Adoption of Telemedicine in a Rural US Cancer Center Amid the COVID-19 Pandemic: Qualitative Study

Abstract

Background The COVID-19 pandemic necessitated a rapid shift to telemedicine to minimize patient and provider exposure risks. While telemedicine has been used in a variety of primary and specialty care settings for many years, it has been slow to be adopted in oncology care. Health care provider and administrator perspectives on factors affecting telemedicine use in oncology settings are not well understood, and the conditions associated with the COVID-19 pandemic offered the opportunity to study the adoption of telemedicine and the resulting provider and staff perspectives on its use. Objective The aim of this paper is to study the factors that influenced telemedicine uptake and sustained use in outpatient oncology clinics at a US cancer center to inform future telemedicine practices. Methods We used purposive sampling to recruit a mix of oncology specialty providers, practice managers, as well as nursing and administrative staff representing 5 outpatient oncology clinics affiliated with the Dartmouth Cancer Center, a large regional cancer center in the northeast of United States, to participate in semistructured interviews conducted over 6 weeks in spring 2021. The interview guide was informed by the 5 domains of the Consolidated Framework for Implementation Research, which include inner and outer setting factors, characteristics of the intervention (ie, telemedicine modality), individual-level factors (eg, provider and patient characteristics), and implementation processes. In total, 11 providers, 3 leaders, and 6 staff participated following verbal consent, and thematic saturation was reached across the full sample. We used a mixed deductive and inductive qualitative analysis approach to study the main influences on telemedicine uptake, implementation, and sustainability during the first year of the COVID-19 pandemic across the 5 settings. Results The predominant influencers of telemedicine adoption in this study were individual provider experiences and assumptions about patient preference and accessibility. Providers’ early telemedicine experiences, especially if negative, influenced preferences for telephone over video and affected sustained use. Telemedicine was most favorably viewed for lower-acuity cancer care, visits less dependent on physical exam, and for patient and caregiver education. A lack of clinical champions, leadership guidance, and vision hindered the implementation of standardized practices and were cited as essential for telemedicine sustainability. Respondents expressed anxiety about sustaining telemedicine use if reimbursements for telephonic visits diminished or ceased. Opportunities to enhance future efforts include a need to provide additional guidance supporting telemedicine use cases and evidence of effectiveness in oncology care and to address provider concerns with communication quality. Conclusions In a setting of decentralized care processes, early challenges in telemedicine implementation had an outsized impact on the nature and amount of sustained use. Proactively designed telemedicine care processes with attention to patient needs will be essential to support a sustained role for telemedicine in cancer care.

Outpatient Video Visits During the COVID-19 Pandemic: Cross-Sectional Survey Study of Patients’ Experiences and Characteristics

“…Our finding that high self-rated health of patients is an influencing patient characteristic for suitability of video visits echoes the finding that patients with less complex, more straightforward clinical needs are more suitable candidates for video visits than those with complex, high-risk diseases [ 10 , 29 ]. Similar findings were identified in an oncological study wherein telemedicine was received favorably for low-acuity cancer care [ 16 ]. In contrast to findings that video visits appear to be more appropriate when the clinician knows the patient beforehand and when it is a follow-up visit [ 10 ], we found that the reason for the visit did not have any influence on whether patients rated the video visit positively.…”

“…The 13-item survey by Hanna et al [7] is designed according to the principles of survey development for telemedicine to evaluate patients' experiences with video visits in pain clinics [26]. This survey was translated into Dutch, and 1 item was removed, as it was already covered by the PEM survey (Multimedia Appendix 1, items [16][17][18][19][20][21][22][23][24][25][26][27]. In total, 4 items were rephrased based on the advice of the patient communication experts.…”

“…This way of providing care offers several advantages, including saving travel time and costs for both patients and their companions and the efficient use of health care resources, such as outpatient clinic space and support [ 12 - 14 ]. As we move into the post–COVID-19 era, video visits are expected to persist as a routine practice, but large-scale use has seemed to stagnate, presumably owing to a lack of guidance, vision, and attention to patients’ needs, as observed in the United States [ 15 , 16 ]. The use and implementation of video visits are expected to be most successful when tailored to the needs of patients, clinicians, and health care organizations [ 17 , 18 ].…”

“…Therefore, it is crucial to understand patients’ perspectives and experiences with video visits and identify specific patient groups that show a greater or lesser degree of appreciation for and suitability to video visits [ 19 ]. Large studies with diverse patient populations covering all medical specialties need to be conducted to learn more about patients’ perspectives [ 16 , 18 ]. However, we are concerned that only a limited number of studies have been published that evaluated video visits for patients within large, diverse populations.…”

Outpatient Video Visits During the COVID-19 Pandemic: Cross-Sectional Survey Study of Patients’ Experiences and Characteristics (Preprint)

“…This way of providing care offers several advantages, including saving travel time and costs for both patients and their companions and the efficient use of health care resources, such as outpatient clinic space and support [12][13][14]. As we move into the post-COVID-19 era, video visits are expected to persist as a routine practice, but large-scale use has seemed to stagnate, presumably owing to a lack of guidance, vision, and attention to patients' needs, as observed in the United States [15,16]. The use and implementation of video visits are expected to be most successful when tailored to the needs of patients, clinicians, and health care organizations [17,18].…”