This study provides 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. 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 5 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.
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 teleeducation 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 time frame 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 Indians in Arizona through a project called Space Technology Applied to Rural Papago Advanced Health Care. Specialists provided assistance by interpreting electrocardiographs and X-ray (Norris, 2002). The military has been another frequent user as telemedicine has been a part of large-scale coordination efforts required for international disaster relief.
Telemedicine affects current caregivers, underserved populations in the city and surrounding areas, and patients needing specialized services not available in their local areas (Maheu, Whitten, & Allen, 2001; Norris, 2002; Spaulding, Russo, Cook, & 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 benefited 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 traveling 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. 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.
This literature review explores 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.
Simonson et al. (2012) defined distance education as "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 videoconferencing 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 education 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).
Ten factors were reported by Berge and Muilenburg (2000) that were considered barriers to distance education: 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 Berge and Muilenburg (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).
Origin. 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; 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).
Telemedicine utilization reports and 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 heightened access to telehealth brings about favorable 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 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, and integration of interactive health services (Norris, 2002; Peabody, 2013).
Latifi, Ong, Peck, Porter, and Williams (2005) concluded that the use of telemedicine in the management of trauma and emergency care is needed in remote areas and catastrophic situations. Because trauma requires immediate care and these types of services are not as prevalent in rural areas, these populations suffer at a higher rate than do 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 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.
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).
Benefits and Barriers Identified by Literature (International). The World Health Organization (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) unwillingness among medical personnel, can produce difficulties towards the endorsement of telemedicine (WHO, 2010).
Removing licensure and professional liability impediments would allow clearer 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. 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, Hayes, Sadasivan, Williamson, and Wittman (1995) also assessed the level of satisfaction among physicians involved in a teleoncology initiative within the state of Kansas. Although the sample size was too small to make generalizations, 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.
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 CEOs' 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, time frame 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 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 CEOs' 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, 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.
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 Rogers' (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 demonstrated benefit to society. Trepidation over the adoption of new methods within the health care industry can be explained using Rogers' (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 correct, 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 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 sociometric 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).
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 have 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 endorsement. Opinion leaders usually have advanced educational degrees as well as other academic credentials. They are also thought to be authorities within their career fields. As a result, the certified physician executive 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 highly qualified, influential contributors 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 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 was 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, and 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) 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 sociopolitical environment recognizing their significant visual, persuasive, and personal qualities. Similarly, Burke, Fournier, and Prasad (2007) proposed that the diffusion of innovative medical procedures such as stents by "nonstars" was positively dependent upon the number of "stars" practicing simultaneously at the same hospitals. Stars were defined as physicians who 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 decrease 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 'nonstars' at the same hospital" (Burke et al., 2007, p. 1).
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. 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).
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.
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 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 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 Pare (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 nonadopter 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 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, p. 38)
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 needs (Campbell et al., 2001, p. 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 nonadopters. 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 nonadopters and that strategies based on diffusion of innovation theory should be devised to introduce this innovative process more effectively to nonadopters" (Spaulding et al., 2005, p. 109).
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 subquestions. 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?
3. What types of strategies do COOs employ to overcome barriers in implementing telemedicine in their health care facilities?
The subquestions analyzed the involvement of administrators and organizational factors on telemedicine adoption and development. In addition, a comparison of additional innovations was explored. The three subquestions 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)?
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 indepth 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 that 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 organizations. 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). Institutional Review Board approval was obtained before data were collected.
Telemedicine services in the Greater Metropolitan Kansas City Area (GMKCA) are limited compared to health care 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 Rogers' (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 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 noteworthy 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.
The population consisted of hospital employees. The target population was CEOs and COOs of hospitals in the greater Kansas City area. Participants in the study consisted of a purposeful sampling of members of 18 Kansas City area hospitals' 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 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, Joseph, & Cook, 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 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 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 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).
Demographic Information Document Results. The majority of the respondents were between the ages of 46 and 55 (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%).
A description of the breakdown of gender classifications provided insightful information. One gender was more strongly represented than the other. The majority of the respondents were male (78%).
There were no respondents from the following ethnic groups: Hispanic/Latino, Native American/American Indian or Asian/Pacific Islander. Therefore, these groups are not represented in this study.
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 participants held degrees in more than one category.
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.
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).
Innovativeness Scale (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 Table 1).
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).
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). 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).
Comparison of Normative Group PORGI and IS Results to Participants' Results
Tables 1 and 2 display comparisons of the normative group scores and participant group scores for the PORGI scale and the IS scale.
Table 3 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.
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, the 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.
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 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).
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.
Meanings and Understandings
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).
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 multistate 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).
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 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.
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) 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
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 telemedicine process. Norris (2002) and Peabody (2013) commented on the significance of payment and reimbursement for services as one of the challenges prohibiting widespread 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, 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, Pearlson, and McDonald (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 (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. Kerimoglu, Basoglu, and Daim (2008) described the importance of management's support as one of the three top reasons to insure success or 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 semiretired 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, Thatcher, Chudoba, & Marett, 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 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 nonadopters and that strategies based on diffusion of innovation theory should be devised to introduce this innovative process more effectively to nonadopters" (Spaulding et al., 2005, p. 109).
RELEVANCE OF THE STUDY
The five themes provided responses to two of the research questions: (1) Which themes are going to emerge? and (2) Which themes are most prevalent? Table 4 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 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
Based on the findings of the study, eight recommendations are offered to the field:
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 and comfort levels;
7. standardize treatment protocols for health care organizations; and
8. form collaborative relationships with local and national telemedicine organizations.
RECOMMENDATIONS FOR FURTHER RESEARCH
Researchers interested in extending this study may want to consider the following four recommendations.
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; and
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 (M. 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 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; O. 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; O. Olukayode, personal communication, July 20, 2014).
Shelley Brown Cooper
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* Shelley Brown Cooper, 4526 Francis Street, Kansas City, Kansas 66103. Telephone: 913-710-3818. E-mail: email@example.com
Shelley Brown-Cooper received her doctoral degree in instructional technology and distance education from Nova Southeastern University in 2014. Her research involved telemedicine adoption among hospital leaders in the Midwest. She has over 25 years of experience in education, most recently at the University of Missouri-Kansas City. In addition, she has completed telemedicine training at the University of Arizona and observations at the University of Kansas-Telemedicine Center. She also holds a master of arts in teaching from the University of St. Mary, a teaching degree from Avila University, and bachelor's degree in business from University of Missouri-Columbia. Cooper owns Diversity Telehealth, LLC, a start-up company whose mission is to connect telemedicine organizations with physicians and health care professionals who provide services to patients in underserved areas and communities experiencing severe shortages in specialists.
TABLE 1 IS Scores Normative Telemedicine Group Leaders M 105.1 113 SD 14.46 10.01 N 1,693 18 TABLE 2 PORGI Scale Scores Normative Group Telemedicine Leaders M 114.23 126 SD 23.59 16.75 N 1683 18 Source: Rogers (2003) and Simonson (2000). TABLE 3 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. TABLE 4 Top Five Themes in Order of Frequency Rank Order Theme i 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