Method and results are reported using the Consolidated Criteria for Reporting Qualitative studies (COREQ) . Ethics approval was received from the Human Research Ethics Committees of the Australian regional hospital, the National Research Ethics Service (UK) and the University of Central Lancashire’s, Buildings, Sport and Health Ethics Committee.
Design and setting
A pre-post qualitative study was conducted with telestroke networks from Australia (Victorian Stroke Telemedicine [VST] Program)  and the UK (Cumbria and Lancashire telestroke network) . Both networks had mobile telemedicine carts in participating hospitals for use at the patient’s bedside, allowing a two-way audio-video connection to specialists, and for brain images to be viewed remotely. Training was provided in how to access images and use the telemedicine equipment Additional training in CT scan interpretation was undertaken in the UK. Training strategy and programme for the UK can be accessed at http://www.astute-telestroke.org.uk/section4.htm
The VST Program commenced with a single pilot hospital in 2011  covering a population of 308,000 and is now active in a further 15 hospitals across five regions in Victoria , a south-eastern state of Australia. A virtual hub of 12 metropolitan-based stroke specialists (all consultant neurologists) provide a 24/7/365 service. A consult payment schedule comprising a daily on-call rate and fee-for-service is used and the on-call role is in addition to their usual duties. Specialists are on-call for 24 h shifts from 8 am; one specialist covers the weekend. Patients presenting to participating regional emergency departments within 4.5 h of suspected stroke onset are eligible. Between July 2011–September 2016, there were 1001 initial telemedicine consults with a further 141 follow-up consults conducted by VST neurologists. Of these, 235 were recommended for thrombolysis and 46 for endovascular clot retrieval.
The UK contribution to this study was part of a multi-phase project: the Acute Stroke Telemedicine: Utility, Training and Evaluation (ASTUTE) [7, 15, 16]. This project ran alongside the development and implementation of the Lancashire and Cumbria Telestroke Network, and produced a standardised telemedicine toolkit (http://www.astute-telestroke.org.uk). The Lancashire and Cumbria Telestroke Network was launched in August 2011, comprising eight hospitals, covering a population of nearly 2.2 million. Fifteen stroke specialists (i.e. stroke geriatricians, neurologists, medical consultants), participate in an on-call rota covering nights, weekends and public holidays. The stroke specialists are on-call from 5 pm until 8 am weekdays and for 24 h shifts at weekends and public holidays. The on-call is incorporated into the specialist’s job plan (i.e. forms part of their usual duties) negotiated at each Trust. Between July 2011–September 2016, there were 1503 telestroke assessments; 672 received thrombolysis.
Participants and procedure
Participants were the specialists providing the telestroke consultations. Participants were identified using maximum variation sampling to try and reflect exposure in terms of sex, clinical experience and geographical location of rostered specialists for both networks. Specialists involved in the development and implementation of each network were approached face-to-face, through telephone or email by network staff and invited to participate in an interview; all agreed.
Semi-structured interviews (using schedules outlining questions and probes used are available from first author) were conducted face-to-face or via telephone with three specialists from each network both pre- and 12 months post-implementation. The pre-implementation interview schedules covered participants’ prior experience with telemedicine, obstacles for implementing the network, and how it might impact on performing their current role. The post-implementation interview schedules included their level of comfort in making decisions via telemedicine consultations, service improvements that could be made, and identifying future applications of telemedicine. The schedule content was reviewed by a stroke specialist ensuring relevance and face validity. Experienced researchers (all female) with qualitative interview expertise, who may or may not have been known to the participant, performed the interviews with no other project personnel present. Interviews were audio-recorded with participant’s consent, transcribed verbatim and de-identified for analysis. Field-notes were taken. No repeat interviews were carried out, and transcripts were not returned to participants for comment, except two UK pre-implementation transcripts (no edits required).
Deductive thematic and content analyses were undertaken by two independent coders (Australia KB; UK CL) within NVivo10 . The Normalisation Process Theory (NPT)  coding framework was used. NPT was designed to explore the integration of interventions into practice  including the assimilation of complex e-health initiatives . The four NPT components (Coherence, Cognitive Participation, Collection Action, Reflexive Monitoring) have four sub-components; detailed in Results. A coding protocol was developed, trialled and refined using an additional transcript from each network. Discussions were ongoing throughout coding ensuring consistent application.
The mean number of comments (i.e. total number of comments divided by number of participants) assigned to each NPT sub-component was calculated by sub-component, pre- and post-implementation. These data are presented in radar plots which depict the distribution of comments across NPT components, allowing comparisons between networks (Australia blue, UK red), and also pre- (solid line) and post- (dotted line) implementation. The more comments made within a sub-component, the further out the point is extended on the plot axis.