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Table 2 Exemplary quotes for facilitators and barriers within each stage

From: Managing innovation: a qualitative study on the implementation of telehealth services in rural emergency departments

Domains

Themes

Facilitators

Barriers

 

Start-up Stage

Strategies

Availability of needs assessment: “We completed a needs assessment among the rural telehealth network senior leaders. They indicated that the integration of a telemedicine solution to help solve the multifaceted behavioral health issues they were facing was their number one priority.” (Hub 4)

Incomplete needs assessment: “We probably should have done a much more detailed needs assessment of the providers in the beginning and built a system that is based on their needs. But we weren’t able to do that.” (Hub 3)

Capability

Experience and expertise: “The hub specialists have been board certified not only in neurology, but also in stroke neurology. They would be the most qualified to take care of telehealth consults.” (Hub 6)

Limited service capacity: “Capacity issues also created a challenge for adding a new telehealth site. There is a lack of human resources to provide services outside of immediate service region due to staff attrition and ongoing position vacancies.” (Hub 4)

Relationships

Existing relationship: “Each of our existing partners own their fair share of the network and get to decide what goes into it. They consider our telehealth service as part of their main business. So, anything that goes to supporting the service, they will facilitate them.” (Hub 4)

Referral patterns limitation: “I think that is where we mis stepped at the beginning. We were not really considering our connections, the existing referral patterns when we built this service.” (Hub 2)

Environment

NA

Politics and contextual issues: “We’ve tried bringing in other specialists, but we face one of the regulatory challenges: they have to be credentialed and privileged. The new specialists are not interested to do that just on a casual basis.” (Hub 1)

 

Utilization Stage

Strategies

Intensive training: “We’ve identified a couple of different instances where those rural sites could use a bit more education. We have also identified that video tutorials would be the most useful for them so we’re planning on doing some short educational videos for these rural EDs to use.” (Hub 2)

Training challenges: “During this past year we identified that a weakness of our service was a higher rate of failed telemedicine consults due to lack of training of the clinical night staff, especially locums, at our partner hospitals.” (Hub 5)

Capability

Robust service capacity: “We have a backup in our telehealth system. And then we even have a backup to the backup, just in case. Because anything can happen. So, we can have two telehealth consults at once. That’s part of being a comprehensive structure. We have to show them that we have that capability.” (Hub 6)

Lack of utilization: “We haven’t seen the uptick in referrals as much as we would have liked through our telehealth system because unfortunately a lot of our rural hospital partners are low volume, so they don’t call as much.” (Hub 3)

Relationships

Close relationship: “Keeping our relationship strong with the physicians, nurses, and administration, and remaining flexible to accommodate the needs of our partner sites has been invaluable throughout this past year and will continue to serve us well throughout the next project year.” (Hub 5)

Lack of buy-in: “One of the things that I think we underestimated was how so many of the providers would feel this service was maybe questioning their skills or giving them the sense that we want to be the big brother. Then choose not to use it.” (Hub 2)

Protocols

Well-defined workflow: “Whenever a hospital here calls about a sick patient, they’ll be connected over telephone with our hub physicians. They’ll briefly talk about the case and then they’ll decide if telemedicine should be initiated. And if so, our physicians will call into their ED, and the unit will automatically answer.” (Hub 5)

Workflow flaws: “Our current system isn’t necessarily set up, for that (TeleED) workflow. I mean, it’s an emergency and it could come anytime 24/7/365 so you’ve got to have enough capacity for that, and our workflow is usually 8 am to 6 pm in terms of clinics.” (Hub 6)

Service Characteristics

Care coordination: “We give them guidance, if somebody’s clearly psychotic or actively suicidal, we say this person is not safe to go home and needs to be admitted. Like I said, the rural providers just want the help, and they are so appreciative of the telehealth service. They are so thankful that we’re there to provide consults.” (Hub 1)

Time consuming process: “The providers were resistant because they know it can be fairly time intensive. It’s easy to pick up the phone and just do a phone consultation. They could be driving and have a two or three-minute conversation about a patient. But the telehealth service is a more time-intensive process on the providers.” (Hub 3)

Environment

NA

Lack of integration: “There is limited ability to create a seamless, electronic method for requesting, registering, and completing documentation for the TeleED service visit. All sites largely operated on disparate electronic health record systems. This situation can create a barrier for the adoption and endorsement of telehealth programs.” (Hub 4)

 

Sustainment Stage

Strategies

Opportunities: “It has opened up a lot of other opportunities. With many of these sites we’re able to do other telemedicine things, services with them, so it was kind of a side benefit in that it was just opening up the conversation about telemedicine. There have been a lot of little side conversations that I think have been very beneficial for all of these sites.” (Hub 2)

Poor fit with needed service: “The only way to extend this long term is that we would have to have additional providers available that fit with rural hospitals’ needs.” (Hub 3)

Capability

Availability of multi-specialties: “We do tele-stroke and tele-burns as well. And we have other ancillary services such as our language line and sign language interpretation. We are planning to keep adding more value to our telehealth service.” (Hub 1)

Attrition: “We found attrition of providers in community health centers at some of our sites, they just don’t have enough people to be able to cover what the needs are.” (Hub 4)

Relationships

Referral patterns: “We have a lot of referrals from sites that currently are not in our TeleED partners list. Those are potential sites for the telehealth service.” (Hub 6)

NA

Financials

Payment model: “That’s one of the big things that has set us apart (only charging for the professional fees). We were looking at something that really doesn’t cost the care site anything.” (Hub 2)

Not a money maker: “Right now the continuation contract went back and forth, and it’s in spokes’ hands. They can’t complain about the price because we are practically giving the service for free. If there’s still a concern about it, I’m not so sure we’d be able to sustain the service.” (Hub 6)

Accountability

Evaluation and quality improvement: “We have started to collect information on why physicians decide to deviate from using the telemedicine service according to the protocol to understand the important clinical reasons driving these decisions, the appropriateness of when to activate telemedicine, and improving the use of telemedicine services.” (Hub 5)

Lack of evaluation measures: “The providers that are involved are not as invested in the hospital. The administrators do not have measures about transfers or about patient centeredness -as far as could you avoid the transfer or could we have found a different option for this patient- which are important for improvement purposes.” (Hub 3)

Environment

NA

Politics and contextual issues: “We’ve heard from our legal staff that there’s some special blessing with grants, but you know they go away. So, that’s part of the fear of how you make something that’ll be sustainable because a lot of specialists are a little daunted by the amount of hurdles and paperwork they’ve got to do to provide the service.” (Hub 1)