. 251).
Computer-based patient records (CPR) are “computerized or electronic patient
records” (Aiken, 2009, p. 94).
Diffusion is “the process in which an innovation is communicated through certain
channels over time among the members of a social system” (Rogers, 2003, p. 474).
Distance education is “the institution-based, formal education where the learning
group is separated, and where interactive telecommunications systems are used to
connect learners, resources, and instructors” (Simonson et al., 2012, p. 7).
Grounded Theory Study is “a methodology, type of design in qualitative research
used when studying a process…systematic, qualitative procedures that researchers use to
generate a theory that explains at a broad conceptual level, a process, action or interaction
about a substantive topic” (Creswell, 2008, p. 432).
HIPAA or the Health Insurance Portability and Accountability Act of 1996
“establishes rights of access to medical information and sets standards for privacy that
impacts how educators and researchers can use medical records” (Reiser & Dempsey,
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2012, p. 203).
Opinion leadership is “the degree to which an individual is able to influence other
individuals’ attitudes or overt behavior informally in a desired way with relative
frequency” (Rogers, 2003, p. 475).
Store and Forward is “the prerecorded interaction between the client and the
expert or prerecorded information that is transmitted” (Wootten et al., 2011, p. 5).
Strategic plan is “a document that outlines the steps than an organization,
division, or department will take to achieve an overall goal or vision” (Grensing-Pophal,
2011, p. 4).
Synchronous education “involves live, two-way interaction in the educational
process that is occurring simultaneously and in real time. Teachers lecture, ask questions,
and lead discussions. Learners listen, answer, and participate” (Simonson et al., 2012, p.
98).
Tele-consulting “involves seeking medical information or advice from someone at
a distance; may be patient to health care professional or between health care
professionals” (Wootton et al., 2011, p. 119).
Telehealth is “public health services delivered at a distance to people who are not
necessarily unwell, but who wish to remain well and independent” (Wootten et al., 2011,
p. 4).
Telemedicine is “the delivery of health care and the exchange of health care
information across distances; also includes tele-education and distance treatment”
(Wootten et al., 2011, p. 4).
Video conferencing is “a common method of real-time interaction between expert
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and client” (Wootten et al., 2011, p. 5).
Purpose of the Study
The purpose of this qualitative study was to explore the opinion leaders’
perspective of the benefits and barriers in telemedicine at hospitals and health care
facilities within the GMKCA. Strauss and Corbin (1998) emphasized the importance of
gathering data in “out in the field to discover what is really going on” (p. 9). As a result, a
multiple site, grounded theory study was conducted to analyze each location separately.
Then a cross-case analysis was conducted to identify common themes among all of the
cases (hospitals). Strauss and Corbin (1998) also insisted that “comparing ‘incident to
incident’ will assist in determining the relevance of the developing theory” (p. 202). A
gatekeeper was identified at each of the 18 locations.
Strauss and Corbin (1998) described the significance of adding objectivity and
sensitivity to the data gathering procedure. Consequently, extensive data were collected
using multiple forms of data collection, such as non-participant observations, interviews
(telephone and face-to-face, when available) and documents. The objective was to
develop an in-depth understanding of each case, singularly and collectively, to describe
the barriers and opportunities of implementing telemedicine from the chief executive
officer (CEO) and the chief operating officer (COO) opinion leaders’ perspective.
Charmaz (2006) suggested offering the interviewee a handful of wide-ranging,
open-ended questions will permit the interviewer to inspire and motivate more
spontaneous responses and unexpected testimonials. Therefore, the questions were broad
to allow the participant to construct meaning from the questions and situations. Questions
were open-ended to allow understanding of the historical and cultural settings of the
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organizations. The interviews were conducted face-to-face when possible, or by
telephone. Research was conducted to obtain open-ended questionnaires from similar
studies when CEOs were interviewed about a new initiative within their organization. If
necessary, existing surveys could have been converted to open-ended questionnaires.
Charmaz (2006) provided detailed guidelines for obtaining rich data by modifying
existing instruments already in existence.
The individual hospitals’ protocols for conducting interviews with their CEOs and
COOs were obtained. Hospital administrators were interviewed to gather their
perceptions of initiatives toward telemedicine within their organizations. Characteristics
of each hospital were described, examined, and compared in order to ascertain their
relationships, if any, to the respective telemedicine initiatives present at the locations. As
CEOs were interviewed, an attempt was made to identify the top five trends, advantages,
barriers, and problems of implementing telemedicine from the opinion leader’s
perspective.
To comply with the HIPAA of 1996, no patient records were viewed, and all
HIPAA regulations were followed (Judson & Harrison, 2010). As recommended by
Charmaz (2006), Institutional Review Board approval was obtained before data were
collected. This study will assist the CEOs at the health care organizations to fine-tune
their organizations.
The population consisted of hospital employees. The target population was CEOs
and COOs of hospitals in the greater Kansas City area. The sample consisted of CEOs
selected from 18 hospitals in the greater Kansas City area.
Telemedicine services in the GMKCA are limited compared to health care
12
services offered face-to-face (Spaulding et al., 2005). While opportunities to participate
in this innovative medical practice are present, Maheu et al. (2001) asserted the presence
of several barriers that preclude the implementation of telemedical, telehealth and health
care education at a distance. An in-depth study of this phenomenon provided insight into
solutions and clarifications to allow more hospitals to develop telemedicine/telehealth
services to the underserved populations in the Kansas City area.
Rural and underserved populations do not have access to equivalent health care
when compared to those in larger, more densely populated cities and higher income areas
(Spaulding et al., 2005). The shortage of physicians in rural areas and underserved
populations in the GMKCA would be assisted by the use of telemedicine. The importance
and prevalence of telemedicine services at hospitals in the GMKCA showed that the
benefits have been valued by its residents (Maheu et al., 2001; Spaulding et al., 2005;
Wootten et al., 2011).
In rural and medically underserved areas, telemedicine is a likely method to
improve the imbalance and respond to the health-care needs of rural citizens (Spaulding
et al., 2005). According to Roger’s (2003) “diffusion of innovation theory,”
Opinion leaders, individuals who are able to influence other individuals’ attitudes
or behavior, are instrumental in persuading adopters toward diffusing innovative
programming such as telemedicine. Opinion leaders were found to have robust
effects within several organizations, including among health-care professionals.
(p. 326)
Spaulding et al. (2005) utilized the diffusion of innovation theory to understand
telemedicine adoption in Kansas’ rural areas. The hospital administrators could likely act
as change agents within their respective organizations. In other words, the CEOs and
hospital presidents are likely to either formally or informally influence their respective
13
organization’s innovation decisions in a direction deemed desirable by the change agency
(Rogers, 2003).
A grounded theory approach (Charmaz, 2006; Creswell, 2008; Strauss & Corbin,
1998) was utilized to chronicle a descriptive view of the strategic planning undertaken by
the chief operating officer and hospital leaders in developing and implementing
innovative telehealth programming within the GMKCA hospitals. Charmaz (2006)
contended grounded theory design affords the chance to obtain abundant, in-depth
information about the routines taking place within the contributors’ day-to-day operations
in their organizations, build hypotheses from the findings, along with observing note-
worthy issues while addressing the basic concerns occurring in the health care
organizations. Observation of the leadership team in relation to perceived opportunities
and barriers to telehealth implementation will provide a deeper understanding of the
processes, events, and actions taken to develop telemedical programming in health care
organizations in Kansas City.
Chapter Summary
The benefits of telemedicine are numerous. In rural and medically underserved
areas, telemedicine is a likely method to improve the imbalance and respond to the
health-care needs of rural citizens (Spaulding et al., 2005). However, barriers are also
present. When opinion leaders within health care organizations implement innovative
telehealth processes, success would be more likely if these change agents approach this
innovative effort armed with solutions in hand. The aim of this study was to identify the
barriers perceived by the organizational leaders in order to circumvent potential
problems.
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Chapter 2: Literature Review
In support of this proposed study, the following literature review presents an
overview of information relevant to the leadership’s perception of planning, design, and
the benefits and barriers to the development of a telehealth program for patients and
physicians in distant locations. This literature review explored the history, benefits and
barriers of medical services delivered at a distance. It also investigated how opinion
leadership influences organizations to develop, construct, implement, and utilize these
programs.
Purpose Statement
The purpose of this qualitative grounded theory study was to chronicle the
benefits and barriers encountered by the upper level management teams in developing
telemedicine/telehealth and health care distance education programming in hospitals
within the GMKCA within the context of the grounded theory approach as explained by
Creswell (2008). At this stage in the research, the central phenomenon was generally
defined as the influence of opinion leaders on the health care administrator level’s
implementation of tele-video, videoconferencing and medical distance education within
18 hospitals in the GMKCA. The hospitals participating in this case study will be
determined based on responses from CEOs. However, larger hospitals in the GMKCA
that participated in this study included: Children’s Mercy Hospital (Main and South
Campuses), Bates County Memorial Hospital, University of Kansas Medical Center,
Menorah Medical Center, Western Missouri Medical Center, St. Luke’s Hospital of
Kansas City (Main and North Campuses), Truman Medical Center, Shawnee Mission
Medical Center, Lawrence Memorial Hospital, Research Medical Center, Atchison
15
Hospital, Miami County Medical Center, Olathe Medical Center, Samuel U. Rogers
Health Center, and Cass County Hospital.
Distance Education
Simonson et al. (2012) defined distance education as “the institution-based,
formal education where the learning group is separated, and where interactive
telecommunications systems are used to connect learners, resources, and instructors” (p.
7). While distance education has a history spanning over 160 years, Simonson et al.
(2012), Moore (2003), and Rice (2012) traced the innovations in this educational method
from correspondence, radio, television through present day video conferencing and
Internet techniques. The changes that have occurred over the years have largely been
attributed to digital technologies and a new generation of technology savvy students.
Simonson et al. (2012), Moore (2003), and Smith (2009) described the benefits of
distance learning as the instructor and learner can be separated by time and space;
instructor expertise can be utilized by many more students worldwide, regardless of
either participant’s location; collaborative activities can be explored via distance
education; and learning environments are no longer dictated by logistics. Simonson et al.
(2012) also noted that distance education can “supplement existing curricula, promote
course sharing among schools, and reach students who cannot (for physical reasons or
incarceration) or do not (by choice) attend school in person” (p. 138).
Maheu et al. (2001) described the history of telemedicine and its origin in their
book entitled E-Health, Telehealth, and Telemedicine. Allen, founder of the American
Telemedicine Association and co-author to the aforementioned text (Allen, Hayes,
Sadasivan, Williamson, & Wittman (1995), also practiced medicine and the University of
16
Kansas Medical Center in Kansas City, Kansas. The demands of rural patients led to the
necessity of tele-video and videoconferencing when consulting with specialists.
Ten factors were reported by Berge and Muilenburg (2000) that were considered
barriers to distance education. These 10 factors were discovered through a study of
people from diverse backgrounds. The factors include “administrative structure,”
“organizational change,” “technical expertise,” “social interaction and quality,” “faculty
compensation and time”, “threat of technology,” “legal issues,”
“evaluation/effectiveness,” “access,” and “student-support services” (Berge &
Muilenburg, 2000, p. 7).
Telemedicine is a subcategory of distance education because it includes medical
education and, as such Berge and Muilenberg (2000) determined, “underlying
constructs” that make up barriers to distance education. Several of these 10 factors are
similar to barriers identified by other researchers that preclude the successful
implementation of telemedicine. These shared barriers consist of “administrative
structure,” “organizational change,” “technical expertise,” “threat of technology,” “legal
issues and access” (Berge & Muilenburg, 2000, p. 7).
Piamjariyakul and Smith (2008) defined telemedicine as a subcategory of
telehealth, that is using digital data and other technological tools, to aid in providing
health care-related education and services at a distance for the general public and
government communities. Telemedicine, “medicine at a distance, usually contains the
following components: separation or distance between individuals and/or resources; use
of telecommunications technologies; interaction between individuals and/or resources
and medical or health care” (Simonson et al., 2012, p. 19).
17
History of Telemedicine
Simonson et al. (2012) reported the origination of the term telemedicine by Byrd
during his creation of a video microwave network in 1968 from Massachusetts General
Hospital to Boston’s Logan Airport. Its key benefit at that time was to provide access to
medical services where it had previously been unavailable. Norris (2002) found evidence
of earlier uses of telemedicine, when physicians used video television to provide medical
care during the 1950s. Telehealth has also been utilized in other countries, both
developed and less economically developed (World Health Organization [WHO], 2010).
Factors That Contribute to Telemedicine Implementation
The factors that contribute to telemedicine implementation include the need to
provide health care to low income or rural areas, shortages of physicians, improvement
in the quality of health care services, reductions in the cost of delivering health care, and
to provide remote care where there is no alternative (Darkins & Cary, 2000; Long, 1998;
Norris, 2002; WHO, 2010).
Needs for Telemedicine
The needs for telemedicine span several areas: (a) hospitals, (b) military locations,
(c) National Aeronautics and Space Administration (NASA), (d) low income-based
underserved cities, and (e) rural areas where specialists and other health care
professionals are in short supply (Bauer & Ringel, 1999). Karinch (1994) compared
telemedicine to a house call where the doctor was able to come to the patient with the use
of video conferencing technology. These technological advances provide assistance to
medical record keeping, surgery, health maintenance, and health education (Karinch,
1994).
18
Telemedicine utilization reports & evaluation data provided by Piamjariyakul and
Smith (2008) enumerated the advantages of telehealth, namely that it provides access and
continuity of care to those in need of medical services in underserved and rural settings.
Piamjariyakul and Smith (2008) also argued that a heightened access to telehealth brings
about favorable results upon medical results. In addition, the need for telemedicine is
growing due to the aging and chronically ill population, substantial health care provider
shortages in the aforementioned areas. Limited access areas include low income based
rural areas, inner cities, underserved communities, disadvantaged neighborhoods or
Native American reservations, senior citizen centers, roadway clinics for truck drivers
and travelers, prisons, and military locations.
Numerous challenges and concerns have been indicated in recent publications
including privacy and confidentiality of medical information, ensuring quality of care and
regulation, clinician liability, accreditation and certification, public investment in
development and research, payment and reimbursement for services, integration of
interactive health services (Norris, 2002; Peabody, 2013).
Latifi, Ong, Peck, Porter, and Williams (2005) concluded the use of telemedicine
in the management of trauma and emergency care is needed in remote areas and
catastrophic situations. Since trauma requires immediate care and these types of services
are not as prevalent in rural areas, these populations suffer at a higher rate than urban
patients. Latifi et al. (2005) noted
The lack of adequately trained personnel and limited continuous medical
education may lead to disproportionate mortality in these areas. In addition, the
lack of access to trauma specialists in remote locations can contribute to lower
success rates among trauma patients who live in these areas.
In catastrophic disasters, telemedicine and tele-presence can be provided via
19
satellite to provide tele-trauma and tele-resuscitation for victims who might not
otherwise have any alternative for medical care. (pp. 293–294)
Latifi et al. (2005) stressed the importance recognizing that in order for tele-trauma and
tele-resuscitation to be successful, they must have the “collaboration and management of
a large number of authorities and organizations with “high-level command, control and
communications (C3)” (p. 294).
Miller, Reese, and Frieson (2008) described the need for telehealth technology
applications with underserved conduct disorder in child/adolescent populations,
especially when access to specialists is needed in remote areas. Rural areas are plagued
with increased rates of preventable risk factors such as, obesity, smoking, poor diet, and
inactivity. They are also more likely to be uninsured and possess lower levels of
education. Telemedicine in these areas can assist in several ways. Distance education can
provide current information on new medical procedures and medications to health care
personnel who are unlikely to venture into urban areas. It can refresh skills and
knowledge on updated specialties. Time sensitive care can provide assistance with stroke,
cardiology, perinatal and neonatal emergencies. The introduction and implementation of
innovative technological medical procedures requires higher level hospital administration
acceptance as well as key physician acceptance to discourage barriers located within the
organizations (Miller et al., 2008). They also insisted that in order to maintain a
successful telemedicine program, support and enthusiasm from senior management
should be relayed via internal communications, demonstrations, and discussions with
representative from other telemedicine programs. Key physicians, or champions, should
be clearly identified and should serve as physician liaisons to other members of the
telemedicine participants.
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Barriers to Telemedicine in the United States
Simonson et al. (2012) and Armstrong (1998) identified several barriers to the
practice of telemedicine: (a) professional licensure; (b) malpractice liability; (c) privacy,
confidentiality, and security; (d) payment policies; and (e) regulation of medical devices.
Darkins and Cary (2000) presented additional financial barriers to successful
telemedicine programs related to (a) reimbursement, (b) telecom cost, (c) general cost,
and (d) operating revenue. According to Darkins and Cary (2000), “financial
sustainability has been provided by grant funding from government agencies
(approximately 90%) or capital investment by hospital providers” (p. 14). The reduction
of costs and professional objection along with the increase in quality of service and
access to health care services made up Darkins’ and Cary’s (2002) “formula for
successful telehealth implementation” (p. 15).
The Rehabilitation Act (1973) requires federal agencies to make their electronic
information technology accessible to people with disabilities. Burgstahler (2002)
described the access challenges for people with disabilities; they include mobility, visual,
learning, hearing and speech impairments, and seizure disorders (p. 5). Section 508
(1986) of the Rehabilitation Act requires that electronic and information technologies that
federal agencies procure, develop, maintain, and use are accessible to the disabled as
well. Telemedicine services, medical education, and services delivered from a distance,
are included in the technological services that should be made available to the disabled,
underserved, and unserved populations. To date, only two states, Kansas and Maine,
provide reimbursement for telehealth services within inner cities. On the other hand, the
use of telemedicine can be found nationwide, specifically in: Arizona (DeChant, Tohme,
21
Mun, Hayes, & Schulman, 1996), California (Bashshur, Shannon, Krupinski, & Grigsby,
2011; Krupinski, 2008; Latifi et al., 2005; Sakles et al., 2011), Florida (Naditz, 2009),
Georgia (Young, Chan, & Cram, 2011), Illinois (Vogel, Gracely, Kwon, & Maulitz,
2009), Iowa (Brown, 2005; Hersh et al., 2001), Massachusetts (Zilis, 2012), Michigan
(Garfield & Watson, 2003; Hopp et al., 2006; Miller, 2001; Whitten, Holtz,
Cornacchione, & Wirth, 2011), Ohio (Cusack et al., 2008), Oregon (Harnett, 2008),
Pennsylvania (Bowles et al., 2011; Stalker et al., 2006), Tennessee (Mulvaney, Anders,
Smith, Pittel, & Johnson, 2012), Virginia (Merrell, 2010), Washington, DC, (Hoffman &
Rowthorn, 2011; Shojania, Silver, & Levinson, 2012), and Wisconsin (Young et al.,
2011).
According to Barker et al. (2005), the Arizona Telemedicine Program designed its
service with several goals in mind. One of the major goals was to develop an “open staff”
model for its physicians “to ensure adequate communication with other health care
organizations” (Baker et al., 2005, p. 397). However, many legal issues have impacted
the adoption of telemedicine (Paul, Pearlson, & McDaniel, 1999; Pozgar, 2012;
Stanberry, 2006; WHO, 2010). Pendrak and Ericson (1996) noted licensure and
credentialing as the strongest factors in preventing telemedicine from being fully
accepted. While some states are proposing changes in their legislature, many have not
made telemedicine legally appetizing or cost effective for physicians and health care
organizations. Pendrak and Ericson (1996) noted the uncertainty in the courts’
establishment of legal precedents in their rulings.
Consequently, malpractice questions continue to prevail for decision makers.
Pozgar (2007) defined malpractice as medical negligence where the physician had a duty
22
of care to a patient, and there was a breach of duty that resulted in an injury caused by the
departure from the standard of care. However, when a physician owes a duty to a patient
(whether face-to-face, or from a distance) to exercise ordinary medical care that a
reasonably prudent physician would have exercised under the same or similar
circumstances, there is concern about the relationship between the caregiver and the
patient when this care occurs via videoconference. Does this threat discourage opinion
leaders from recommending the adoption of telemedicine into their organizations?
Pendrak and Ericson (1996) proposed two critical questions for administrators to ponder
when considering the adoption of telemedicine: “Did a doctor-patient relationship exist?”
and “Did the physician breach his or her duty of care?” (p. 48).
Telemedicine in the Midwest
In his essay, Jacobus (2004) presented three reasons that led the adoption rate of
telemedicine to the slow (telehealth) initiatives. In the beginning, telemedicine products
seemed to be too expensive and not directed at a particular audience, which resulted in
uncertainties among payers and cloudy cost-benefit rates. He recommended rectifying
these issues by clarifying the profitability potential for insurance companies and health
care organizations. Jacobus (2004) revealed conclusive facts that substantiated the
usefulness of telemedicine programming. Specifically, it showed how health care-related
education and services can be less expensive. Yet, historically there has not been a clear
and easy-to-follow revenue process or formula to help insurance payers induce the
regular population to rapidly give up conventional methods in favor of telemedicine
adoption.
These factors must be well thought out by opinion leaders when considering the
23
adoption of telemedicine. The cost effectiveness and potential profit margin of any
proposed project is important during this analysis process.
Kansas
The University of Kansas’ Medical Center has been and continues to be a leading
provider of telemedicine in the Midwest. Spaulding, Velasquez, He, and Alloway (2012)
presented cost analysis data on their telemedicine efforts in the field of home telehealth
for the elderly. While Spaulding et al. (2012) suggested additional studies utilizing
randomized controlled trials with larger samples, their study concluded that “hospital
days, emergency department visits, total costs and hospital costs were significantly
lower during a home telehealth intervention” (p. 2).
Rural and urban areas within the Midwest serve individuals from diverse
demographic backgrounds. However, the need for health care remains a constant
concern for most populations, regardless of their location. Members of the underserved
population of the Midwest have received assistance from telemedicine efforts from
multiple locations such as Kansas and Missouri (Maheu, Whitten, & Allen, 2001;
Spaulding et al., 2005). Video conferencing, health care education via distance methods,
telemedicine robots, child psychiatry, teleoncology, tele-dermatology, and tele-radiology
have been offered in the Midwest for several years.
Doolittle (2001) insisted that “all participants are should be brought together
when designing telemedicine care: physicians, nurses, patients and other vital partners’
expertise are needed to define the needs, outline specific goals, analyze and test the
technology, and develop plans for implementation” (p. 43). In 1991, telemedicine
programming in urban and rural Kansas, teleoncology (cancer care at a distance), tele-
24
hospice (the use of telemedicine to provide end-of-life care), and school-based pediatrics
(ambulatory medical and psychiatric) services were successfully delivered. However,
additional attempts within the same geographic area were unsuccessful. Doolittle (2001)
maintained that tele-cardiology (heart care at a distance) and home telecare for cystic
fibrosis patients have been unsuccessful as a result of strained interactions involving
caregivers, product complications, and not enough recognized desire for the products
and services.
Nelson (2004) found that many patients lived hours from the Kansas University
Medical Center and did not have child psychiatrists or psychologists in their counties.
Telemedicine provided specialty mental health care at a distance. Krupinski (2002)
noted that clinical telemedicine is especially helpful and used most often in specialty
settings. However, the mental health providers in Kansas found mixed reactions.
Families receiving psychotherapy over interactive video were satisfied with the services
(Ermer, 1999). In fact, these systems have been praised for providing help without travel
or waiting months to see a professional. Telehealth could be used to link therapists who
were miles away with children in rural settings or could be used to link therapists with
settings common to the child, such as the school or the pediatricians office. Factors to
consider include the urban or rural setting, the telemedicine room set-up, the presenter,
the format, session characteristics, outcome measures, patient population and treatment
package. Nelson (2004) provided research that supports her notion that “tele-mental
health intervention works” (p. 136).
Whitten and Cook (1999) provided school-based telemedicine to low-income
urban children who would otherwise not receive basic medical care. The Wyandotte
25
County Kansas area was designated as a “Federal Health Profession Shortage Area” due
to its high population-physician ratio and high population of residents who lived in
poverty. Its main objective was to provide medical services for children while they were
at school to circumvent the need for transportation. This program was a successful
attempt at providing much-needed medical services to an underserved population.
Whitten and Spaulding (2004) argued the benefits of telehealth within the
underserved and poverty-stricken populations. A general demographic description of
this population includes 75% receiving free/reduced lunches, 50% black, 25% Hispanic
with languages other than English being spoken in their homes; inadequate
transportation, lack of economic resources; lack of familiarity with the medical
community, and questionable citizenship status. “These high risk groups, such as
children living in poverty, children from racial and ethnic minority groups and children
in remote areas, will particularly benefit from access to health services from their
schools” (Whitten & Spaulding, 2004, p. 249).
Doolittle and Spaulding (2006) emphasized the importance of determining the
needs for telemedicine before beginning the implementation process. A needs-assessment
should be required before designing and planning the telemedicine program. Doolittle
and Spaulding (2006) observed that a “bottom-up” (p. 277) strategy has been crucial to
an effective plan. Simply stated, a poor health care area needs to be identified and
planned for, rather than creating a program then locating a place to put it. In addition,
locating a stable funding source and reliable equipment were found to be equally
important in the success of a telemedicine initiative. In short, Doolittle and Spaulding
(2006) presented six steps to defining the needs of a telemedicine service:
26
1. Defining the need for a telemedicine service
2. Planning a service
3. Conducting a needs assessment (clinical, economic, technology)
4. Developing a health-care team
5. Marketing
6. Evaluating the program. (p. 277)
Doolittle, Spaulding, and Spaulding (2004) showed the cost savings involved in
providing teleoncology services in rural Kansas. There were a number of factors involved
in calculating the cost per visit amount for teleoncology services in comparison to face-
to-face visits such as equipment use and personnel salaries. However, Doolittle et al.
(2004) provided ample support for the continuation of this type of medical assistance for
rural, underserved communities in need of oncology services.
Opinion leaders should heed the views of the consumers and operators of
telemedicine services. Patients’ perceptions of many of these services have been
gathered by researchers in order to gain a better understanding of how the service could
be improved. Researchers at a study conducted in Kansas attempted to determine the
Patients’ perceptions of a telemedicine specialty clinic. As a result of the study, it was
determined that “the technology did not impair the service, nor did it present itself as a
major concern” (Mair, Whitten, May, & Doolittle, 2000, p. 38). However, it was noted
that the patients’ level of satisfaction was more closely related to the fact that only
partial services were being obtained at a distance. There remained an impersonal feeling
following the telemedicine visit which the patients attributed to the absence of a
traditional or conventional, “face-to-face interaction” (Mair et al., 2000, p. 38).
The sparsely populated areas that make up the Midwest have benefitted from
several telemedicine initiatives. Warren, Fletcher, Connors, Ground, and Weaver (2004)
described their medical education initiative developed at the University of Kansas
27
Medical Center as a combined effort with Cerner, a worldwide, innovative, health care
technology organization that provides a wide range of services supporting the clinical,
financial, and operational needs of organizations (Cerner, 2014). “The SEEDS Project,
Simulated Electronic Health Delivery System, is a live-application clinical information
system with virtual patients within a virtual health care delivery system” (Warren et al.,
2001, p. 225). Additional telemedicine-related efforts located within the Midwest that
have proven to be successful include teletherapy (Nelson, 2006), Kendallwood palliative
or end-of-life care (Doolittle, 2001), home telehealth (Spaulding et al., 2012), robots
(Cass Regional Medical Center, 2012), clinics (Mair et al., 2000), teleoncology,
telehospice, and school-based pediatrics, (Doolittle et al., 2004).
Diffusion of Innovations
Rogers (2003) “diffusion of innovations theory suggests that organizational
structures and cultures will affect health professionals’ perceptions of telehealth” (p. 73).
In her essay, Whetton (2003) did not pinpoint one specific or consistent factor present
that affected the adoption of telemedicine. Considering the fact that health-related
businesses tend to be rather conventional, in addition to slower to change, telehealth may
possibly provide a progressive course of action that will produce unrest within
hierarchical framework of the organization. Instead, Whetton (2003) insisted that the
successful diffusion of an innovation such as telehealth within the health care industry is
a result of the interaction between the “innovation, organization and participating
adopters” (Whetton, 2003, p. S: 90). Recruiting champions in strategic management
positions within the organization was cited as necessary for adoption of telemedicine
within the health care organization (Whetton, 2003).
28
Berwick (2003) recognized the challenge diffusion of innovations presents within
the health care industry. The innovators exhibit riskier behavior; thus, they tend to be a
little disconnected from the rest of the pack. Early adopters tend to follow the innovators;
thus, they are more similar to the remaining members of their peer group. As such, they
act as opinion leaders for their peers. “It should be noted that no style is best in all
circumstances” (Berwick, 2003, p. 1973). Berwick (2003) argued that finding and
supporting early adopters is crucial to effective diffusion within the health care
community. In addition, Berwick (2003) encouraged early adopters to garner their ideas
from innovators in a formal fashion to ensure that the process continues on a consistent
basis. Next, Berwick (2003) insisted that early adopters’ activities be made visible
through open communication in order to encourage members of the early majority to
accept these new ideas. “There should also be time allowed for early adopters to find
innovators, test the innovations and create confidence in the reinvention so the remaining
peers will trust and follow” (Berwick, 2003, p. 1974). Finally, leaders must invest the
time and energy in the key players that encourages change toward a new process or
method. Most importantly, leaders must follow up by leading by example and change
their methods as well.
Considering the limited amount of time physicians have for socializing and
networking, many influential conversations take place within their network of hospital
peers (Wenrich, Mann, Morris, & Reilly, 1971). Consequently, informal dialogue results
in peers obtaining knowledge from informal educators (Wenrich et al., 1971). These
informal educators act as persuasive peers who indirectly affect medical decisions,
whether in private practice or in hospital settings.
29
Menachemi, Burke, and Ayers (2004) described the key benefit of telemedicine,
namely the ability to deliver medical services or health-related education from a distance.
Most of these types of products and services are essential to individuals who reside in
underserved locations such as urban and rural areas, and correctional facilities where
medical professionals tend to be scarce (Menachemi et al., 2004). Menachemi et al.
(2004) noted the importance of considering the viewpoint of opinion leaders and
administrators when considering adopting new medical technologies within a health care
organization.
The focus of this research consisted of interviewing administrators such as chief
operating officers and chief executive officers about their viewpoints of the influence of
opinion leaders on adopting telemedicine within their health care organizations.
Menachemi et al. (2004) discussed Rogers’ (2003) diffusion of innovation theory as it
applied to telemedicine adopters. When new technologies are under consideration,
administrators must study Rogers’ adoption factors: (a) relative advantage, (b)
compatibility, (c) trialability, (d) observability, and (e) complexity (Menachemi et al.,
2004). Advantages such as cost savings, profitability and increased market share will be
crucial in this decision-making process. Next, the compatibility of the innovation with the
organization’s current mission and vision will influence the possibility of adoption.
Compatibility with current HIPAA compliance guidelines and accreditation Joint
Commission for Accreditation of Healthcare Organizations (JCAHO) should also be kept
in mind. When making an allowance for trialability, administrators should ponder
telemedicine funding, leasing equipment, training participants, and alternate uses for the
new infrastructure. Observability, the ability to observe the benefits of telemedicine, may
30
not be apparent when it is first implemented. A higher quality of care that results could
take considerable time and public relations efforts to be visible to those out of direct
contact with the department. Administrators might experience a high level of complexity
due to hazy guidelines and regulation regarding telemedicine. As a result, “flexibility and
creativity” (Menachemi et al., 2004, p. 623) are required to ensure a successful
telemedicine implementation result (Menachemi et al., 2004). According to Menachemi
et al. (2004) administrators should create cost-effective programs that are easy to use with
infrastructures that reduce implementation and maintenance costs.
Bonneville and Paré (2006) noted that “more information is needed about the
factors that influence the diffusion; implementation; outcomes and behaviors associated
with the spread of information and communication technologies (ICT)” (p. 217). Factors
such as lack of economies of scale, budget competition within health care departments,
reorganization of medical practices, and questionable patient care were discussed as
reasons for hindering ICT efforts such as telemedicine.
Gagnon et al. (2005) conducted a study that explored the influence of hospitals’
organization characteristics on telehealth adoption by health care organizations in
Quebec. The data captured with the use of questionnaires and telephone interviews were
triangulated and analyzed for correlations with adopter versus non-adopter status.
Gagnon et al. (2005) found the size as well as the location of the hospital influenced the
adoption of telehealth services within its organization. Lack of resources in a hospital,
such as specialists within a certain department resulted in referrals rather than telehealth
utilization. However, when telehealth was considered a major concern by key members
of hospital administration, the impact of their decisions concerning financial viability and
31
physician acceptance took priority. To ensure success, physicians and daily operators of
the equipment should be consulted and remain active in the design of the telemedicine
infrastructure. Administrators also discovered the importance of gathering logistical
desires from clinicians and other participants (Gagnon et al., 2005). The findings of the
study supported the following hypotheses:
The influence of functional differentiation on telehealth adoption depends on
groups’ values towards the system; few planning and control systems have a
negative influence on telehealth adoption; decentralization of power has a variable
influence on telehealth adoption, depending on physicians’ values towards the
technology; smaller hospitals are more likely to adopt telehealth; and hospitals
located in remote and isolated regions are more likely to adopt telehealth.
(Gagnon et al., 2005, pp. 38–39)
Campbell, Harris, and Hodge (2001) discovered six themes that related to the
adoption of telemedicine in Missouri: “turf, efficacy, practice, context, apprehension,
time to learn and ownership” (p. 419). Each of these themes could also have been
considered either a barrier or expediter of change. Turf pertained to the physician’s
perception of telemedicine as a threat or advantage to their practice. Efficacy referred to
the participant’s belief that telemedicine would provide assistance in their medical
practice. Practice and context implied the notion of acceptance of telemedicine within the
local area in Missouri. Apprehension meant the comfort level or (technophobia)
experienced by the individual providers toward the introduction of telemedicine within
their respective practices. “Time to learn” indicated “hesitancy” among clinicians to take
the time to learn a new technological method and convince the clients to accept it as a
viable method of treatment. Finally, ownership denoted the level of “professional and
emotional investment” in the new technological method. In other words, it described how
vested they would be in telemedicine and whether it had been adapted to their specific
32
needs (Campbell et al., 2001, 422).
Campbell et al. (2001) found that rural participants would be more likely to accept
telemedicine if certain perceptions of organizational dynamics are present:
Rural providers acceptance of telemedicine is more likely “when the organization
has accepted technology as an integral component of its procedures, better time
efficiency, closer affiliation with a tertiary care center, perceived increase in
ownership, enhanced ability to accommodate the changes, a reduction in
apprehension, and the realization of the slower pace of change in a rural
community. (p. 422)
Spaulding et al. (2005) randomly surveyed physicians and physician assistants
within 20 counties in Kansas in order to gather a better understanding of their
telemedicine use. Spaulding et al. (2005) applied Rogers’ (2003) diffusion of innovations
theory was used to gather a better understanding of the slow adoption of telemedicine
within the state of Kansas. Spaulding et al. (2005) discussed Rogers’ five core
characteristics of innovation diffusion analyzed in this study: (a) relative advantage, (b)
compatibility, (c) complexity, (d) trialability, and (e) observability. The presence and
impact of an opinion leader at the rural site was also examined. The presence of an
opinion leader was reported more frequently by adopters than non-adopters. In addition,
the presence of the opinion leader resulted in a higher rate of referrals made to
telemedicine clinics. It was implied that adopter of telemedicine might possess “different
perception of telehealth than non-adopters and that strategies based on diffusion of
innovation theory should be devised to introduce this innovative process more effectively
to non-adopters” (Spaulding et al., 2005, p. S:109).
Paying for telemedicine in the United States has been a concern for several
participants within the health care arena. Jonathan Linkous, Chief Executive Officer of
the American Telemedicine Association, itemized five primary sources that support
33
telemedicine. These sources provide financial sustenance for telehealth in the United
States. Hospitals and health care systems; private, public and employer insurers; federal
Medicare; state Medicaid; and health services provided to beneficiaries make funding
available for telemedicine services. Hospital and health care systems offer two ways of
supporting telemedicine: managed care, health home and accountable are plans allowing
providers the flexibility to pay for and use telemedicine wherever it is needed. Another
approach hospitals and health care systems provide financial backing for telemedicine is
between facilities in an effort to lower costs by sharing specialty services and increasing
revenue from expanded referrals (Linkous, 2013).
Next, several large health insurers have expended their coverage to include
telemedicine. At the article’s printing, 16 states mandated private insurance coverage and
13 more states had pending legislation. In addition, federal Medicare reimbursement was
made available for remote imaging services. Furthermore, synchronous consultations are
eligible for reimbursements for patients in rural areas, plus some State Medicaid coverage
is available in 44 states. Finally, according to the American Telemedicine Association,
health services provided to beneficiaries directly from state and federal agencies such as
the Veterans Administration, Department of Defense, Indian Health Service, federal and
state and local corrections departments are active and prevalent in the field of remote
health care (Linkous, 2013).
International Telemedicine
Applications of telemedicine have been shown to provide medical services and
education to underserved populations within cities including: London, United Kingdom
(Barlow, Bayer, Castleton, & Curry, 2005; Brebner, Brebner, Ruddick & Bracken, 2005;
34
Finch, Mort, May & Mair, 2005; Hjelm, 2005; Levy et al., 2003; Mort & Finch, 2005;
Mort, May, & Williams, 2003; Newton, 2003; Padgham, Scott, Krichell, McEachen, &
Hislop, 2005; Stanberry, 2006; Varga-Atkins, & Cooper, 2005), and Tehran (Akhlaghi,
Asadi, & Akhlaghi, 2005).
Entire nations have had medical services and education for underserved
populations improved by providing telemedicine: Alberta, Canada (Jennett et al., 2003;
Klein, Davis, & Hickey, 2005); Africa and the Middle East (Hailey, Roine, & Ohinmaa,
2002; Khoja, Durrani, Nanyani, & Fahim, 2012); Australia (Paul, Carey, Hall, Lynagh,
Sanson-Fisher, & Henskens, 2011; Darkins & Cary, 2000; Hailey & Crowe, 2003; Loane
& Wootton, 2002; Omar, Wahlqvist, Kouris-Blazos, & Vicziany, 2005; Ryan, Stathis,
Smith, Best, & Wootton, 2005; Smith, Bensink, Armfield, Stillman, & Caffery, 2005;
Wootton, 2001; Wootton & Batch, 2005; Wootton, Youngberry, Swifen, & Swifen, 2004;
Yellowlees, 1997); the Balkan countries (Doarn et al., 2009); Brazil (Gundim & Chao,
2011; Kavamoto, Wen, Battistella, & Bohm, 2005); Bulgaria and Greece (Anogianakis et
al., 2003); Calgary, Canada (Hailey, 2005); Canada (Roine, Ohinmaa, & Hailey, 2001);
Estonia (Port, Palm, & Viigimaa, 2005); Europe (Marsh, 2003; Routsalainen & Pohjonen,
2003); Greece (Bray, 2003; Kokolakis & Spyros, 2003); Japan (Hasegawa & Murase,
2007); the Netherlands (Berg, 1999; Broens et al., 2007; Esser & Goossens, 2009;
Vollenbroek-Hutten & Hermens, 2010); Norway (Burkow & Nilsen, 2005); Nova Scotia,
Canada (Allen, Sargeant, Mann, Fleming, & Premi, 2003); Pakistan (Bajwa, 2010);
Singapore, China, and Canada (Goldberg, Sharman, Bell, Ho, & Patil, 2005); Sweden
(Carlfjord, Lindberg, Bendtsen, Nilsen, & Andersson, 2010); Taiwan (Liu, 2011; Wang,
2009); Toronto, Canada (Boydell, Volpe, Kertes, & Greenberg, 2007).
35
Hjelm (2005) proclaimed several benefits and drawbacks of telemedicine in his
article of the same name: “The benefits included improved access to information,
provision of care not previously deliverable, improved access to services and increasing
care delivery, improved professional education, quality control of screening programs
and reduced health-care costs” (Hjelm, 2005, p. 60). However, Hjelm (2005) also
expressed concern over the drawbacks of telemedicine, namely (a) breakdown in the
relationship between health professional and patient, (b) breakdown in the relationship
between health professionals, (c) issues concerning the quality of health information,
and (d) organizational and bureaucratic difficulties.
The Western Governors Association’s Telemedicine Action Report of 1994 also
listed six noteworthy telemedicine barriers:
1. problems with infrastructure planning and development,
2. problems with telecommunications regulations,
3. problems with reimbursement for telemedicine services because of absent or
inconsistent policies,
4. problems with licensure and credentialing because of conflicting interests with
regard to ensuring quality of care regulating professional activities and
implementing health policies,
5. problems with medical mal-practice liability because of uncertainties with
regard to the legal status of telemedicine within and between states and
finally,
6. problems with confidentiality, because of increased risk of unauthorized
access to patient information compared with information on paper. (Hjelm,
2005, p. 69)
Brebner et al. (2005) maintained a list of reasons for failure of telemedicine
programming: (a) service was not needs-driven, (b) no commitment to provide the
service, (c) no suitable exit strategy after research funding expired, (d) poor
communication, (e) lack of training, (f) technical problems, (g) outdated work practices,
and (h) poor or non-existent protocols. Conversely, Brebner et al. (2005) insisted that
36
An established steering group provides guidance during the design and
implementation process. In addition, champions need to be identified at the main
a peripheral sites to maintain open lines of communication between the steering
group and the practitioners. On-going evaluative measures are required to ensure
sustainability, success and effectiveness. (pp. S1–5)
Bower (2005) identified several indicators to explain the diffusion of health care
information technology and pinpoint key drivers of diffusion. Within his research,
interviews with chief information officers (CIOs) proposed policy direction and various
other reasons for incomplete diffusion, ranging from “cost to technical need to
technological progress of competing innovations” (Bower, 2005, p. 13). Bower (2005)
described “social pressure via activated peer group networks” (p. 27), whereby
“physicians and hospital administrators gather their facts concerning health care
information technology through casual or informal associations with their peers” (p. 27).
The “epidemic effects” described by Bower (2005) resulted from informal discussions
with peer groups in a similar fashion to Rogers’ (2003) influence by “opinion leaders.”
Rogers (2003) mentioned the importance of opinion leaders during the diffusion
of innovations process. He observed that opinion leaders were more influential with
implementing change than with workshops or mandates from superiors. In the health care
field, opinion leaders have also been referred to as “champions, lay health advisors,
health advocates, or community leaders” (Rogers, 2003, p. 882).
According to Valente and Pumpuang (2007), “opinion leaders can act as
gatekeepers for interventions, helping change social norms, and accelerating behavioral
change” (p. 881). These researchers analyzed approximately 200 studies involving
opinion leaders and the methods used to influence their peers. These approaches were
categorized into 10 methods. The importance of opinion leaders in the introduction of
37
innovative medical procedures was noted, especially when communicating with their
peers and other members within their communities. The 10 techniques used for
identifying opinion leaders categorized by Valente and Pumpuang (2007) are shown in
Table 1.
Locock, Dopson, Chambers, and Gabbay (2001) expressed difficulty in
discovering a universal definition of opinion leaders. Opinion leaders were often referred
to as product champions who were needed to prompt their peers toward adopting a new
idea, product, or process. The influence of opinion leaders could also be negative by
discouraging the acceptance of innovative methods into the mainstream of their peer
group or organization. Opinion leaders were seldom innovators; on the contrary, they
were more connected to innovative ideas. Locock et al. (2001) reported of medical
champions who were crucial to the adoption of new procedures involving stroke patients.
Interpersonal skills and charisma were noted as prerequisites to the acceptance of fresh
ways of solving medical obstacles (Locock et al., 2001). Furthermore, Locock et al.
(2001) discovered that “the closer the project was to reaching completion and
implementation, the more importance the opinion leaders’ view became” (p. 753).
Finally, the opinion leaders effect on his peers was noted to be dependent upon his
“intrinsic characteristics and the extrinsic circumstances of his environment” (Locock et
al., p 756).
The British Medical Journal (Coiera, 2002) reported that many opinion leaders
were being paid by pharmaceutical companies for their participation in introducing new
drugs to their colleagues. Also known as thought leaders among their peers, opinion
leaders were key players for getting their peers to try new procedures and medications.
38
Furthermore, drug companies worked to make opinion leaders into “product champions”
(Coiera, 2002, p. 1043). Most pharmaceutical companies maintained databases of their
potential product champions or “key opinion leaders” (Coiera, 2002, p. 1043). These key
opinion leaders possessed immeasurable influence toward potential prescription success
or failure. The right nod toward a particular product could “influence thousands of
research, lectures, publications and their participation on advisory boards, committees,
editorial boards, professional societies and guideline/consensus document development”
(Coiera, 2002, p. 1043). However, payments to key opinion leaders have been viewed as
“corrupt and not in the best public interest” (Coiera, 2002, p. 1043).
Rogers and Cartano (1962) were key players in the introduction of opinion
leadership. These influential individuals were consulted before decisions were made or
processes adopted. This influence was more powerful than workshops, journals,
mandates from superiors, or any otherwise credible sources. Furthermore, Rogers and
Cartano (1962) listed three generalizations about opinion leaders: (a) they deviate less
from group norms than the average group members, (b) little overlap exists among the
different types of opinion leaders, and (c) Rogers and Cartano (1962) differ from their
“followers in information sources, cosmopolitanism, social participation, social status,
and innovativeness” (Rogers & Cartano, 1962, p. 437).
Herzlinger (2006) identified six forces that can help or hinder innovations in
health care:
39
Table 1
Methods, Techniques, Advantages, Disadvantages, and Instruments Used for Identifying
Opinion Leaders
Methods Techniques Advantages Disadvantages Instruments
Celebrities Recruit well-known people who are national, regional, or local celebrities.
Easy to implement, Preexisting opinion leaders, High visibility
Contradictory personal behavior, Difficult to recruit
Media or individuals identify
Self-selection
Volunteers are recruited through solicitation
Easy to implement, Low cost
Selection bias, Uncertain ability
Individuals volunteer for leadership roles
Self-identification
Surveys use a leadership scale and those scoring above some threshold are considered leaders
Easy to implement, Preexisting opinion leaders
Selection bias, Validity of self-reporting
When you interact with colleagues, do you give or receive advice?
Staff selected
Leaders selected based on community observation
Easy to implement Staff misperceptions, Leaders may lack motivation
Staff determines which persons appear to be opinion leaders
Positional Approach
Persons who occupy leadership positions such as clergy, elected officials, media, and business elites
Easy to implement, Preexisting opinion leaders
May not be leaders for the community, Lack of motivation, Lack of relevance
1. Do you hold and elected office or position of leadership? 2. Are you a member of any community organizations? Which ones?
Judge's ratings
Knowledgeable community members identify leaders
Easy to implement; Trusted by community
Dependent on the selection of raters and their ability to rate
Persons who are knowledgeable identify leaders to be selected and rate all community members on leadership ability
Expert identification
Trained ethnographers study communities to identify leaders
Implementation can be done in many settings
Dependent on experts' ability
Participant observers watch interaction within the community and determine who people go to for advice
Snowball method
Index cases provide nominations of leaders who are in turn interviewed until no new leaders are identified
Implementation can be done in many settings; Provides some measure of the social network
Validity may depend on index case selection; It can take considerable time to trace individuals who are nominated
Randomly or conveniently selected index cases are asked who they go to for advice
Sample socio-metric
Randomly selected respondents nominate leaders and those receiving frequent nominations are selected
Implementation can be done in many settings; Provides some measure of the network
Results are dependent on the representatives of the sample; May be restricted to communities with less than 5,000 members
Randomly selected sample or cases are asked who they go to for advice
Socio-metric All (or most) respondents are interviewed and those receiving frequent nominations are selected
Entire community network can be mapped; May have high validity and reliability
Time-consuming and expensive to interview everyone; May be limited to small communities (i.e., less than 1,000 members)
All respondents are asked who they go to for advice.
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1. Players can destroy or help an innovation’s chance of success
2. Funding (generating revenue and acquiring capital) can affect the possibility
of future accomplishment of innovative medical processes.
3. Policy or government regulations have the ability to help adopt new practices
within the health care arena.
4. Technology evolves at a fast rate and these changes impact competition within
the health care field.
5. Customers are more knowledgeable about health care options and can impact
the success or failure of innovative products.
6. Accountability on the part of health care innovators is necessary to satisfy
consumers and insurance payers. (p. 61)
Paul et al. (1999) acknowledged technological obstacles to telemedicine within
various clinical environments which might impact telemedicine usage activity. These
kinds of hindrances involved (a) the caliber of audio broadcasts as well as video graphics
transmitted; (b) the capability of medical care specialists to make use of the tools; (c)
end-user instruction; (d) difficulty associated with operating telemedicine gear; and (e)
the perceived weaknesses connected with digital health documents, along with tele-
consultation transmission to unauthorized staff members. Additional noted limitations
involved fiscal, specialist, and legal concerns (Paul et al., 1999).
Bower (2005) identified additional technological barriers to the implementation of
telemedicine. “The lack of interoperability among health care systems has prevented a
synchronous flow of information among and between clinics, hospitals and various other
health care organizations” (Bower, 2005, p. 51). Multiple products that were
manufactured by countless vendors were not systematically consistent with each other to
allow a plug and play type of compatibility. Often individual doctor offices would
purchase a system that works for their clientele and specific physician’s needs without
confirming the compatibility with its cooperating hospital. This major purchase of
software and hardware represented a significant investment in time, effort, and money.
41
However, the local hospitals within the neighboring areas might have recently installed
an incompatible telemedicine or electronic health records system within its regional or
national group of hospitals that would not talk to the smaller offices. This scenario
created a huge barrier to the successful flow of information between the parties involved;
thus, precluding the advancement of telemedicine within the health care group (Bower,
2005).
Communication between large health care organizations and the individual
physicians is critical to the advancement of telemedicine within the field. Opinion leaders
should be consulted as to the compatibility and integration of technological advances
within the health care organizations in order to maximize the potential gains of this
innovation. Bower (2005) argued,
Three things must be present in order to ensure interoperability and result in
significant gains for patient care. Separate pieces of hardware must be technically
compatible, software from different vendors must share a common medical
vocabulary, and the different systems must be electronically interfaced so that
they can communicate with each other. (p. 58)
Bower (2005) continued with additional data related to the 8% annual
improvement in productivity in the field when health care information technology was
implemented correctly. The factors required to ensure this growth were listed as:
1. Intense competition
2. Tremendous technical improvement
3. Aggressive deregulation followed by minimal government intrusion
4. Firms that are integrated to the right level to make optimal IT investment
decisions
5. Physical ability to lay down a fixed IT investment combined with support
from the IT infrastructure. (p. 52)
Bower (2005) confirmed the importance of the epidemic effects of key opinion
leaders within the medical community. The impact of such influencers within the
42
adoption process ought to be acknowledged and appreciated when contemplating
providing innovative products and services into the mainstream. Similarly, Liu (2011)
argued the significance of the character of leaders in the adoption of innovations within
health care institutions. Furthermore, additional key factors were identified that impacted
the adoption of technology in general, and telecare in particular, within the health care
environment. Liu (2011) found that “government support, technological knowledge,
compatibility, supplier support, and team skills were key factors influencing the intention
of the study’s location to adopt telecare” (p. 6).
Benefits and Barriers Identified by Literature (International)
The WHO (2010) listed a multitude of potential benefits and barriers to
telemedicine diffusion: “Telemedicine can help underserved communities and those in
rural areas with shortages of medical personnel. Socioeconomic benefits to patients,
families, health practitioners and the heal system, including enhanced patient-provider
communication and educational opportunities have been demonstrated” (p. 11). However,
several barriers were noted as well. Cultural, linguistic, or traditional practices may
preclude patients from participating in telemedicine activities. Legal restraints, cost, local
skills, resources and technological complications may impede the adoption of
telemedicine in developing countries. Specifically, (a) product malfunctions; (b)
deficiencies in repair service throughout smaller, outlying health care facilities; (c) lack
of technology experts, along with fewer health-related technicians; (d) sluggish
bandwidth speeds; and (e) an unwillingness among medical personnel, can produce
difficulties towards the endorsement of telemedicine (WHO, 2010).
Removing licensure and professional liability impediments would allow clearer
43
understanding for physicians and health care organizations regarding acceptability of
patients from other states in need of a physician’s care. Siegal (2012) expressed the need
and importance of state medical boards in developing an “expedited licensure-by-
endorsement process to facilitate multistate practice” (p. 266). As noted and discussed by
Siegal (2012), The Joint Committee and Centers for Medicare & Medicaid Services
produced a ruling allowing for “practitioners who render care using live/interactive
systems be allowed to obtain credentials and privileges at the consultant site when they
are providing direct care to the patient” ( p. 269). Nevertheless, additional safeguards
were proposed to alleviate the fear of excessive malpractice claims (Siegal, 2012).
Increased insurance coverage and consistent standards of care should provide improved
protection for the patient and caregiver. In addition, in-depth training programs should
educate all concerned parties. Finally, attention should be given to the informed consent
documents and HIPAA regulations regarding IT tools.
Opinion leaders and health care administrators cannot ignore the perceptions of
patients and physicians when designing telemedicine operations within hospitals or other
settings (Sheng, Hu, Wei, Higa, & Au, 1998). Allen and Hayes (1995) examined patient
satisfaction with teleoncology within a rural setting to determine levels of satisfaction
among rural cancer patients being seen using interactive videoconferencing (IAVC).
Although the sample size was considered too small to draw conclusions regarding all
rural cancer patients, these particular rural cancer patients rated their treatment utilizing
the interactive videoconferencing system in a favorable way (Allen & Hayes, 1995).
Allen et al. (1995) also assessed the level of satisfaction among physicians
involved in a teleoncology initiative within the state of Kansas. Similarly, the sample
44
size was too small to make generalizations. However, the study revealed that there was a
“reasonable level of physician satisfaction with, and confidence in, the use of video to
replace some on-site oncology consultations” (Allen et al., 1995, p. 36).
Opinion leaders and decision-makers on the administrative level should be
familiar with the inner-workings of a successful telemedicine consultation. Ferguson
(2006) noted the required communication media needed during a synchronous exchange
of medical information. The environment, session initiation, dialogue, and the session
closure will impact the diagnosis of the patients and delivery of the service. Further,
Ferguson (2006) recommended the standardization of Internet quality and reliability.
The environment should be well planned, adequately equipped, and its staff should be
efficiently trained.
Whited (2010) relayed the importance of economic considerations when planning
and executing a telemedicine program within health care organizations. Opinion leaders
and decision makers should study these factors before designing innovative systems.
Whited (2010) enumerated several perspectives for administrators to consider: (a) fiscal,
(b) social, (c) medical system, (d) patient, (e) predetermined as opposed to changing
expenses, (f) labor prices, and (g) cost-effectiveness as they relate to telemedicine. It
was noted that telemedicine in general, and tele-dermatology in particular, are cost-
saving methods of medical treatment because they save patients and health care
providers money by avoiding travel costs and lost wages. However, Whited (2010)
discussed additional cost-related factors that will affect telemedicine programming. As a
result, administrators should be familiar with these factors and investigate their impact
on the bottom line before implementing innovative health care endeavors.
45
Theoretical Framework–Diffusion of Innovations
Rogers (2003) presented diffusion as the “process by which an innovation is
communicated through certain channels over time among the members of a social
system” (p. 11). While these identifiable elements are shown to be present in most
diffusion programs, this study will also identify the CEO’s perception of the benefits and
barriers of the innovation as it is introduced into the health care setting. When applied to
a hospital environment, the four major factors influencing the diffusion process are seen
as (a) innovation itself, telemedicine or telehealth programming; (b) how information
about innovation is communicated, informally by the opinion leaders, formally via
mandatory proclamation from the administration or a variation within this range; (c) time,
timeframe from introduction to implementation, and (d) nature of social system in which
innovation is being introduced (Rogers, 2003).
Organizational innovativeness also impacts the rate of adoption within an
organization’s setting (Rogers, 2003). Specifically, “Larger organizations have been
shown to be more innovative” (Rogers, 2003, p. 433). When innovation-decisions are
made within an organization, Rogers (2003) indicates that these decisions fall within
three categories:
Optional innovation-decisions, choices to adopt or reject an innovation that are
made by an individual independent of the decision by other members of a system;
collective innovation-decisions, choices to adopt or reject an innovation that are
made by consensus among the members of a system; and authority innovation
decisions, choices to adopt or reject an innovation that are made by a relatively
few individuals in a system who possess power, high social status, or technical
expertise. (p. 403)
One of the goals of this study was to determine if the CEOs perceive the decision-
making process to be optional, collective, or authoritative. The results of the interviews
46
should assist in learning which type(s) of decision-making took place when the
telemedicine programming was implemented within the health care organization.
In addition to organizational size, Rogers (2003) also related innovativeness to
individual (leader) characteristics, such as “positive attitude toward change; internal
organizational structural characteristics, such as large size, decentralization, complexity
and interconnectedness; and external characteristics of the organization, such as system
openness” (p. 411).
The CEO’s perception of the innovation will also affect its rate of adoption by the
organization (Rogers, 2003). “The five perceived attributes of an innovation are its
relative advantage, compatibility, trialability, observability, and complexity” (Rogers,
2003, p. 222). Perceived attributes of an innovation as identified by Rogers (2003)
include:
(a) Relative advantage—“the degree to which an innovation is perceived as better
than the idea it supersedes” (p. 229);
(b) Compatibility—“the degree to which an innovation is perceived as consistent
with the existing values, past experiences and needs of potential adopters” (p.
240), an idea that is more compatible is less uncertain to the potential adopter and
fits more closely with the individual’s situation;
(c) Complexity—“the degree to which an innovation is perceived as relatively
difficult to understand and use” (p. 257). Innovations that are perceived as
complex are less likely to be adopted;
(d) Observability—“the degree to which the results of an innovation are visible to
others” (p. 258). If the observed effects are perceived to be small or non-existent,
47
then the likelihood of adoption is reduced; and
(e) Trialability—“the degree to which an innovation may be experimented with
on a limited basis” (p. 258). Trialability is positively related to the likelihood of
adoption.
Additional Diffusion Literature
Bauer and Ringel (1999) noted that “telemedicine’s reputation still suffers in
some quarters because early adopters often installed hardware, usually an interactive
video system funded by a big grant, and then tried to figure out what to do with it” (p.
146). Conversely, the needs and uses for telemedicine should be identified before the
expenditures are made. Given the theory that the use of technologies in any area is merely
changing the vehicle that provides medical services, an evaluative needs-assessment
should be conducted before decisions are made to implement a telemedicine initiative
within the health care organization (Clark, 2001; Simonson et al., 2012).
Diffusion of new technologies within an organization can present benefits to
potential adopters, but it also can lead to additional problems related to uncertainty about
its consequences. The planned end users tend to be unsure if the recently released
invention is going to be much better or perhaps as efficient when compared to the
previously used product or process (Rogers, 2003). The software and hardware needed
when new technological innovations are introduced creates uncertainty about its
acceptance and continued use within the organization.
Burbano, Rardin, and Pohl (2011) proposed additional factors related to the
adoption of new technologies within the health care arena. A causal loop provides a
pictorial representation of the interconnectedness between multiple variables as they
48
cause and affect each other Erdil (2009). Burbano et al. (2011) displayed a causal loop
diagram that provides an explanation of the factors affecting the health care adoption rate.
The causal loop focuses on technology adoption standards by health care providers with
relation to the external environment. The categories identified by Burbano et al. (2011)
include (a) health care provider population, (b) adoption rate, (c) organization, (d)
environment, and (e) technology. The influence from these factors is dependent upon the
effect of their components, such as (a) federal involvement, (b) supplier assistance, (c)
market demands, (d) technological options and preparedness, (e) comparative
engineering advantages, (f) clinical provider alternatives, and (g) organizational openness
to complex technological processes and internal social dynamics.
Another model related to organizational adoption of innovations is the Bass
forecaster model (Bass, 2004). The Bass forecaster model has been used to help predict
the acceptance of new products in the marketplace by insisting that prospective adopters
are inspired by a couple of varieties of communication channels–mass media and social.
It argued that interpersonal communication is more important to new adopters, while
media channels are more important for early adopters. Teng, Grover, and Guttler (2002)
demonstrated the use of the Bass diffusion model to show the diffusion of several
technological innovations within organizations.
Sheng et al. (1998) presented relevant information on the adoption and diffusion
of telemedicine technology in health care organizations in Hong Kong. These types of
results suggested a new sort of design intended for efficient, successful organizational
adoption and diffusion of telemedicine innovation within medical care structure.
Organizational acceptance and efficient management of telemedicine efforts continue to
49
be critical to the success of telemedicine within the health care facility. Sheng et al.
(1998) stressed the value associated with an interrelationship between the organizational
and personal levels of participation within the professional medical institutions
throughout the adoption and diffusion stages associated with telemedicine. Specifically,
the management of the adoption and diffusion of telemedicine within a health care
organization needs to be carefully orchestrated in order to be successful. Success of
telehealth systems has been due to the supervision of the technological adoption along
with the diffusion connected with their particular techniques within the health care
environment (Sheng et al., 1998).
According to Sheng et al. (1998) telemedicine adoption was a bottom-up course
of action whereby the health professionals instigated involvement in the idea as well as
motivated the health care facility administrators within the C-Suite to take on the newest
technological innovations and diffuse them within the organization. Technology adoption
was made on the organizational level, but diffusion was accomplished on the physician
level. This adoption and diffusion process was comprised of four phases:
Attitude formation (individual physicians’ positive or negative feelings about
telemedicine), program initiation (individual physicians’ campaign toward
implementing telemedicine that is either reinforced or denied by management),
technology adoption (organization’s decision to implement telemedicine) and
technology diffusion (information is communicated to physicians who begin
routine use of telemedicine). (Sheng et al., 1998, p. 253)
In the study conducted by Sheng et al. (1998), the physician that adopted
telemedicine within his area failed to act in a positive manner toward the new innovation.
As a result, his role as opinion leader resulted in discontentment with telemedicine since
he took no measures to help inspire the usage of the particular invention which he aided
to diffuse inside the health care organization (Sheng et al., 1998). However, in a
50
successive attempt at telemedicine implementation, the division head became the adopter
by thoroughly planning the intricate steps needed to initiate an effective and efficient
program. Meanwhile, another physician acted as an opinion leader through the promotion
of telemedicine technology amid his colleagues (Sheng et al., 1998). When management
was involved and supportive, and the staff participated in the implementation, the
initiative was successful. However, when management took a hands-off approach and
excluded the clinicians from the decision-making process, the initiative failed miserably
(Sheng et al., 1998).
Sheng et al. (1998) argued that change agents, which can be similarly compared
to opinion leaders, are an integral factor in the successful acceptance of telemedicine
within a health care system. These change agents (opinion leaders) enhance the top-down
assistance coming from an inside supporter in addition to make use of private
communications to coach, persuade, and encourage various other doctors to adopt the
innovation using a peer-to-peer framework (Sheng et al., 1998). Another key component
to successful adoption and diffusion of telemedicine is an internal champion or maybe a
loyal, prominent level medical administrator ready to provide managerial clout and
personal influence in order to help navigate the innovative technology purchase through
the entire establishment (Sheng et al., 1998).
Daim, Tarman, and Basoglu (2008) confirmed the active engagement by the
administration and medical professionals in the diffusion of innovative developments
inside the clinical care service areas of hospitals. Specifically, a combination of medical,
technical, clinical, financial and administrative staff was needed to make adoption
decisions and take collective responsibility for the outcome. According to Daim et al.
51
(2008) physicians and end users tended to be disregarded in the design and style stages
associated with implementing newly acquired technological systems within the clinical
environment. Consequently, hospital administrators should be supportive and inclusive
when implementing telemedicine technology programming within their organizations. In
an information-dependent market including health care, obvious transmission programs
were essential to be sure powerful knowledge moves throughout the corporation (Daim et
al., 2008).
When physicians, managers and other clinical staff members present innovative
health care methodologies, health care leaders need to be open to change. Daim et al.
(2008) stressed the importance of attentiveness to cultural transformations, fiscal
preparation, and logistical organization in order to develop a productive technological
setup within the health-care related industry. Technology acceptance model (TAM)
reinforced the significance of perceived ease of use and perceived usefulness when
diffusing an innovation within an organization (Venkatesh & Davis, 2000).
Support from management has been emphasized in a study related to
organizational adoption of information technologies (Kermoglu, Basoglu, & Daim,
2008). In fact, management support was listed as one of the top three reasons for
innovation failure of information technology-related projects. Attention should be paid to
the individuals involved in the implementation of the technological innovation.
Cooper and Zmud (1990) presented an information technology implementation
model that addressed adoption and infusion of innovative technology within an
organization. “The six stages involved a product’s initiation, adoption, adaptation,
acceptance, routinization and infusion” (Cooper & Zmud, 1990, p. 125). When
52
considering the technology diffusion and organizational innovation, Kwon and Zmud
(1987) presented five contextual components associated with the operations and
merchandise within all of the execution phases: (a) attributes of the user associated with
individual group, (b) features with the organization, (c) characteristics of the
technological know-how currently being adopted, (d) traits of the activity to which the
technological innovation is being applied, and (e) the qualities of the organizational
atmosphere. Stanberry (2006) reported a number of legal and moral facets of
telemedicine concerning basic political principles, recommended practices and
methodologies, vendors, merchandise liability and safety, standards and interoperability,
and intellectual property right privileges. The multitude of unresolved issues related to
telemedicine and its application within today’s medical community have precluded its
acceptance on a worldwide basis. Stanberry (2006) concluded that uncertainty in the
widespread areas will continue to preclude unanimous acceptance and implementation of
telemedicine.
Carter, Thatcher, Chudoba, and Marett (2012) presented valuable information on
the importance of personal innovativeness with the implementation and continued use of
innovative technologies. Factors affecting the acceptance of innovative technologies
include “intention to use IT; intention to explore IT; trying to innovate with IT; perceived
usefulness of IT; perceived ease of use of IT and autonomy” (Carter et al., 2012, p. 3).
While Carter et al. (2012) insisted that “implementing new technologies and gaining
initial user acceptance does not guarantee that users will fully exploit the capabilities of
the installed IT, opinion leaders could possibly take this information into account when
deciding to implement telemedicine at their health care organizations” (p. 2). However,
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Carter et al. (2012) argued that enhanced autonomy amid players resulted in greater
probability that the new technologies would be used to complete tasks within the work
place. In addition, Carter et al. (2012) claimed that most of these autonomous individuals
should have the ability, determination, drive, and opportunity to make help make
purposeful choices concerning the approval and endorsement with regard to new brand-
new systems within the work environment.
In his book, Berwick (2004) expressed the need to change the health care system.
These necessary innovations which relied heavily on Rogers (2003) diffusion of
innovations theory, entitled “Berwick’s rules for spreading good change” (p. 118) were
comprised of seven practical steps innovators must take to facilitate improvement in the
current health care system. Berwick (2004) insisted that change agents and opinion
leaders “find sound innovations; find and support innovators; invest in early adopters;
make early adopter activity observable; trust and enable reinvention; create slack for
change and lead by example” (p. 118). “By utilizing these seven ‘rules for spreading
good change’ health care leaders encourage original thought and nurture innovation in all
its rich and many costumes” (Berwick, 2004, p. 123).
Researchers have often applied Roger’s (2003) diffusion of innovations theory in
their studies of change within organizations (Baxley, 2008; Calderone, 2003; Davis,
2006; Hanson, 1998; Karwoski, 2006; McDade 1996; Sillup, 1990; Valente & Davis,
1999). The adoption of medical innovations within the health care industry has increased
as new products entered the marketplace. Sillup (1990) expressed concern over the use of
new medical technologies despite their proven benefit to society. Trepidation over the
adoption of new methods within the health care industry can be explained using Rogers’
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(2003) S-shaped rate of adoption curve. This kind of diffusion process demonstrates
precisely how many innovative developments tend to be adopted so quickly, showing a
sharp curve; even though various other inventions have a sluggish adoption pace, causing
a far more gradual curve (Rogers, 2003; Sillup, 1990).
Importance of Opinion Leaders
Opinion leaders are very powerful within an organization. Opinion leadership
influences an innovation’s rate of adoption or rejection. Rogers (2003) defined opinion
leadership as “the degree to which an individual is able to influence other individuals’
attitudes or over behavior informally in a desired way with relative frequency” (p. 27).
However, opinion leadership is not some sort of functionality of the individual’s official
position or rank within a corporation or group (Rogers, 2003). The standing is usually
attained because of the individual’s technological proficiency and skill set, interpersonal
ease of access, along with conformity to the system’s norms (Rogers, 2003).
Opinion leaders are critical for the legitimization of new innovations (Thakkar &
Weisfeld-Spolter, 2011). If this is true, then discovering the identity of opinion leaders
within the medical profession would be crucial to the diffusion of telemedicine within the
health care organizations. If hospital administrators can determine the identities of
opinion leaders within a medical environment and target them, then the introduction of
additional medical innovations would likely have a higher probability of becoming
adopted.
Thakkar and Weisfeld-Spolter (2011) emphasized the importance of using two
methods to determine the identity of the opinion leaders within an organization. Self-
description (also known as self-determination) and sociometry were noted as the most
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widely used techniques for discovering the identities of opinion leaders. However,
according to Rogers (2003) self-determination was discovered to be much less reliable
when compared with sociometry, because it is dependent upon the precision and
reliability with which participants could distinguish and report their own self-images. The
socio-metric method, which involves asking system members to tell to whom they go for
advice and information about an idea, is the easiest to administer and has the highest level
of validity. However, the key drawback is usually that it demands numerous respondents
to locate only a few opinion leaders (Rogers, 2003).
To what degree does the COO or CEO act as an opinion leader and influence
decisions within the health care organization with respect to the diffusion of new
technological ideas? The COO or CEO could act as one of three types of decision makers
with respect to the diffusion of innovative medical technology. First, telemedicine
adoption could be seen as an optional innovation decision whereby choices to adopt or
reject an innovative method of health delivery are made by “an individual independent of
the decisions of the other members of the system” (Rogers, 2003, p. 28). Second, the
decision to adopt telemedicine could be any collective or group innovation choice,
whereby the options to take on or perhaps decline an innovation are made simply by
general opinion among the associates of the organization (Rogers, 2003). Third, the COO
or CEO could act as an expert innovation decision maker in which the options to consider
or perhaps avoid an invention are made by a comparatively small number of people
within an organization who retain power, reputation or even specialized technological
knowledge (Rogers, 2003). Rogers (2003) argued that “nearly all authority decisions are
embraced at the swiftest speed of the three alternatives” (p. 31).
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Characteristics of Opinion Leaders
Rogers (2003) identified opinion leaders with seven generalizable characteristics.
First, opinion leaders were shown to have greater exposure to mass media than their
followers. Second, they were more cosmopolite than their followers. In other words, they
would have the perception of being on the edge of new discoveries. Third, opinion
leaders had greater contact with change agents, because change agents would attempt to
utilize the opinion leaders to assist in achieving success. Fourth, opinion leaders had
greater social participation than those who followed them. These people would have had
more social interaction than most other members within their social circle. Fifth, opinion
leaders would generally have had higher socioeconomic status than their followers. A
sixth characteristic of opinion leaders was their perceived level of innovativeness among
their peers. Notice it is the perception of innovativeness, not necessarily the possession of
the characteristic that sets the opinion leader apart from his or her peer group. Finally, the
system’s norms determined the level of innovativeness of the opinion leader. In other
words, “when a social system’s norms favor change, opinion leaders are more innovative,
but when the system’s norms do not favor change, they are not especially innovative”
(Rogers, 2003, p. 318). In addition, Rogers (2003) argued that opinion leaders are more
likely to spread their influence by encouraging their peers to adopt new innovations. “The
traits most likely to be possessed by opinion leaders were communication, knowledge
and humanism” (Rogers, 2003, p. 33).
Karwoski (2006) identified crucial characteristics in neuromuscular experts that
aided in discerning these individuals as opinion leaders to function as change agents in
order to encourage the diffusion of health-related innovations. The traits identified in the
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study were “approachability (pleasant personality), declarative knowledge (factual
information), procedural knowledge (clinical skill) and translational ability (making clear
how to apply information to clinical practice” (Karwoski, 2006, p. iii). These traits can be
compared to Rogers’ (2003) description of opinion leaders “whereby, they provide
information and advice about innovations to other individuals, exposed to all forms of
external communication and more cosmopolite; higher socioeconomic status; have
greater social participation; have greater contact with change agents; and more
innovative” (p. 27). Change agents function through opinion leaders in order to coax
innovative developments to be adopted by members within the cultural system of the
organization (Rogers, 2003).
Karwoski (2006) argued that the social influence exhibited by physicians is
valued and adhered to by their peers. These informal advisors have been labeled as
“informal educators, educationally influential physicians, or educational influential, and
if used in formal roles, opinion leaders or champions” (Karwoski, 2006, p. 3).
Considering the limited amount of time available for reading and research, condensed
information provided by influential peers or opinion leaders would be taken seriously and
followed by the mainstream group of physicians.
Karwoski (2006) maintained that although opinion leaders influence the adoption
of innovative technological methods in the health care field, other factors must also be
considered. Physician characteristics will play a part in the adoption, as well as practice
environment, patient characteristics, economic issues and legal considerations. Doctors
having a substantial rate of innovativeness within a health-care’s social community may
not be viewed as influential in convincing his or her associates. The cost of new
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equipment and patient preference are key factors when considering the adoption of new
medical technology. Potential litigation and possible inability to administer the highest
level of patient care can influence the adoption of new methods of health care.
Karwoski (2006) surmised that “the use of opinion leaders and patient-mediated
interventions proved to be the most effective strategy when attempting to influence
physicians concerning continuing medical education” (p. 26). Interpersonal influence has
been shown to play an essential role whenever colleagues contemplate progressive
strategies of health care (Karwoski, 2006). The role of opinion leader was considered to
be very important in the innovative technologies adoption process.
Hills et al. (2004) provided results on characteristics of opinion leaders as
technology transfer agents in substance abuse treatment agencies. They found that
opinion leaders within this field differed from their peers in slightly higher competency,
more post graduate education, more professional credentials and years of experience in
mental health treatment. These opinion leaders were perceived as providing crucial
methods for disseminating and adopting innovating treatment practices within their
organizational settings. These people aided in promoting trustworthiness in adopting
novel clinical procedures along with employing new programs and plans since they were
trusted by their fellow medical associates (Hills et al., 2004). One should understand how
opinion leaders tend to be inspired or swayed by ways of organizational factors like
administrative backing, fiscal as well as technological means, coaching and career
satisfaction while implementing innovative medical techniques (Hills et al., 2004).
Rogers (2003) discussed the significance of discovering the identities of opinion
leaders by using social network analysis. Jonnalagadda, Peeler, and Topham (2012)
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explored the centrality of opinion leaders using social network analysis as they related to
medical topics. These centrality measures were associated to prestige, power,
prominence, and importance. They found that identifying these measures helped in
defining the opinion leaders (subject experts) within the medical field they explored.
Finally, they found that open, two-way dialogue was a critical ingredient in a recipe for
successful implementation of this type of endeavor (Jonnalagadda et al., 2012).
However, opinion leaders are not limited to those with higher socioeconomic
status. Sharkey, Chopra, Jackson, Winch, and Minkovitz (2011) discovered the
importance of a variety of influential factors related to caregivers as they sought health
care for their children in South Africa. Sharkey et al. (2011) found that in addition to
physical access, financial access, availability of services, and performance of health
workers, another factor influenced mothers as they pursued medical help for their
children. The cultural opinion leaders located inside certain communities possessed titles
such as witch doctors, in-laws, and faith/spiritual healers (Sharkey et al., 2011). Cultural
traditions within various societies determined the persuasive power of opinion leaders.
Even when a child’s health could deteriorate and death would certainly result, the opinion
leaders of the village, in-laws and traditional healers, possessed the power to restrict the
caregiver from seeking Western medical treatment and save their loved ones.
Rogers (2003) characterized opinion leaders as members of the group of early
adopters that are well integrated and respected in local networks; similar to their peers in
socioeconomic status and in other personal characteristics. This group of early adopters
from which the opinion leaders emerged comprises only 13.5% of a typical group. The
remaining groups consist of innovators, 2.5% of the group who adopt change first, but are
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not typically well integrated with their peers. The next group, called the early majority,
34% of the members who consider the adoption of a new idea for a longer period of time
than either of the first groups, normally does not produce opinion leaders. The late
majority, 34% of the group that is typically skeptical of new ideas and does not adopt
them until most of their peers have done so, does not produce opinion leaders either.
Finally, the laggards, the last 16% of the group, “are the last within the network to adopt
a new idea, usually as a result of peer pressure” (Rogers, 2003, p. 281).
Borbas, Morris, McLaughlin, Asinger, and Gobel (2000) recognized the influence
of local, informal medical opinion leaders in the diffusion and adoption of medical
innovation of medical practice within the realm of clinical practice. Clinical opinion
leaders would tend to drive the innovation of medical technology in the health care
environment. Borbas et al. (2000) stressed the notion that these opinion leaders are most
often informal leaders who are not authority figures or physicians in administrative roles.
So, how do these opinion leaders guide the innovative process within the medical arena?
Several studies identified these methods within the medical field (Coleman, Katz &
Menzel, 1966; Wenrich et al., 1971). The medical opinion leaders assisted in the adoption
of new practices and procedures by providing enthusiasm and support for the projects
which alleviated the usual apprehension and push-back from their colleagues.
Encouragement from opinion leaders can assist in heightening the awareness of
several medical illnesses, such as hypertension. Deshmukh, Dongre, and Garg (2008)
discovered when they motivated opinion leaders, located within their community, to
inspire more attention toward hypertension consciousness; the results were a very
positive integrated health campaign on hypertension. The results included an
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improvement in knowledge of the symptoms of hypertension and its causes among
respondents. The proportion of patients who requested treatment regularly also increased.
Pharmaceutical companies often utilize the strong influence of opinion leaders to
encourage adoption of their drugs (Liberati & Magrini, 2003). It is important to recognize
the ethical dilemmas that can ensue from these types of arrangements. Profit from
pharmaceutical sales should not outweigh the side-effects from drugs. Liberati and
Magrini (2003) emphasized that the dissemination of information to health professionals,
especially opinion leaders, via medical journals and conferences should be high quality
information.
Physician executives who also act as opinion leaders in biotechnology and
pharmaceutical environments face additional requirements. Tan (2003) recognized the
importance of the additional skills a physician would need to become an advisor in these
innovative fields. Since physician executives who act as opinion leaders have the ability
to make a substantial effect on the adoption of new pharmaceutical products, it is
recommended that they have additional educational endorsements, such as a certified
physician executive (CPE) endorsement. Subsequently, opinion leaders usually advanced
educational degrees as well as other academic credentials. They are also thought to be
authorities within their career fields. As a result, the CPE guarantees that they have been
board certified in their specialized medical niche. In addition, they possess clinical,
business and administrative acumen that validates their standing as a highly-qualified,
influential contributor to vital adoption decision-making. In addition to the
aforementioned qualifications, Tan (2003) stressed the following characteristics are held
by physician executives who also act as opinion leaders: (a) passionate about what they
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do, (b) aware of risks, (c) practical and market-oriented, and (d) creative and innovative.
Similar qualities were also mentioned by Rogers (2003) in his description of an opinion
leader.
While Rogers (2003) has been a leader in the diffusion of innovation theory for
over 50 years, others have expressed the belief that opinion leaders have changed over
the years. Doumit, Wright, Graham, Smith, and Grimshaw (2011) agreed that the four
approaches to identifying opinion leaders (a) sociometric, (b) key-informant, (c) self-
designating, and (d) observation have been adequate. However, the use of the Hiss
instrument has been used to identify opinion leaders within the health care industry. In
1978, interviews with several Michigan-based, general practitioners resulted in the
identification of three traits associated with opinion leaders: “encourage learning and
enjoy sharing their knowledge, clinical experts considered up-to-date, and treat others as
equals” (Doumit et al., 2011, p. 1). Social network analysis was also used to determine
relationship ties between individuals within the medical network. Doumit et al. (2011)
plotted the social network to attain a graphic rendering of the human relationships among
participants and their associates who have been recognized as opinion leaders. It was
found that the opinion leaders present within the social network were influential in the
attitudes and health care behaviors of its members.
Opinion leaders can influence large medical networks, hospitals, smaller
organizations as well as individual practices. Carpenter and Sherbino (2010) discovered
how opinion leaders can influence a group of emergency physicians through social
means. Rogers (2003) argued that diffusion of innovation required four elements, namely
the innovation, communication, time and a social system. Further, Berwick (2003)
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applied Rogers’ theory to the field of medicine when he specified that the adoption of
new clinical practices is dependent upon three influences: (a) perceptions of the
innovation, (b) the clinical context, and (c) the characteristics of the individuals engaged
with the innovation. In fact, Berwick (2004) argued “in health care, invention is hard, but
spread seems even harder” (p. 101). Carpenter and Sherbino (2010) echoed Berwick and
Rogers by arguing that “early adopters lead the opinion within a clinical group and
without their endorsement, efforts to change will be resisted” (p. 1). The close proximity
of physicians’ social and work environment was identified as a key component in the
strength of opinion leaders. Specifically, opinion leaders influence the choices of
physicians’ practices as a result of collective discussions, informal gatherings, and
protocol modifications larger than conventional or approaches like seminars,
conventions, and other published materials (Carpenter & Sherbino, 2010).
Therefore, it is important to be able to identify opinion leaders within an
organization. Davis (2006) reiterated the notion that opinion leaders have an effect on
technology procedure selections and communication within most companies. Further,
since opinion leaders are very powerful within an organization, one should recognize that
they are “not always in positions of formal authority within a formal hierarchy” (Davis,
2006, p. 5). Conversely, one must analyze the organization’s history to discover who the
opinion leaders might be. Further, it is important to understand the relationship among
the opinion leaders before attempting to utilize their influence within the organization.
Marko (2011) identified the role of opinion leaders in the dissemination of media
messages within a socio-political environment recognizing their significant visual,
persuasive and personal qualities. Similarly, Burke, Fournier, and Prasad (2007)
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proposed that the diffusion of innovative medical procedures such as stents by non-stars
was positively dependent upon the number of stars practicing simultaneously at the same
hospitals. Stars were defined as physicians that completed their medical residency at a
hospital ranked in the top 30 nationally recognized hospitals. Rogers (2003) likened these
stars to opinion leaders within an organization. As such, these key individuals possessed
persuasive abilities within a social group based upon their personality and other
characteristics. Burke et al. (2007) found that the absence of local contact with legendary
medical professionals may well the adoption pace within a smaller sized medical setting.
Further, “the diffusion of innovative medical procedures, such as laparoscopic
gastric bypass surgery was found to be impacted by the ‘positive asymmetric influence’
of star physicians upon ‘non-stars’ at the same hospital” (Burke, et al., 2007, p. 1).
Research Questions
The research questions examined the emergence and prevalence of themes and
likely association to innovativeness. There were three research questions:
1. Which themes are going to emerge?
2. Which themes are most prevalent?
3. Is there an association between the level of innovativeness of the organization
and the innovativeness of the individual?
There were six interview questions: three central questions and three sub
questions. The central questions were related to barriers, drivers and strategies related to
telemedicine implementation. The central questions were:
1. Which barriers do CEOs show to be most likely to deter telemedicine
implementation at health care organizations in Kansas City? How has reimbursement
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affected the development of telemedicine in area hospitals?
2. What are the drivers that persuade health care providers to development
telemedicine programming within their organizations?
3. What types of strategies do COOs employ to overcome barriers in
implementing telemedicine in their health care facilities?
Sub questions. The sub questions analyzed the involvement of administrators and
organizational factors on telemedicine adoption and development. In addition, a
comparison of additional innovations was explored. The three sub questions were:
1. What is the role of the COO in the development of telemedicine/telehealth
services?
2. How do the legal, legislative, ethical, financial, equipment and training aspects
of implementing telemedicine/telehealth services affect hospital leaders?
3. How does the telemedicine adoption and diffusion process compare with the
adoption of other technologies within the health care industry in general (e.g. diffusion of
electronic health records)?
Limitations
The study findings are limited to the geographical area where the study was
conducted. The location is one of convenience limited to the GMKCA. Future studies
should extend beyond the Midwest to provide a clearer and more valid portrayal of
opinion leaders’ influence on administrators in their implementation of telemedicine. Past
studies involving the diffusion of innovations within several fields such as medicine,
marketing, and other areas revealed the importance of opinion leaders during the decision
making process.
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Following the collection, transcription, and summary of the interview data
collected from the CEOs and COOs who participated in this study, a clearer indication
will be made available as to the impact of opinion leaders’ on the development of
telemedicine within hospitals in the Midwest. Future implications of this study might lead
to a new tool that can be used to guide CEOs and COOs in their efforts to present
innovative medical procedures within a health care setting.
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Chapter 3: Methodology
Aim of the Study
This chapter will describe the strategy used for the qualitative research study. The
purpose of this study was to describe the perceived benefits of, and barriers to,
telemedicine as experienced by 18 leaders of hospitals and health care facilities within
the GMKCA. The areas to be discussed will include (a) the grounded theory
methodology, (b) purposeful sample of CEOs and presidents, (c) interviewing and
observation strategies, and (d) analysis of the transcribed field notes. Meloy (1994)
emphasized the importance of personal rather than detached examination of subjects
while performing qualitative research. Therefore, interviews played an integral part in the
data gathering process of this study.
Qualitative Research Approach
A qualitative approach was utilized to conduct the grounded theory study research
of perceptions of 18 CEOs when they implemented telemedicine programming in health
care organizations in the GMKCA. The observations and interviews were those in 18
health care sites. Interviews were conducted face-to-face when possible, or by telephone
if it was the interviewee’s preference. Interviews were conducted according to procedures
described by Dewalt and DeWalt (2011), Rubin and Rubin (2005), and Seidman (1991).
Interviews fostered interactivity with participants, elicited in-depth, context-rich
accounts, perceptions, and perspectives. Verbatim transcriptions documented the
interview. Interviews allowed data to be collected in their natural setting as it provided
the opportunity to “gain a better understanding of the fundamental processes of social
life” (DeWalt & DeWalt, 2011, p. 3). Creswell (2007) stated data collection activities
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consisted of the following steps: “locating the site/individual, gaining access and making
rapport, purposeful sampling, collecting data, recording information, resolving field
issues and storing data” (p. 118).
Rationale for Grounded Theory Study
Bloomberg and Volpe (2012) reported that the grounded theory approach allows
the researcher to generate or discover a theory of a process grounded in the views of the
research participants. All of the participants would have experienced the process. The
development of theory might explain the practice, or provide a framework for further
research. A core component is that “theory development is generated by or ‘grounded’ in
data from the field” (Bloomberg & Volpe, 2012, p. 33). “Grounded theory research
approach involves gathering data and simultaneous analysis in order to generate a theory
about the process” (Charmaz, 2006).
Interviewing the CEOs and COOs about their perceptions of benefits and barriers
delved into how leading administrators think about implementing telemedical/telehealth
practices within their organizations. Discussions about innovative medical processes,
such as telemedicine, also revealed how diffusion of non-traditional medical operations
occurred in health care organizations. Charmaz (2006) insisted that using the grounded
theory approach results in theories directly drawn from data are more inclined to provide
understanding, enrich comprehension, and supply a purposeful guide to active
engagement. A realistic description of the perceptions of telemedicine implementation
would provide a useful depiction of how CEOs and other upper level hospital
administrators experience this health care method. Helpful solutions could possibly result
from the data collected from this study.
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Creswell (2007) suggested this research approach when an issue is “explored in a
bounded system, over time, through detailed, in-depth data collection involving multiple
sources of information (e.g. observations, interviews, audiovisual material, and
documents and reports) and reports a case description” (p. 73). A multiple-site, grounded
theory study was conducted to analyze each location separately. Then an in-depth
analysis was conducted to identify common themes among all of the cases (hospitals).
The gatekeeper, “an individual who is a member of or has insider status within an
organization that is the initial contact for the research and leads the researcher to the
participants” (Creswell, 2007, p. 125) was identified at each of the 18 locations.
Extensive data were collected using multiple forms of data collection, such as non-
participant observations, interviews (telephone and face-to-face, when available) and
public documents. The objective was to develop a thorough understanding of each
location, singularly and collectively, to describe the barriers and benefits of implementing
telemedicine from the CEO and COO’s perspective.
Participants
Creswell (2007) defined purposeful sampling as “selecting individuals and sites
for study because they can purposefully inform an understanding of the research problem
and central phenomenon in the study” (p. 125). In this study, purposeful sampling was
demonstrated by selecting the CEO, COO, or president of 18 health care organizations as
the key participants in this study. These opinion leaders are critical in the decision-
making tasks necessary to design, build, equip, and organize the processes necessary to
implement telemedicine and telehealth programming within their respective
organizations.
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Participants that were studied held the highest level of authority within their
respective health care organizations. The roles of COOs and CEOs in hospital settings are
multifaceted. According to Kouzes and Posner (2007), the leader of an organization is
one of the most important positions because he or she determines the “values, vision and
trajectory of the work community” (p. 338). As such a vital member of the company, the
leadership style, including innovativeness and motivation will be emulated by the
employees. This leadership position involves (a) planning, (b) management of finances,
(c) people, and (d) organizational culture. Additional duties include (a) the highest level
of responsibility involving marketing and public relations, (b) community relationships,
and (c) programmatic effectiveness. In a hospital setting, as in nearly all establishments,
competence and confidence in the business specialty is required for organizational
effectiveness and sustainability. Likewise, clinical, technological, and administrative
expertise should prove to be vital leadership attributes when directing the organization
(Kouzes & Posner, 2007). Clawson’s (2009) Level Three Leadership added global
leadership characteristics such as deep self-awareness, culturally diverse, humility,
lifelong learning and curiosity, honesty, well-spoken, acts with integrity, insightful, open
to criticism, and a good negotiator.
A detailed description of the study’s participants was obtained using a
demographic document. Obtaining individual identifying information such as age,
gender, race, highest level of college attainment, and previous experience provided a
more detailed understanding of the participants involved in the study. Other key factors
that were assessed were the organizational structure, the presence or absence of
telemedicine services and the perceptions of COOs and/or CEOs (key adopters).
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“Relevant demographic information is needed to help explain what may be underlying an
individual’s perceptions, as well as similarities and differences in perceptions among
participants” (Bloomberg & Volpe, 2012, p. 105). It is also important to consider
demographic information, e.g. gender, age, class and ethnicity when conducting research
because they might present barriers to participation in some studies (DeWalt & DeWalt,
2011). “Personal characteristics as individuals, such as ethnic identity, class, sex, religion
and family status will determine how researchers interact with and report on the
participants being studied” (DeWalt & DeWalt, 2011, p. 34).
Data Collection Tools
The research setting was 18 hospitals located within the GMKCA. The
participants that were interviewed were a purposeful sample of the COOs and CEOs of
Kansas City’s health care organizations. This process consisted of a face-to-face or
telephone interview, in which the 18 COOs/CEOs (see Appendix A) responded to open-
ended questions during a semi-structured interview. In addition, the Innovativeness Scale
and the Perceived Organizational Innovativeness survey (PORGI) were completed by
each interviewee. Individual innovativeness data were obtained using the Hurt-Joseph-
Cook Innovativeness Scale (IS; see Appendix C; Hurt, Joseph, & Cook, 1977), and
perceptions of organizational innovativeness using the Hurt-Teigen scale of Perceived
Organizational Innovativeness (PORGI; see Appendix D; Hurt & Teigen, 1977).
Interviewing the participants was the primary data collection tool activity.
Details of the study were explained and participants were assured of anonymity
and confidentiality. An informed consent permission form was provided to the participant
that clearly identified the purpose and uses of the information that was obtained. The
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interview and questionnaire activities were conducted utilizing the Institutional Review
Boards (IRB) approved protocol instruments obtained from the Nova Southeastern
University’s Mental Measurements Yearbook or Tests in Print databases.
The Innovative Survey
Hurt et al. (1977) wrote that the IS analysis provided considerable predictive
validity as an instrument that measures innovativeness. It was designed to measure an
individual’s willingness to change. The IS analysis is a 20-item, self-report instrument
with the potential to consistently predict the willingness to adopt innovations among
diverse populations.
The IS analysis can be used to identify the types of adopters based on a
willingness-to-change prior to the introduction of the innovation. It uses a 7-point Likert
type scale that ranged from 1 = strongly disagree to 7 = strongly agree to score the
participant responses. This inexpensive and easily administered instrument provided three
main advantages. First, the self-report techniques allowed innovativeness to be measured
more systematically and consistently than other instruments (Hurt et al., 1977). Second,
the measured innovativeness was not dependent upon the innovation. Instead, it could
measure innovativeness across a variety of innovation concepts (Hurt et al., 1977). Third,
the Likert, self-report scales have a high level of reliability, as well as construct and
predictive validity. The reliability coefficient of the IS analysis is .89 (Hurt et al., 1977).
The Perceived Organizational Innovativeness Survey
The PORGI was developed by Hurt and Teigen in 1977. It was designed to
measure a “member of an organization’s orientations toward change” (Hurt & Teigen,
1977, p. 377). The PORGI was used in this study because it has been found to be highly
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reliable and contains high predictive validity. The internal consistency reliability of
PORGI is .96 (Hurt & Teigen, 1977). This self-administered instrument consists of 25
statements related to some of the ways member of organizations perceive their
organization to be. It uses a Likert scale that ranges from 1 = strongly disagree to 7 =
strongly agree to score the participant responses.
In addition, both the PORGI and the IS have been found to be noteworthy
predictors of employee participation at each stage of the organizational innovation-
decision process (Hurt & Teigen, 1977). The internal consistency reliability of PORGI is
.96, whereas the IS reliability coefficient is .89 (Hurt et al., 1977). However, both surveys
provided quantitative data that were analyzed along with the qualitative data gathered
from the participant interviews.
Procedures
These procedures are described in DeWalt and DeWalt’s book (2011) and in a
book by Seidman (1991), as appropriate for a study such as this one.
Questions were broad to allow the participants to construct meaning from the
questions and situations. Questions were open-ended to allow understanding of the
historical and cultural settings of the organizations. Literature was reviewed to obtain
open-ended questions from similar studies when CEOs were interviewed about a new
initiative within their organization. Existing surveys containing open-ended question
were revised and utilized to disclose innovativeness. This process is recommended by
Hanson (1998) in his work. The PORGI survey and the IS analysis were used to
determine the CEO’s level of innovativeness within the organization (Simonson, 2000).
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Data Analysis
The interviews asked about the potential perceived benefits of telemedicine. The
suggested list of benefits included (a) reduction in transportation time/cost for medical
care, (b) shared clinical data/diagnostic images, (c) continuing medical
education/training, (d) home health/geriatric/school medical care, and (e) medical care for
underserved urban and rural areas (WHO, 2010).
The interviews also helped to identify the perceived barriers to
telemedicine/telehealth implementation, including (a) lack of reimbursement, (b)
legal/policy (malpractice/licensing/JCAHO), (c) consistent safety and standards, (d)
privacy, security and confidentiality (HIPAA), (e) telecommunications infrastructure, (f)
and sustainability (WHO, 2010).
Conducting the Interview
Creswell (2007) recommended several steps when conducting interviews:
1. Identify interviewees based on purposeful sampling procedures.
2. Determine what type of interview is practical.
3. Use adequate recording procedures.
4. Design and use an interview protocol with five open-ended questions.
5. Determine the place for conducting the interview.
6. Obtain consent from the interviewee.
7. During the interview, stay to the questions and complete the interview
within the specified time. (p. 132)
Following the interviewing and observation process, the field notes were
transcribed. The subsequent transcriptions were delivered to the study’s individual
contributors to permit them to verify the precision and accuracy of their statements
(Bloomberg & Volpe, 2012). Charmaz (2006) encouraged member checking to allow
research participants to confirm their comments and contributions to the study. It also
encouraged correction and collaboration to provide richer data collection.
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Ethical Considerations
Creswell (2008) emphasized the importance of maintaining anonymity and
confidentiality among the research participants. Further, the assignment of numbers to the
individuals and site collections, as well as keeping the data as confidential as possible
assisted in this goal. It was also important to protect the participant, his or her
organization and resulting reputation from harm by intentionally identifying comments
and results given by that participant (Rubin & Rubin, 1995).
Creswell (2007) argued that “maintaining confidentiality, and protecting the
anonymity of individuals” (p. 44) should be considered critical to the research process.
Kaiser (2009) noted that “deductive disclosure, also known as internal confidentiality,
occurs when the traits of individuals or groups make them identifiable in research
reports” (p. 1). The aim of an ethically responsible researcher is to make the participant’s
unidentifiable to the typical observer. Respondent confidentiality should not allow for
anything reported by the participants to be easily identified by the reader. Consequently,
participant responses were assigned random numbers and CEO or COO identities were
altered as to make them unidentifiable.
Kaiser (2009) suggested that “discussions about informed consent forms,
beneficence (researchers must not harm their study participants), and confidentiality take
place before any data are obtained by participants” (p. 4). Further, data cleaning, the
removal of identifiers to create a clean data set took place following the data collection
process. However, Kaiser (2009) claims that “too much data cleaning can alter the
meaning and significance of the data” (p. 5). As a result, it was recommended that all
demographic information should be changed to protect the participants and interview
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locations.
The participant interviews were handwritten. The resulting field notes and hand-
recorded responses were stored in locked file cabinets until transcription. Resulting
information from the interviews, PORGI questionnaires, and demographic documents
were coded using random identifiers to reduce the likelihood of deductive disclosure. All
interviews, surveys, and other participant data were fact-checked with the participant
before publication.
The transcribed interviews, PORGI data, and demographic information were kept
locked in the file cabinets. Duplicate copies were being kept in a cloud-based storage
retrieval system, such as Dropbox, which is password protected. Additional hardcopies
are being kept in a safety deposit box at a local bank.
Trustworthiness
Yin (1994) insisted that researchers follow the three principles of data collection.
The first principle is to use multiple sources of evidence. Documentation (news articles
and public service announcements), archival records, and physical artifacts such as video-
tapes and photographs were gathered to enhance the richness of the data. Telephone and
face-to-face interviews with the participants to gather information on how perceptions of
the telemedicine programming were developed, as well as how innovative decisions were
made within the upper echelons of the organization also helped to provide information
about the CEO’s perspective.
Yin (1994) also recommended that the researcher create a research database. An
Excel spreadsheet was created to organize information associated with the subjects, field
notes, documents, locations, and other pertinent information related to the study. The
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names and contact information of all participants have been stored in at least three
locations to ensure safety.
Finally, Yin (1994) contended that researchers “increase reliability of the
information” (p. 98) in a research study by maintaining a chain of evidence. Citations and
actual evidence should be succinctly maintained so as to provide airtight records of the
researcher’s observations and record keeping. For this study, information was gathered in
a precise manner whereby all field notes, observations, interviews, documents and other
materials can be clearly related to exact occurrences and activities. The archived
documents obtained from interviews were coded according to topic and relevance to
ensure their reliability.
All hospitals and health care organizations within the GMKCA were identified as
potential locations for the study. The CEOs and presidents of the hospitals were contacted
by letter and asked to participate in the study as potential interviewees. A letter was
mailed and/or emailed to each potential interviewee until 15–20 CEOs agreed to
participate in the study. All refusals and non-responsive participants were documented.
Moreover, the total number of potential subjects was noted along with explanations for
non-participation. A letter of agreement and follow-up phone call confirmed
participation. All communication between the participants and non-participants was
documented as records of the study. A biographical (demographic) form was forwarded
to each participant to obtain background information on the interviewees. Suggested
interview questions, and the PORGI and IS surveys were sent to the participants
beforehand to allow the information to be gathered before the interview. The signed letter
of agreement, biographical form, surveys, and interview questions have become
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appendices to this study. Following the receipt of the biographical form and signed letter
of agreement, the interview was scheduled based on the interviewee’s convenience. This
process is recommended by Bloomberg and Volpe (2012), and Creswell (2007).
Interview questions were constructed based on Seidman’s (1991) position that
interviewing is a basic mode of inquiry for researchers to understand people’s behavior
and actions in a given situation. In this case, the implementation of telemedicine within
the respective health care organizations comprised the subject of inquiry. Seidman (1991)
also suggested “the establishment of access, scheduling the interviews, conducting the
interview, transcription of the data and sharing what was learned” (p. 5). Interview
questions were constructed based on the grounded theory method whereby “the
investigator seeks to systematically develop a theory that explains a process or action”
(Creswell, 2007, p. 64). For example, one theory described the process, benefits and
barriers of implementing telemedicine within a hospital. As data were collected, they
were analyzed, and theoretical interpretations were formed as to how organizational
leaders perceived that the telemedicine implementation process took place.
Eighteen interviews were conducted at the arranged times and locations as agreed
upon with the participants. The interviews were handwritten during the discussions.
Minimal notes and comments were taken during the interview to avoid distracting the
interviewing process. However, Rubin and Rubin (2005) insisted that collecting main
ideas during the interview prompt the interviewer to ask follow-up questions at the
conclusion of the interview. Immediately following the interviews, abbreviated notes,
comments, and key word responses were fleshed out and added to supplement the initial
notes by the interviewer while the ideas were fresh and memorable (Rubin & Rubin,
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2005).
The hand-recorded notes and resulting transcriptions were coded using “open
coding” methods recommended by Creswell (2007). Interviews were analyzed and
synthesized in order to describe and understand the CEO’s perspective of the
telemedicine implementation process. Examining the interviews can help with
transforming the data into “evidence-based interpretations” (Rubin & Rubin, 2005, p.
201) that can be the inspiration for the styles, designs, and developments of the research
(Rubin & Rubin, 2005).
Data collection was conducted by utilizing an IRB-approved, questionnaire
protocol and a written form for recording participant information (see Appendix F).
These data were collected utilizing the following instruments. The biographical
questionnaire provided a demographic profile of each of the participants. The IS and
PORGI surveys produced quantifiable information concerning the participants’
perceptions of their own and their organizations’ status regarding change (Hurt et al.,
1977; Hurt & Teigen, 1977). After the interviews and collection of quantitative data, a
profile of each participant was developed to further describe the purposeful sample.
A summary was written about each transcribed interview that contained the name
of the interviewee, the time and location of the interview, the reasons the interviewee was
included in the study, and how long the interview lasted. Likewise it included the main
details produced throughout the course of the interview that addressed the research
questions as recommended by Rubin and Rubin (2005). The resulting information was
recorded in a detailed manner, coded and stored for analysis, and presented in the study
results.
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Access to the health organizations was obtained through gatekeepers within the
organizations. Telephone and face-to-face interviews with the purposeful sample
comprised of 18 CEOs or COOs provided data related to the perceived benefits and
barriers to telemedicine in health care organizations in the GMKCA. The interviews,
observations, and other data were collected as soon as approval was obtained.
Data Collection
The data collection methods had advantages and disadvantages. Advantages
included flexibility in administration and diversity of participants. Disadvantages
included finding the gatekeepers and establishing relationships with the participants
through telephone, email, and traditional letter correspondence. Another disadvantage
was conducting telephone interviews versus face-to-face interaction.
Advantages. Administration of the collection tools allowed for flexibility for the
participants. The demographic information document, IS and PORGI survey could be
self-administered by the participant, thereby eliminating the need for face-to-face
interaction with the researcher. This feature also allowed for flexibility in the time of day
when the participant completed the data collections tools. To add convenience for the
participants, the completed data collection instruments were returned via U.S. mail in
postage paid, self-addressed envelopes.
The participating organizations represented a diverse mixture of hospitals and
health care organizations. A mixture of contributed to the study: old and new, private and
public hospitals located in affluent and low-income neighborhoods. They were located in
rural and urban areas. Hospital sizes varied from 35 to 672 beds. In addition, they were
affiliated with a variety of religions. Some of the health care organizations maintained
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one location, while others had multiple facilities or were members of regional health care
systems (Kansas City Metropolitan Health Care Council, 2014).
Disadvantages. Gatekeepers within an organization serve several purposes. They
control the flow of communication and access to respective individuals, especially those
in powerful or influential positions. Obtaining access to the study’s participants required
contacting them via phone, email, or U.S. postal mail. Unfortunately, the hospital leaders
lead very busy lives and have hectic schedules that require an astute gatekeeper who
protects their time and privacy. The gatekeepers were quite efficient at their duties
because attempting to make contact with the potential research study participants was
extremely difficult. Often multiple attempts through various methods of communication
were required before contact was made with them.
All documents provided to the research participants were sent through the U.S.
Postal Service. Self-addressed, stamped envelopes were included to encourage the
participants to complete and return the required paperwork. Unfortunately, the addresses
obtained for the participants were not always correct, and therefore some of the
documents were returned due to inaccurate information. Delivery delays and misdirected
mail may have impacted the return rate and the number of participants involved in the
study.
Creswell (2007) maintained that phone interviews supply the researcher with the
most ideal source of data in the event direct access to the participants is not possible.
However, communication signals expressed through body language and facial
expressions are not obtainable when using this method. Nonetheless, all field notes were
transcribed, coded, and grouped by theme to await member verification and
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corroboration.
Potential Research Bias
Rubin and Rubin (1995) stressed the importance of remaining neutral during the
data gathering process. While participants may put their personal slant on a topic or an
issue, the researcher should remain impartial and objective when recording information.
In fact, Rubin and Rubin (1995) insisted that the examiner ought to probe more deeply
whenever slanted facts are offered, the aim being to gain an improved viewpoint of the
matter at hand, as well as a greater understanding of the participator and their intentions.
Limitations
Eighteen health organization leaders were interviewed. This purposeful sample
size was very limited in number and could have potentially led to skewed results.
Creswell (2008) warned against small sample sizes because sampling error might result.
“The larger the sample, the less the potential error that the sample will be different from
the population” (Creswell, 2008, p. 156).
Chapter Summary
This chapter presented information on the processes that was undertaken in order
to obtain the CEO’s perception of the benefits and barriers in implementing telemedicine
and telehealth programming in health care facilities in the GMKCA. The interviews and
observations obtained by the leaders of these organizations are presented in Chapter 4,
Results. The recommendations for future studies in telemedicine implementation are
discussed in Chapter 5, Conclusions, Generalizations, and Suggestions.
To summarize, this process was followed to collect information related to the
research questions of this study:
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1. Hospitals were identified
2. Participants were contacted
3. The first 18 participants that responded were selected
4. Participants were notified of acceptance
5. Permission was obtained from the organizations and IRB
6. Interviews were scheduled
7. Innovativeness Scales (IS), Perceived Organizational Innovativeness Scales
(PORGI), biographical/demographic questionnaires and permission forms were sent
8. Interviews (phone or face-to-face) were conducted
9. Field notes were taken to record the interviews
10. Following the interviews, field notes were transcribed
11. Transcriptions were forwarded to participants for member checking
12. Verified transcripts were analyzed and coded
13. Results are summarized in Chapter 4
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Chapter 4: Findings
Overview
Telemedicine––the ability to have access to medical care and health care related
education from a distance—provides much needed, life-saving assistance to the
underserved and unserved populations of the world (Norris, 2002). Benefits such as lower
mortality rates, improved communication between caregivers and patients, better
continuing education, and reduced costs can be experienced by participants (Norris,
2002). However, barriers such as legal, cultural, financial, technological, and educational
roadblocks often preclude the establishment of telemedicine (Maheu et al., 2001).
This study was designed to provide better understanding of how, despite
considerable barriers, opinion leaders influence the adoption of innovative programming,
such as telemedicine, among hospital administrators in the Midwest. While telemedicine
has been available and utilized for many years, the adoption of this method of health care
and medical education has not been implemented at a steady pace at all hospitals. Rogers’
(2003) diffusion of innovations theory was used to gather a better understanding of the
adoption of telemedicine within the Midwestern region of the United States. An
exploration into the effects of opinion leaders’ influence on administrators provided a
clearer look into this process. As a result of providing a better understanding of the
adoption process, additional innovative medical methods such as electronic health
records, mobile devices, and other forms of medical technology might be more easily
accepted by hospitals.
Participants
Determining sample size. The pool of participants was obtained from lists
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provided from The Kansas City Metropolitan Health Care Council. The Health Care
Council is a regional office for both the Kansas Hospital Association and the Missouri
Hospital Association. The Kansas Hospital Association is a voluntary non-profit
organization existing to provide leadership and services to 128 Kansas community
hospitals and nine other health care organizations. The Missouri Hospital Association is a
not-for-profit association in Jefferson City, Missouri, that represents 153 Missouri
hospitals (Kansas City Metropolitan Health Care Council, 2014). The lists of institutions
contained the names, addresses, and phone numbers of hospital administrators. Leaders
were contacted in an attempt to obtain an interview sample of 15 to 20 participants. A
preliminary personal letter was sent via U.S. postal mail to the names provided on the list
provided by the Kansas City Metropolitan Health Care Council. Then, after the
preliminary letter was sent, telephone calls were made to identify at least 15 to 20
individuals who would agree to participate. This process ended when 18 individuals
agreed to participate. Permission letters were mailed to the 18 locations in order to obtain
authorization to discuss the study (Appendix A). The letters described the extent of the
study and requested permission to contact the key leaders to describe the study in more
detail. Once permission letters were signed by the prospective participants and returned,
the prospective participants were contacted via email and telephone with a detailed
description of the activities needed to comply with the study (Creswell, 2007; Rubin &
Rubin, 1995).
Recruitment letters were mailed to each of the hospitals and health care
organizations that returned the permission letters. The recruitment letters gave step-by-
step directions on how the study was to be conducted. When the agreement was obtained
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from the potential participant, a consent form was mailed to the subject. Eighteen
authorization and consent forms were received. After signed consent forms were received
from the participants, interviews were scheduled using the participants’ administrative
assistants or similar gatekeepers (Creswell, 2007).
Interviews
Face to face interviews are preferred in order to establish and nurture relationships
between the participants and interviewers. However, telephone interviews have been
found to provide useful information as well (Rubin & Rubin, 1995, p. 141). Visible
conversational clues such as facial expresses, body language and other non-verbal forms
of communication are not observed during a telephone interview. However, when
previous communication methods, such as letters, emails, and short telephone
conversations take place before the scheduled telephone interview, it is possible to
establish an acceptable relationship that yields informative and rich data (Rubin & Rubin,
1995, p. 142).
Interview Questions
There were six interview questions: three central questions and three sub
questions. The central questions were related to barriers, drivers, and strategies related to
telemedicine implementation. The central questions were:
1.Which barriers do CEOs show to be most likely to deter telemedicine
implementation at health care organizations in Kansas City? How has reimbursement
affected the development of telemedicine in area hospitals?
2. What are the drivers that persuade health care providers to development
telemedicine programming within their organizations?
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3. What types of strategies do COOs employ to overcome barriers in
implementing telemedicine in their health care facilities?
Sub questions. The sub questions analyzed the involvement of administrators and
organizational factors on telemedicine adoption and development. In addition, a
comparison of additional innovations was explored. The three sub questions were:
1. What is the role of the COO in the development of telemedicine/telehealth
services?
2. How do the legal, legislative, ethical, financial, equipment and training aspects
of implementing telemedicine/telehealth services affect hospital leaders?
3. How does the telemedicine adoption and diffusion process compare with the
adoption of other technologies within the health care industry in general (e.g. diffusion of
electronic health records)?
Next, an abstract, demographic information document, IS analysis, PORGI
survey, and interview questions were forwarded to the participant via email in
preparation for the interview. Prior to the interview, the participant was asked to
complete the demographic document, IS, and PORGI. Subsequently, the interview was
conducted with the participant via telephone or face-to-face, depending on the method
preferred or most convenient for the participant (Creswell, 2007, p. 132). These
interviews were conducted with the chief executive officers, chief medical officers, chief
nursing officers, vice presidents of medical operations, and individuals in similar key
leadership and decision making roles. While two interviews were taken onsite, face-to-
face with two participants, the remaining interviews took place by telephone in order to
accommodate scheduling conflicts and at the convenience of the subjects. The interview
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consisted of six open-ended interview questions previously sent to the participant
(Creswell, 2007; Glesne, 2011).
The responses were recorded by hand using an Interview Guide (Appendix F).
When possible, additional information was requested based on the participant’s initial
answer. Immediately following the interview, the responses were reviewed in order to fill
in incomplete answers while the conversation was fresh and easy to recall (Glesne, 2011).
Data Collection Instruments and Reliability
Demographic information. The demographic document was used in order to
obtain detailed information about the participants. The information gathered from the
demographic document included: age, gender, ethnicity, highest level of educational
attainment, professional status, and health care related professional experience.
Bloomberg and Volpe (2012) and DeWalt and DeWalt (2011) stressed the importance of
gathering demographic information about the participants in order to gain a richer
understanding of their personal characteristics and the possible impact these
characteristics might have on the study results. (Appendix B).
Quantitative information. Individual innovativeness data were obtained by
administering the Hurt-Joseph-Cook Innovativeness Survey (Hurt et al., 1977). It was
developed to measure Rogers’ (2003) construct of individual innovativeness, which is
defined as “the degree to which an individual or other unit of adoption is relatively earlier
in adopting new ideas than the other members of a system” (p. 475). The IS had
acceptable reliability coefficients across multiple studies, and was found to be a
significant predictor of individual innovativeness. The IS consists of 20 questions and
participants responded using a 5-point Likert scale from “strongly disagree” to “strongly
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agree.” The scoring procedure allowed individuals being categorized into one of five
groups that have been defined by Rogers (2003): (a) Innovators, (b) Early Adopters, (c)
Early Majority, (d) Late Majority, and (e) Laggards/Traditionalists (Hurt et al., 1977;
Rogers, 2003). The IS “has the potential to predict willingness to adopt innovations
across populations and socioeconomic status” (Hurt et al., 1977, p. 63) and has reported
reliability coefficients ranging from 0.86 to 0.90 (Hurt et al., 1977; Simonson, 2000).
Hurt et al. also revealed the process they applied to determine the construct and
predictive validity for the Innovativeness Scale. The “IS was reported to be highly valid”
(Simonson, 2000, p. 72).
Perceptions of organizational innovativeness were gathered by the Hurt-Teigen
scale PORGI (Hurt & Teigen, 1977). The results of the PORGI, when combined with the
results of the IS (Hurt & Teigen, 1977), were an important forecaster of employee
participation in the innovation-decision process. The subjects for the PORGI consisted of
members in key leadership roles. The PORGI has “exceptional reliability and equally
acceptable construct and predictive validity” (Hurt & Teigen, 1977, p. 383) and has
reliability coefficients reported in two studies ranging from 0.95 to 0.98 (Hurt & Teigen,
1977; Simonson, 2000). The PORGI is comprised of 25 questions and participants
responded using a 7-point Likert scale from “strongly disagree” to “strongly agree.”
The scoring procedure resulted in participants’ organizations (i.e., hospitals) often being
categorized into one of five groups that have been defined by Rogers (2003): (a)
Innovators, (b) Early Adopters, (c) Early Majority, (d) Late Majority, and (e) Laggards.
Rogers’ (2003) five perceived characteristics of the innovation are (a) relative
advantage: the degree to which an innovation is perceived as being better than the idea it
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supersedes; (b) compatibility: the degree to which an innovation is perceived as
consistent with the existing values, past experiences, and needs of potential adopters; (c)
complexity: the degree to which an innovation is perceived as relatively difficult to
understand and use; (d) trialability: the degree to which an innovation may be
experimented with on a limited basis; and (e) observability: the degree to which the
results of an innovation are visible to others.
Menachemi et al. (2004) examined the relationship between Rogers (2003) five
perceived characteristics of innovation and four key adopter groups: physicians, hospital
administrators, patients and healthcare payers. Participants must consider the advantages
to those involved in the endeavor when contemplating telemedicine adoption.
Advantages to physicians, patients and administrators included: increased efficiency and
collaboration among physicians; increased access to services for rural patients; decreased
travel time and related travel costs. Disadvantages were: licensing requirements, fear of
new technological methods, perceived vulnerability in security, confidentiality, privacy,
and HIPAA violations (Menachemi et al., 2004, p. 622). Compatibility was an integral
factor in the adoption of telemedicine because it was necessary to consider how well it fit
in with the traditional practices of patient care. Telemedicine would be negatively
compatible if it required an inordinate amount of training for physicians or made the
patients feel uncomfortable with the new methods and use of technology (Menachemi et
al., 2004, p. 623). Financial considerations were a strong influence in telemedicine
trialability. Costs of equipment, Medicaid and Medicare reimbursement, and funding for
health care department renovations are vital factors in this area (Menachemi et al., 2004,
p. 623). The observability of telemedicine will impact its adoption because it is not as
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familiar as traditional medical methods. Increased marketing and informational
undertakings would be necessary to educate physicians, patients and administrators
(Menachemi et al., 2004, p. 623). Finally, the level of perceived complexity in adopting
telemedicine could decrease its acceptance. Equipment demonstrations, physician
training, legal requirements, malpractice concerns, and political and religious suspicions
will impact the successful adoption, implementation, and ongoing utilization of
telemedicine in health care organizations (Menachemi et al., 2004, p. 623).
Results of Data Collection Instruments
Demographic information document results. The majority of the respondents
were between the ages of 55 and 46 (50%). The remaining categories were comprised of
comparable percentages: 35 to 44 years old (11%), 45 to 54 years old (17%), and 65 to 74
years old (22%). Table 2 presents the results of the demographic document.
One gender was more strongly represented than the other. The majority of the
respondents were male (78%), with the remaining being female (22%). A description of
the breakdown of gender classifications is shown in Table 3.
There were no participants from the remaining ethnic groups: Hispanic/Latino,
Native American/American Indian or Asian/Pacific Islander. A description is shown in
Table 4.
The minimum educational level, a bachelor’s degree was held by only 5% of the
population. The educational attainment distribution was as follows: master’s degree 76%,
professional degree (10%), and doctoral degree 10%. It should be noted that some
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Table 2
Key Leaders’ Age Descriptions
Age Quantity Percentage (%)
35-44 2 11
45-54 3 17
55-64 9 50
65-74 4 22
Table 3
Key Leaders’ Gender Classifications
Gender Quantity Percentage (%)
Male 14 78
Female 4 22
Table 4
Key Leaders’ Ethnic Descriptions
Ethnic origin Quantity Percentage (%)
White 16 89
Black or African American 2 11
Table 5
Key Leaders’ Educational Attainment
Educational attainment Quantity Percentage (%)
Bachelor’s degree 1 5
Master’s degree 16 76
Professional degree 2 10
Doctoral degree 2 10
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participants held degrees in more than one category. An itemization of educational
attainment is shown in Table 5.
The participants held professional titles such as, Chief Executive Officers (33%),
Chief Operating Officers (10%), Chief Medical Officers (5%), President (5%), Executive
Vice-President (10%), Senior Vice-President (19%), and Vice-President (19%). Several
individuals held multiple titles in more than one category. For example, one participant
was a CEO and VP of Regional Health Systems whose responsibilities included
management of a health care system comprised of four hospitals, inpatient rehabilitation
at three campuses, and oversight of system e-health/telemedicine programs. A description
is shown in Table 6.
Participants also divulged information about previous professional experience.
These descriptions varied between narratives regarding proficiencies as former business
owners, health care administrators, physicians, nursing directors, and career military
officers. Their experience spanned the range from running a small rural hospital to
“building a 650-bed, $4 billion new hospital from scratch in United Arab Emirates”
(Participant 1).
Normative Group Innovativeness Scale
A normative assessment involves evaluating the results of the participants by
comparing them against the performance of others using the same instrument. Figure 1 is
a visual display of Simonson’s (2000) modified IS of Hurt & Teigen’s instrument (1977).
The Normative Group Innovativeness Scale scores averaged (mean) 105.1 with a
standard deviation of 14.46 (Simonson, 2000). Table 7 shows the categorization of
scores.
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Table 6
Key Leader’s Professional Status Descriptions
Professional Title Quantity Percentage (%)
Chief Executive Officer 7 33
Chief Operating Officer 2 10
Chief Medical Officer 1 5
President 1 5
Executive Vice-President 2 10
Senior Vice-President 4 19
Vice-President 4 19
Note. Participants possessed multiple and/or combined titles.
IS
The IS was completed by all 18 participants. The mean score for the telemedicine
leaders was 113, with a standard deviation of 10.01. The highest score was 133 and the
lowest score was 91. The IS normative mean score was 105.1 with a standard deviation
of 14.46. When compared to the normative group, it was found that the study participants
had a higher mean score, 113 versus 105.1 (see Figure 2).
Figure 1. Adopter categorization on the basis of innovativeness. Laggards = last 16% to adopt, Late
Majority = 34%, Early Majority = 34%, Early Adopters = second 13.5%, Innovators = first 2.5%. Adapted
from Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.
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However, the participant group had a lower standard deviation, 10.01 compared to
the normative standard deviation, 14.46. In other words, according to Rogers (2003)
definitions of innovators, early adopters, early majority, late majority, and laggards, the
telemedicine leaders scored higher than the normative group’s distribution. The mean
individual scores were higher than the normative group’s mean IS scores (see Figure 3).
Figure 2. Distribution of normative population scores: Individual Innovativeness Scale scores for the
normative group. Scores can range between 20 and 140. Mean = 105, Standard Deviation = 14, N = 1693.
Laggards = last 16% to adopt, Late Majority = 34%, Early Majority = 34%, Early Adopters = second
13.5%, Innovators = first 2.5%. Adapted from Rogers, E. M. (2003). Diffusion of innovations (5th ed.).
New York, NY: Free Press and Simonson, M. (2000). Personal Innovativeness, Perceived Organizational
Innovativeness, and Computer Anxiety: Updated Scales. Quarterly Review of Distance Education, 1(1),
69–76.
PORGI Scale
The PORGI scale was also completed by all 18 study participants. The mean
score was 126, with a standard deviation of 16.8. Scores can range between 25 and 175.
The highest score was 155 and the lowest score was 95. The Normative PORGI Scale
scores had an average (mean) of 114.23 with a standard deviation of 23.59 (see Figure 4).
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When compared to the participant group, the normative scale average score was
considerable lower, 126 to 114.23. However, the normative group’s standard deviation
was higher than the participant group, 23.59 to 16.75, respectively. In other words,
according to Rogers’ (2003) definitions of innovators, early adopters, early majority, late
majority, and laggards, the telemedicine leaders scored higher than the normative group’s
distribution. The mean PORGI scale scores were higher than the normative group’s mean
PORGI scale scores. As a group, the telemedicine leaders scored higher in perceived
organizational innovativeness than the normed group measured by Simonson (2000; see
Figure 5).
Figure 3. Telemedicine leaders’ distribution of IS scores. Mean = 113, Standard Deviation = 10.01, N = 18.
Scores can range between 20 and 140. The lowest score was 91 and the highest score was 112. Each cross
represents scores calculated on the modified Individual Innovativeness Survey Scale. Adapted from
Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press and Simonson, M.
(2000). Personal Innovativeness, Perceived Organizational Innovativeness, and Computer Anxiety:
Updated Scales. Quarterly Review of Distance Education, 1(1), 6976.
Comparison of Normative Group PORGI and IS Results to Participants’ Results
Tables 7 and 8 display comparisons of the normative group scores and participant
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group scores for the PORGI scale and the IS scale.
Figure 4. Distribution of normative PORGI scale scores. Scores can range between 25 and 175. Mean =
114, SD = 23.59, N = 1693. Laggards = last 16% to adopt, Late Majority = 34%, Early Majority = 34%,
Early Adopters = second 13.5%, Innovators = first 2.5% to adopt. Rogers, E. M. (2003). Diffusion of
innovations (5th ed.). New York, NY: Free Press and Simonson, M. (2000). Personal Innovativeness,
Perceived Organizational Innovativeness, and Computer Anxiety: Updated Scales. Quarterly Review of
Distance Education, 1(1), 69-76.
Figure 5. Telemedicine leaders’ distribution of PORGI scale scores. Scores can range between 25 and 175.
Mean = 126, Standard Deviation = 16.75, N = 18. The lowest score was 95 and the highest score was 155.
Each cross represents scores calculated on the modified PORGI. Adapted from Rogers, E. M. (2003).
Diffusion of innovations (5th ed.). New York, NY: Free Press and Simonson, M. (2000). Personal
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Innovativeness, Perceived Organizational Innovativeness, and Computer Anxiety: Updated Scales.
Quarterly Review of Distance Education, 1(1), 69-76.
Table 7
IS Scores
Mean, SD, N Normative group Telemedicine leaders
Mean 105.1 113
Standard deviation 14.46 10.01
N 1693 18
Table 8
PORGI Scale Scores
Mean, SD, N Normative group Telemedicine leaders
Mean 114.23 126
Standard deviation 23.59 16.75
N= 1683 18
Note. Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press. Simonson, M.
(2000). Personal Innovativeness, Perceived Organizational Innovativeness, and Computer Anxiety:
Updated Scales, Quarterly Review of Distance Education, 1(1), 69–76.
Table 9 displays the correlation matrix of PORGI, IS, and Age. The Pearson
Correlation matrix shows there is a modest (.49) relationship between telemedicine
leaders’ IS scores and PORGI scores. The relationship between PORGI scores, IS scores,
and age is not shown to be significant: .17 and .14, respectively.
Table 9
Pearson Correlation Matrix Among PORGI, IS, and Age
Variables PORGI IS Age
PORGI - .49 .17
IS - - .14
Age - - -
Note. Pearson Correlation for Predicting the Correlations among PORGI, IS, and Age
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Qualitative Data
Qualitative data were obtained through the use of face-to-face and telephone
interviews. The goal was to interview 18 purposeful samples of CEOs or similar
members of the C-suite in hospitals in the Greater Kansas City area to obtain their views
on the influence of opinion leaders on telemedicine adoption in the Midwest. A total of
18 members in key leadership roles (14 males and 4 females) participated in the study.
The study was conducted using the responses from the 18 participants. All 18 participants
were asked the same six questions. An interview script was used for the interviews (see
Appendix E). Interview responses were recorded by hand on the interview guide (see
Appendix F).
Grouping by Question
The responses were first categorized by question in summary format. The first
question asked about the participants’ opinion on barriers to the implementation of
telemedicine. A summarized list of the responses can be found in Appendices I-N. The
overwhelming response from the majority of respondents indicated financial feasibility
and return on investment as the most significant barriers to the implementation of
telemedicine within their respective facilities. Reimbursement and fee for services were
challenges to putting telemedicine into action. “Without Medicare reimbursement, no one
would pay for it” (Participant 7). “Ensuring appropriate reimbursement, regardless of the
payer, Medicaid limits payment for telemedicine services and reimburses only providers
in rural areas. If telemedicine is adopted, the payers need a regulatory reimbursement
environment that supports it” (Participant 4).
The second interview question asked about the drivers that persuade health care
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providers to develop telemedicine programs within their organizations. Most participants
indicated access to specialists on a more continual and consistent basis as their leading
impetus to initiate a telemedicine program at their hospital. Specifically, “creating
connectivity with specialists in Kansas City” and “having access to a specialist 24/7”
were critical goals for key leadership (Participant 11). “Now medical specialists and
subspecialists have become so good at procedures that offering no less than 35
subspecialists, oncologists, cardiologists, pulmonologists, urologists, gastroenterology,
and others is expected” (Participant 15). “There’s such a lack of specialty care in this area
(rural location). I need specialty care doctors. We can’t find or afford specialty care. All
drivers are need based from this standpoint with cardio and mental being the major
thrust” (Participant 13). In addition, participants mentioned the significance of remaining
competitive by offering the latest and greatest technology in the form of robots. “Robots
can improve the patient experience. The data doesn’t support a better experience.
Younger surgeons expect it, so it becomes a key component” (Participant 1). “With
respect to other innovational technologies like robotic surgeries, robots cost
approximately $2MM and we will never get the return from it. Studies say robots are no
better than an open procedure. Hospitals don’t want to do it. The vast majority of CEOs
don’t want to spend more money on robotics, but they do. Telemedicine is easier and
costs less than robots. We do robots because of competition. Competition guides or
drives the process. Others have it, so we should have it too. Not as sexy: Just a tool”
(Participant 7).
The third interview question inquired about the strategies employed by chief
operating officers to overcome the barriers to telemedicine implementation. Many
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participants mentioned establishing or seeking partnerships for sharing costs as a strategy
to overcome the financial challenge to telemedicine implementation. Changing the
hospital’s culture was also stated as a strategy to making telemedicine more accessible to
the organization. Several respondents revealed the limited scope of their doctors in
embracing new concepts in health care delivery. “Health care in general is fairly resistant
to change. Doctors are resistant to change” (Participant 11). Many doctors and patients
were apprehensive of telemedicine because it is different. “Patients want face to face
contact with their physician” (Participant 11). “So we have to educate the staff that’s with
the patient. Make sure they’re comfortable with it” (Participant 6). “Doctors need to
touch it or see it in action in order to be convinced. There is resistance from doctors who
haven’t used telemedicine before. They don’t view telemedicine as being as good as
hands-on medicine. Because this is something we don’t know. We’re skeptical about it”
(Participant 15). There was also reluctance of the providers to pay for the service in the
same way as face to face care delivery.
The fourth question inquired about the role of the chief operating officer in the
development of telemedicine or telehealth services within the organization. The response
to this question led to the culture of the organization. The more innovative organizations
took a collaborative approach to telemedicine development. In other words, innovative
organizations utilized a team-based approach, whereas, less innovative organizations
implemented a top-down approach to developing telemedicine operations within their
respective organizations. One organization employed a Chief Innovation Officer (CIO)
whose job was to act as a change agent in unfamiliar areas. Specifically, the CIO’s goal
was to “make sure we’re all on the same page when it comes to embracing change. My
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job is to create strategies to excite people about changes the organization will make”
(Participant 14). Another organization saw the COO’s role as “always having open
dialogue about the challenges and solutions. Involve people for a much lower failure rate
because you’re asking for opinions, not just mandated changes coming down from the
top. And you will increase buy-in” (Participant 4). In contrast, less innovative
organizations saw the COO’s .role as strictly “leadership, gaining additional sites” and
“being very strategic about it by decreasing costs and personnel” (Participant 3).
The fifth question was a summative inquiry into the multiple aspects (legal,
legislative, ethical, financial, equipment and training) involved in telemedicine
implementation. Consequently, the responses to this question were varied and diverse.
Some participants commented on the complexity of integrating all of the factors and
stakeholders together in order to yield a successful program. Most respondents noted the
legal and legislative issues related to licensure of physicians caring for patients across
state lines. Since physicians are licensed by the states in which they practice, a physician
that treats a patient located in another state (via telemedicine) may not be in compliance
with the guidelines established by the American Medical Association and its State
Medical Boards. Therefore, the majority of participants indicated concern regarding the
legal and legislative efforts to provide acceptance of telemedicine practices nationwide,
regardless of the physician’s licensure jurisdiction. “State professional licensing can be a
barrier. If you’re doing telehealth, doctors must be licensed in the same state” (Participant
4). Possible solutions were presented by a participant to avoid this dilemma. “You may
partner with an academic medical center that may not be in the same state or may be
across the state line. It’s an example of state regulatory barriers” (Participant 4).
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Another legislative concern expressed by several participants involved the volatile
climate of Medicaid reimbursement. Legislative changes are occurring on a continual
basis. This topic has become an integral factor in the establishment of telemedicine at
several health care organizations due to the financial impact on the operation. “No
reimbursement leads to challenges” (Participant 16). “Telemedicine has affected
reimbursement” (Participant 8). “Telemedicine reimbursement is a major detraction”
(Participant 13). “Reimbursement has made some changes concerning payment for
patients. Right now there is not payment for those patients, for any of their monitoring,
telehealth visits, so really you would be incurring all of that expense with no
reimbursement. And right now hospitals already do a ton of stuff that we don’t get paid
for. So changing the reimbursement model to treat diseases is going to be a key step”
(Participant 4). “Payment incentives are backward and upside down” (Participant 14).
The sixth and final question involved a comparison of telemedicine diffusion
process to the diffusion of other health care technologies, such as electronic health
records. All of the participants commented on the enormity of telemedicine in the field of
health care. They also expressed optimism in the need for telemedicine, whether
financially feasible or not. Telemedicine keeps patients healthier. It is time-saving in
terms of operation and supports quality of life. Telemedicine provides additional access
to provide additional care. “We could put neonatal care units in local hospitals instead of
sending doctors to local hospitals to look at a sick baby” (Participant 15).
However, when asked about the adoption of additional innovative health care
technologies such as electronic health records, most respondents indicated the difference
in adopting and diffusing this type of change. Policy changes in health care such as the
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Affordable Care Act provided financial incentives to induce health care organizations to
adopt electronic health records. Telemedicine adoption did not receive this type of
financial incentive. Therefore, implementation of telemedicine within a health care
organization does not ensure return on investment due to Medicaid reimbursement issues.
In addition, in many cases, insurance companies do not view telemedicine as identical to
face to face care delivery. “Insurance companies are not helping. They are slowing the
diffusion of the innovations by saying it’s not a real visit. Private insurers aren’t helping
either” (Participant 3). As a result, fees for services are not guaranteed for all
telemedicine services in all locations. This issue creates uncertainty regarding dedicating
resources (money, staffing and equipment) for a service that may or may not yield a
profitable outcome. “The major difference is electronic health records has a lot of
government subsidies. Telemedicine doesn’t have any carrots for its implementation”
(Participant 6). “There is no comparison because the federal government provided money
to implement electronic health records” (Participant 6, 14). “The implementation of
electronic health records is much more difficult than telemedicine. In fact, the
implementation of electronic medical records is 20 times bigger than a telemedicine
initiative because telemedicine involves a remote specialty, a smaller subset and affects
staff, physicians, just in a different a different location. They’re both technological
solutions. Electronic medical records affect every piece of hospital operations”
(Participant 4). “Electronic health records is about the patient, telemedicine is the patient”
(Participant 6).
Data Analysis
Data collection procedures. Data collection was conducted by utilizing an IRB-
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approved questionnaire protocol (see Appendix F). These data were collected utilizing
the following instruments. The biographical questionnaire provided a demographic
profile of each of the participants. The IS and PORGI surveys produced quantifiable
information concerning the participants’ perception of their own and their organizations’
status regarding change (Hurt et al., 1977; Hurt & Teigen, 1977). After the interviews and
collection of quantitative data, a profile of each participant was developed to further
describe the purposeful sample.
Coding procedures. The handwritten notes were transcribed and typed using
Microsoft Word. The resulting transcriptions were coded using “open coding” methods
recommended by Creswell (2007). Interviews were analyzed and synthesized in order to
describe and understand the CEO’s perspective of the telemedicine implementation
process. Examining the interviews can help with transforming the data into “evidence-
based interpretations” (Rubin & Rubin, 2005, p. 201) that can be the inspiration for the
styles, designs and developments of the research (Rubin & Rubin, 2005).
Transcription procedures. A summary was written about each transcribed
interview that contained the anonymous, coded name of the interviewee, the time and
location of the interview, the reasons the interviewee was included in the study, and how
long the interview lasted. Likewise it included the main details produced throughout the
course of the interview that addressed the research questions as recommended by Rubin
and Rubin (2005). The resulting information was recorded in a detailed manner, coded
and stored for analysis, and presented in this chapter entitled, Study Results. More
information regarding these results will be presented in Chapter 5.
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Discussion
This chapter explored the quantitative and qualitative data gathered from 18
hospital administrators in the GMKCA. The demographic information and levels of
individual and organizational innovativeness were discussed. The data were presented in
both narrative and table or figurative formats. Qualitative data were quantified in an
attempt to discover if a relationship exists between the level of personal and
organizational innovativeness and other factors, such as education, age, ethnicity, gender,
and professional status. The Pearson correlation between the PORGI and IS scores
resulted in a .49 correlation. It shows a modest relationship exists between personal
innovativeness and perceived organizational innovativeness. Other relationships yielded a
much lower Pearson coefficient and weaker relationship involving education, gender,
ethnicity, and professional status. There is a chance that the correlation is small due to the
small sample size. It could be possible to obtain a stronger relationship if the sample size
were larger. In other words, a more direct relationship might result if a larger sample size
had been used.
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Chapter 5: Discussion
The problem addressed in this study involved the effect of opinion leaders on the
adoption of telemedicine. Benefits and barriers involved in the implementation of
telemedicine in hospitals and other health care organizations were also examined.
Rogers’ (2003) diffusion of innovation Theory was applied to gather a deeper
understanding of the adoption process. A demographic inquiry document, IS, and the
PORGI Survey were administered to gather quantitative data on the participants and their
personal level of innovativeness as well as their perceived level of organizational
innovativeness. In addition, interviews of hospital administrators provided information on
the hospital administrators’ personal perspectives regarding opinion leaders’ influence
and perceived benefits and barriers to telemedicine adoption. A secondary purpose of the
interviews was to gather information about the role of the hospital administrator in the
telemedicine adoption process. Lastly, the interviews yielded possible associations
between the resulting themes and Rogers (2003) diffusion of innovation theory.
Approach
Qualitative inquiry. A qualitative study afforded the opportunity to gather
information in a question-answer process that yielded rich data about the topic,
telemedicine. Glesne (2011) discussed the value of developing understanding of the
research area through interviewing. Qualitative research provided an introduction to the
participant’s perspective on the subject matter in a way that allowed in-depth probing and
reflection. The reflexive nature of interviewing participants to gather data encouraged the
participants to provide responses that led to additional questions which, in turn, revealed
perspectives that could not have been obtained through other inquiry methods. Through
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continuous probing, participants in this study offered solutions to issues that had not been
discussed in prior conversations. In effect, this qualitative inquiry allowed a “brief,
personal peek into the world of hospital administrators and physicians that shed light on
the complex process of telemedicine adoption and implementation” (Glesne, 2011, p.
272).
Grounded theory. In grounded theory research, attempts are made to explain or
describe an activity and develop a theory that explains a process, action or interaction at
an organization related to particular topic, in this case, telemedicine (Creswell, 2007).
Charmaz (2006) argued that the grounded theory research approach involves gathering
data and simultaneous analysis in order to generate a theory about the process.
In this study, several members of key leadership employed in the health care
industry were interviewed in an attempt to generate a theory that describes the process
involved in implementing innovative types of medical endeavors. In addition,
demographic, individual innovativeness and perceived organizational innovativeness data
were gathered through self-administered inquiry documents and surveys.
Chapter 1 discussed the history and need for telemedicine as a supplement to
health care services and education provided from a distance. The introduction of
innovative programming and processes was explored by Rogers (2003). As a result,
Rogers (2003) diffusion of innovations theory was used as a theoretical framework in this
study. An examination of opinion leaders’ influence on the adoption of telemedicine by
health care administrators in the Midwestern states was the purpose of this study.
Chapter 2 presented and overview of information relevant to the organization’s
leaders’ perception of planning, design, and the benefits and barriers to the development
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of a telehealth program for patients and physicians located in distant locations. The
literature investigated how opinion leadership influences organizations to develop, build,
implement and operate telemedicine services in relation to Rogers (2003) diffusion of
innovation theory.
Chapter 3 described the strategy used for this qualitative research study whereby
leaders of 18 hospitals and health care facilities within the GMKCA were interviewed in
order to obtain an understanding of their perception of the benefits and barriers to
telemedicine. The grounded theory approach was used to generate a theory of processes
based on the views of the purposeful sample of 18 hospital leaders (Bloomberg & Volpe,
2012).
Chapter 4 relayed the results of the research gathered by the instruments used in
this study: demographic inquiry document, IS, PORGI Survey and six interview
questions. The research questions remained the focus of the study:
1. Which themes are going to emerge?
2. Which themes are most prevalent?
3. Is there an association between the level of innovativeness of the organization
and the innovativeness of the individual?
Chapter 5 summarizes the study and makes recommendations for future research.
In addition, this chapter discusses the needs and uses of telemedicine, telemedicine
adoption, Rogers’ diffusion of innovation theory (2003) as a theoretical framework,
impact of the interviews, compilation of the five themes, limitations of the study, and
recommendations for future studies. Finally, significance of the study and
recommendations for change within the field will be presented, along with a summary of
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the study.
Meanings and Understandings
Needs and uses of telemedicine. Telemedicine has been shown to provide
medical services to the underserved, unserved, rural populations and those located in
areas where physicians are in short supply (Craig, 2013, Cuyler & Holland, 2012; Maheu
et al., 2001; Norris, 2002; Viegas & Dunn, 1998). The needs for telemedicine span
several areas: hospitals, military locations, NASA, low income-based cities, correctional
facilities, and areas where specialists and other health care professionals are in short
supply (Bauer & Ringel, 1999; Craig, 2013, Viegas & Dunn, 1998).
Telemedicine adoption. Multiple studies have presented scenarios of how
telemedicine and telehealth have been adopted (Ball, 2013; Craig, 2013; Helitzer, Heath,
Maltrud, Sullivan, & Alverson, 2003). Specifically, the advantages of telemedicine
included access to specialists and subspecialists, convenience for the patient and
physician in terms of miles traveled and money spent trying to reach the health care
provider or medical service (Craig, 2013; Gattoni & Tenzek, 2010). The disadvantages of
telemedicine adoption included vague return on investment structures, unclear medical
protocols, Medicare/Medicaid reimbursement issues, difficulties in obtaining multi-state
licensure, staff training, equipment costs, incompatible equipment and software issues
and resistance to change (Cuyler & Holland, 2012; Norris, 2002; Stanberry, 1998; Viegas
& Dunn, 1998; West & Miller, 2009; Wootton et al., 2011).
Rogers’ (2003) diffusion of innovation theory. The theoretical framework
provided a basis for examining the phenomenon of the diffusion of new medical
technologies within the health care environment (Rogers, 2003). Sorting the participants
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into categories allows for telemedicine leaders and key decision makers to evaluate the
strategic planning process based on the players involved. Bass (2004) used a derivative of
Rogers (2003) diffusion of innovation model to formulate the forecasting model used by
business and industry to aid in product development and marketing introduction.
Interviews. Six open-ended interview questions were posed to 18 key leaders in
hospitals and health care organizations in the GMKCA. Major factors were discussed that
impact the decision making process, whether positively or negatively. The interviews
ranged from 30 to 60 minutes in length. The hand-recorded responses were transcribed
shortly after the interviews. The responses to these questions yielded rich data that were
used to provide insight into the role opinion leaders play in the adoption of telemedicine
in the health care arena. After the transcripts were coded and analyzed for themes, the
resulting themes were categorized by topic and frequency.
Several themes were developed within the interview narratives. The participants
emphasized the importance of five key ideas when implementing telemedicine within
their health care organizations: financial feasibility, resistance to change/acceptance of
the new technology, access to specialists and subspecialists, collaborative governance
roles among members of key leadership, and champion/opinion leader roles in the
adoption process. According to the key leadership in these organizations, focusing on
these concepts while adhering to sound medical practices produces an efficient and cost
effective telemedicine program.
The participants were interviewed and reaffirmed the notion that Rogers (2003)
diffusion of innovations theory was present as they adopted new medical technologies
such as telemedicine. Three of the five themes specifically related to Rogers (2003)
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diffusion of innovations theory: resistance or acceptance to change, leadership roles and
adopter characteristics. The role of opinion leaders’ influence in the adoption of
telemedicine was mentioned by the hospital leaders during their interviews. While this
study focused on the social and interactive aspects of the telemedicine adoption process,
fiscal responsibility was the theme noted most frequently by the hospital leaders. Bass
(2004) reported on Rogers (2003) diffusion of innovations theory but supplemented his
research with business forecasting features. Bass (2004) integrated economic factors such
as demand and pricing into his innovative model revealing a relationship between
innovation and consumerism of technological products that resulted in a new theory that
has been helpful in business and industry product development.
Implications of the Study
Trends and themes. As information was gathered from the telephone and face-
to-face interviews, trends and themes began to develop from the responses to the
interview questions. The five themes included: financial feasibility, resistance to
change/acceptance of the new technology, access to specialists and subspecialists,
collaborative governance roles among members of key leadership, and champion/opinion
leader roles in the adoption process.
Financial feasibility was demonstrated by multiple references in regard to the
importance of obtaining return on the financial investment from telemedicine operations.
“Capital expenditures are pretty high on the front end. This will be a detractor of the
dissemination of the innovation until there are payment mechanisms for reimbursement
for the telehealth visits keep up with the capital expansion” (Participant 3).
Several researchers presented evidence on the impact of financial feasibility in the
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telemedicine process. Norris (2002) and Peabody (2013) commented on the significance
of payment and reimbursement for services as one of the challenges prohibiting wide-
spread adoption of telemedicine. Darkins and Cary (2000) elaborated on the need for
“financial sustainability” (p. 14) and reduction of costs as an integral part in the “formula
for successful telehealth implementation” (p. 15). Jacobus (2004) offered information on
the lack of an easy-to-follow revenue process when implementing telemedicine. Linkous
(2013) gave multiple examples of the importance of financial sustainability when
developing and implementing a telemedicine program. As the leader of the American
Telemedicine Association, Linkous (2013) discussed recent legislative developments that
will make funding for telemedicine more viable and thus promote a higher likelihood of
its adoption on a more global level.
Resistance to change and acceptance of the new technology was presented in
multiple references to patients, physicians, payers and others push back from
telemedicine due to its perceived newness to the field of health care. “Patients want face
to face with physicians” (Participant 11). “When patients are sick, they want high touch,
not a high tech approach. Patients feel better if meeting with the doctor. Patients don’t
feel that it’s the same as seeing a doctor face to face when viewing it through a video
conference. Resistance from doctors who haven’t used telemedicine before can be a
deterrent. Don’t view telemedicine as being as good as hands-on medicine. Because this
is something we don’t know. We’re skeptical about it. Recent medical graduates are more
open; seasoned providers are less open” (Participant 6).
Health care education is considered an integral dimension of telemedicine. Health
care education is considered an integral dimension of telemedicine. Video conferencing,
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health care education via distance methods, telemedicine robots, child psychiatry,
teleoncology, tele-dermatology, and tele-radiology have been offered in the Midwest for
several years (Maheu et al., 1995; Spaulding et al., 2005). Berge and Muilenburg (2000)
reported on the importance of the “threat of technology” and “need for technical
expertise” as viable barriers to distance education (p. 7).
Access to specialists and subspecialists was another theme presented in the data.
Many of the participants expressed a desire to provide access to specialists and
subspecialists to more of its patients. “These partners shared in the investment so their
patients can have access to the subspecialists at home. This practice expansion will take
on more patients…spread out specialists throughout the area…access to the specialist is
faster and more organized. Board certified cardiologists and stroke doctors cannot be in
every city. We will need to gain access with equipment. Everybody should have access.
If I can do it, I should make it possible” (Participant 8).
Paul et al. (1999) argued the necessity of medical care specialists to make use of
telemedicine tools as an obstacle within clinical environments. Gagnon et al. (2005)
found the size of the hospital had an impact on the adoption of telehealth services
because it reduced the lack of resources, notably, access to specialists and subspecialists.
The financial viability of obtaining specialists and subspecialists in a small, rural
environment increases when these professionals are made available through the use of
telemedicine. Further, logistics play a critical role in the access of specialists and
subspecialists in small towns and rural areas because the shortage of physicians in those
areas increases their demand. Telemedicine allows their services to be provided to
patients who would not ordinarily have the opportunity to receive their level of expertise
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(Craig, 2013).
Collaborative governance roles among members of key leadership were evident in
the steps taken to develop telemedicine operations within the hospitals. All of the
participants acknowledged the importance of a team approach when introducing and
planning the implementation of telemedicine programming within the hospital setting.
“Understanding what the problem is and why you believe a change needs to be made and
then laying that case out with the people who will be on the front lines. It is important to
have a discussion with them about it. The way to overcome barriers is when you have
clearly identified problems and how you make the solutions to be implemented. Make
sure you’re not missing anything. If it’s a clearly articulated case, you really need the best
solutions with the people who are going to be working with you. Laying the case out to
the people on the front lines and talking about it, how it might affect their world…we
work with very bright people who want to do the right things and know oftentimes that is
dialogue” (Participant 4). “Setting the vision for the delivery of care enables you to get it
done. Physicians, vendors, hospital staff should all get together. Empower the staff and
assist in financial and IT barriers. Management should act as a facilitator to work through
the details and cooperate with all parties to complete the vision of patient access,
physician access, and specialty access to telemedicine” (Participant 2).
Doolittle and Spaulding (2006) expounded on the need for working as a “team to
define the needs of a telemedicine service” (p. 277). Sheng et al. (1998) described the
telemedicine adoption process as a bottom-up course of action where physicians play an
integral role as opposed to a managerial command. Kermoglu et al. (2008) described the
importance of management’s support as one of the three top reasons to insure success or
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failure in the innovation of technology-related projects. In addition, Rogers (2003)
diffusion of innovations theory described the significance of collective or group choice in
the innovation process.
Champion and opinion leader roles in the telemedicine adoption process are
critical to the success of telemedicine. It is important to get buy-in from the opinion
leaders in order to have an efficient and effective program. “You never know who will
emerge as early adopters. One of the first champions 10-12 years ago was a semi-retired
cardiologist. Doctors are careful with selecting early champions. Champions are
innovative, embrace change; not set in their ways promulgating technology through their
early adoption. Their thinking becomes contagious; peers want to use it too. When those
champions begin to use telemedicine, then we see a shift in the proliferation of
telemedicine. We practiced implementation in that manner” (Participant 12). “Having a
physician champion within the specialty group helps. Opinion leaders adopt technology
and a new care delivery model. Somebody that would adopt the technology and the new
care delivery mechanisms and promote them to their colleagues. To decide who the
champions are, you really have to go to all groups and talk with them and ask who they
think is an opinion leader. That strategy works whenever you’re adopting something new
or implementing change of any type” (Participant 12).
Several researchers furnished support for the role of champions and opinion
leaders in the persuasion of their peers in the adoption of innovative technological
processes (Carter, 2012; Karwoski, 2006; Rogers, 2003; Sheng et al, 1998; Thakkar &
Weisfeld-Spolter, 2011). Bower (2005) confirmed the importance of the effect of opinion
leaders within the medical community. Liu (2011) supplied additional research on the
117
impact of the character of leaders in the adoption of innovations within health care
institutions. Spaulding et al. (2005) reported on the necessity of opinion leaders in the
telemedicine adoption process. Reference was made to the adopter of telemedicine
having a “different perception of telehealth than non-adopters and that strategies based on
diffusion of innovation theory should be devised to introduce this innovative process
more effectively to non-adopters” (Spaulding et al., 2005, p. S:109).
Relevance of the Study
Five themes. As previously stated, the five themes provided responses to two of
the research questions.
1. Which themes are going to emerge?
2. Which themes are most prevalent?
3. Is there an association between the level of innovativeness of the organization
and the innovativeness of the individual?
Table 10 displays the answers to Research Questions 1 and 2; emerging themes and
trends and their prevalence were discovered as a result of this study. Three of the five
themes were related to concepts presented in Rogers (2003) diffusion of innovations
theory: resistance to change, leadership roles, and adoption characteristics of opinion
leaders.
The outcome of Research Question 3 involves the possibility of an association
between the level of innovativeness of the individual and the perceived level of
innovativeness of the organization. The Pearson Correlation of .49 intimates a modest
relationship between these two indicators. In other words, there exists a small correlation
118
Table 10
Top Five Themes in Order of Frequency
Rank order Theme
1 Financial feasibility
2 Resistance to change and acceptance of new technologies
3 Access to specialists and subspecialists
4 Collaborative governance roles
5 Champion and opinion leader roles in the adoption process
between the characteristics of the key telemedicine leaders who participated in this study
and the characteristics of the organizations where they work. Bearing in mind that both of
these instruments were self-administered and no objective observations were conducted,
internal validity on both instruments was reported to be “highly valid” (Simonson, 2000,
p. 72).
Recommendations Based on the Results of the Study
1. Encourage champions and opinion leaders to play a larger role in telemedicine
planning and implementation
2. Urge more telemedicine involvement within medical specialties and
subspecialties
3. Collaborate with legislative bodies to provide standardized reimbursement for
telemedicine services
4. Work with state licensure boards to enact medical compacts or universal
licenses to practice medicine across state lines
5. Allocate financial resources for telemedicine research
6. Extend exposure of telemedicine to the general public to increase familiarity
119
and comfort levels
7. Standardize treatment protocols for health care organizations
8. Form collaborative relationships with local and national telemedicine
organizations
Conclusions and Recommendations for Further Research
1. Additional research should be done to increase the generalizability of the
findings (ex: increase the participant sample size)
2. Enlarge the geographic locations of the study to include additional areas
within the United States and internationally
3. Extend the study to other health care populations for a more inclusive
purposeful sample
4. Include vendors and policymakers in focus groups to gain a deeper
understanding of external factors
This study provided insight into several areas related to telemedicine adoption by
hospital leaders. It reported on the influential role opinion leaders play in the decision
making process (Cuyler & Holland, 2012). It discussed how telemedicine leaders handle
resistance to change and acceptance of new technological innovations like telemedicine
(West & Miller, 2009). Information was supplied on the importance of telemedicine
adoption within all communities (Berwick, 2002; WHO, 2010). This study is one small
tile in a vast mosaic. Yet, when placed in the right position, one tile can have an
incredible effect on the big picture (Simonson, personal communication, July 14, 2014).
Telemedicine provides medical services and health care education to individuals in
locations where local provisions are unavailable. Similarly, implementing more effective
120
and efficient telemedicine services by health care organizations and standardizing these
services for the benefit of all stakeholders can create a ripple effect. Making medical
services and health care education attainable for everyone through telemedicine will save
lives. Providing effective, widespread telemedicine programming at health care facilities
in underserved, rural locations where clinicians are sparse can mean the difference
between life and death for these populations (Craig, 2013; Oyedepo Olukayode, personal
communication, July 20, 2014).
This study interviewed the leaders of telemedicine within hospitals and clinics. It
stressed the importance of innovativeness among its leaders and their organizations when
adopting new health care technologies. While concerns about financial feasibility,
resistance to change, access to specialists, leadership roles and adopter characteristics
play integral parts in key leaders implementing innovative medical technologies; it is
clear that telemedicine does not replace doctors. Instead telemedicine combines medicine
with technology to save lives whether in large urban cities, small rural neighborhoods or
in distant places such as Nigeria (Craig, 2013; Oyedepo Olukayode, personal
communication, July 20, 2014)
121
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Appendix A
Interview Protocol for Hospital Administrators
142
Ms. Shelley Brown Cooper
4526 Francis Street
Kansas City, Kansas
Date
[Recipient Name]
CEO
[Company Name]
[Street Address]
[City, ST ZIP Code]
Dear [Recipient Name]:
I am a doctoral student at Nova Southeastern University. I am conducting research on the
use of telemedicine (tele-health) in the greater Kansas City area. You have been invited
to participate in a doctoral research study involving telemedicine: Opinion Leaders’
Perspective of the Benefits and Barriers in Telemedicine: A Grounded Theory Study of
Telehealth in the Midwest. The goal of this study is to provide a better understanding of
how opinion leaders influence the adoption of innovative programming, such as
telemedicine, among hospital administrators in the Midwest. We are inviting you to
participate because you are a chief executive officer, chief operating officer or similar
higher level administrator at one of the hospitals in the Greater Kansas City Area. There
will be 10 participating hospitals selected in this limited research study.
Would you be willing to participate in my research study? If so, may I send you a short
letter giving me authorization to proceed with the data collection process? This letter is
required by Nova Southeastern University’s Institutional Review Board. All participants
and information given will be held confidential. All the data collected will be included in
an anonymous report.
Please consider the importance of this data-gathering endeavor and its influence in the
continuation of telemedicine in the Midwest. If you choose to participate, please respond
by February 28 by calling the phone number below or sending me an email that provides
a convenient time for me to tell you more about this important study. Thank you.
Thank you.
Sincerely,
Shelley Brown Cooper
Doctoral Student
913.710.3818
143
Appendix B
Demographic Information Document
144
Demographic Information Document
These demographic questions are designed to help the survey researcher determine what
factors may influence a respondent’s answers, interests, and opinions. Collecting
demographic information will enable the researcher to cross-tabulate and compare
subgroups to see how responses vary between these groups.
Q. Age: What is your age?
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years or older
Q. Gender: What is your gender?
Male _______
Female _______
Q. Ethnicity origin (or Race): Please specify your ethnicity.
White
Hispanic or Latino
Black or African American
Native American or American Indian
Asian / Pacific Islander
Other _________________________
Q. Education: What is the highest degree or level of school you have completed? If
currently enrolled, highest degree received.
High school graduate, diploma or the equivalent (for example: GED)
Some college credit, no degree
Trade/technical/vocational training
Associate degree
Bachelor’s degree
Master’s degree
Professional degree
Doctorate degree
Q. Marital Status: What is your marital status?
145
Single, never married
Married or domestic partnership
Widowed
Divorced
Separated
Q. Professional Status: What is your current title…?
____________________________________________________
Q. Previous experience: Please describe your previous professional experience in the
field of health care?
__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Additional information: Please list any additional information you believe will be helpful
in describing your characteristics.
146
Appendix C
Innovativeness Scale
147
Individual Opinion Survey Please Circle the Number that
Most Closely Relates to your Opinion SD = Strongly Disagree
D = Disagree
MD = Mildly Disagree U = Uncertain
MA = Mildly Agree SA = Strongly Agree
SD D MD U MA A SA 1. My peers often ask me for advice or information. 1 2 3 4 5 6 7
2. I enjoy trying out new ideas. 1 2 3 4 5 6 7
3. I seek out new ways to do things. 1 2 3 4 5 6 7
4. I am generally cautious about accepting new ideas. 1 2 3 4 5 6 7
5. I frequently improvise methods for solving a problem
when the answer is not apparent. 1 2 3 4 5 6 7
6. I am suspicious of new inventions and new ways of thinking. 1 2 3 4 5 6 7
7. I rarely trust new ideas until I can see whether the vast
majority of people around me accept them. 1 2 3 4 5 6 7
8. I feel that I am an influential member of my peer group. 1 2 3 4 5 6 7
9. I consider myself to be creative and original in
my thinking and behavior. 1 2 3 4 5 6 7
10. I am aware that I am usually one of the last people
in my group to accept something new. 1 2 3 4 5 6 7
11. I am an inventive kind of person. 1 2 3 4 5 6 7
12. I enjoy taking part in the leadership responsibilities
of the groups I belong to. 1 2 3 4 5 6 7
13. I am reluctant about adopting new ways of doing things
until I see them working for people around me. 1 2 3 4 5 6 7
14. I find it stimulating to be original in my thinking and behavior. 1 2 3 4 5 6 7
15. I tend to feel that the old way of living and doing things is the best. 1 2 3 4 5 6 7
16. I am challenged by ambiguities and unsolved problems. 1 2 3 4 5 6 7
17. I must see other people using new innovations
before I will consider them. 1 2 3 4 5 6 7
18. I am receptive to new ideas. 1 2 3 4 5 6 7
19. I am challenged by unanswered questions. 1 2 3 4 5 6 7
20. I often find myself skeptical of new ideas. 1 2 3 4 5 6 7
148
Appendix D
Organizational Innovativeness Scale
149
Organizational Opinion Survey Please Circle the Number that
Most Closely relates to your Opinion
SD = Strongly Disagree D = Disagree
MD = Mildly Disagree
U = Uncertain MA = Mildly Agree
SA = Strongly Agree
The Organization where I work is: SD D MD U MA A SA
1. cautious about accepting new ideas. 1 2 3 4 5 6 7
2. a leader among other organizations. 1 2 3 4 5 6 7
3. suspicious of new ways of thinking. 1 2 3 4 5 6 7
4. very inventive. 1 2 3 4 5 6 7
5. often consulted by other organizations for advice and information. 1 2 3 4 5 6 7
6. skeptical of new ideas. 1 2 3 4 5 6 7
7. creative in its method of operation. 1 2 3 4 5 6 7
8. usually one of the last of its kind to change
to a new method of operation. 1 2 3 4 5 6 7
9. considered one of the leaders of its type. 1 2 3 4 5 6 7
10. receptive to new ideas. 1 2 3 4 5 6 7
11. challenged by unsolved problems. 1 2 3 4 5 6 7
12. follows the belief that “the old way of doing things is the best”. 1 2 3 4 5 6 7
13. very original in its operating procedures. 1 2 3 4 5 6 7
14. does not respond quickly enough to necessary changes. 1 2 3 4 5 6 7
15. reluctant to adopt new ways of doing things
until other organizations have used them successfully. 1 2 3 4 5 6 7
16. frequently initiates new methods of operation. 1 2 3 4 5 6 7
17. slow to change. 1 2 3 4 5 6 7
18. rarely involves employees in the decision-making process. 1 2 3 4 5 6 7
19. maintains good communication between supervisors and employees 1 2 3 4 5 6 7
20. influential with other organizations. 1 2 3 4 5 6 7
21. seeks out new ways to do things. 1 2 3 4 5 6 7
22. rarely trusts new ideas and ways of functioning. 1 2 3 4 5 6 7
23. never satisfactorily explains to employees
the reasons for procedural changes. 1 2 3 4 5 6 7
24. frequently tries out new ideas. 1 2 3 4 5 6 7
25. willing and ready to accept outside help when necessary. 1 2 3 4 5 6 7
150
Appendix E
Interview Questions
151
Central questions
1. Which barriers do CEOs show to be most likely to deter telemedicine
implementation at health care organizations in Kansas City? How has reimbursement
affected the development of telemedicine in area hospitals?
2. What are the drivers that persuade health care providers to development
telemedicine programming within their organizations?
3. What types of strategies do COOs employ to overcome barriers in
implementing telemedicine in their health care facilities?
Sub questions
1. What is the role of the COO in the development of telemedicine/telehealth
services?
2. How do the legal, legislative, ethical, financial, equipment and training aspects
of implementing telemedicine/telehealth services affect hospital leaders?
3. How does the telemedicine adoption and diffusion process compare with the
adoption of other technologies within the health care industry in general (e.g. diffusion of
electronic health records)?
152
Appendix F
Telephone Interview Guide
159
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
1. Which barriers do CEOs show to be most likely to deter telemedicine implementation at health
care organizations in Kansas City? How has reimbursement affected the development of
telemedicine in area hospitals?
If none, ask why: Record Explanation:
160
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
2. What are the drivers that persuade health care providers to develop telemedicine programming
within their organizations?
If none, ask why: Record Explanation:
161
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
3. What types of strategies do COOs employ to overcome barriers in implementing telemedicine in
their health care facilities?
If none, ask why: Record Explanation:
162
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
1. What is the role of the COO in the development of telemedicine/telehealth services?
If none, ask why: Record Explanation:
163
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
2. How do the legal, legislative, ethical, financial, equipment and training aspects of implementing
telemedicine/telehealth services affect hospital leaders?
If not, ask why: Record Explanation:
164
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
3. How does the telemedicine adoption and diffusion process compare with the adoption of other
technologies within the health care industry in general (e.g. diffusion of electronic health
records)?
If no comparison, ask why: Record Explanation:
165
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
Additional follow-up questions here.
If none, ask why: Record Explanation:
166
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
Additional follow-up questions here.
If none, ask why: Record Explanation:
167
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
Additional follow-up questions here.
If none, ask why: Record Explanation:
168
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
Additional follow-up questions here.
If none, ask why: Record Explanation:
169
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
Additional follow-up questions here.
If none, ask why: Record Explanation:
170
Interview Guide
CEO, COO, CFO Interviews
Date/Time of Interview: _________________________________
Hospital: _____________________________________
Participant: ______________________________________________
Additional follow-up questions here.
If none, ask why: Record Explanation: