Telemedicine in Rural Areas

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Telemedicine in Rural Areas

Finding solutions to change the attitude towards the use of

telemedicine

Paul Kleinjan Esther Nijboer Alice van Riel

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Telemedicine in Rural Areas

Finding solutions to change the attitude towards the use of telemedicine

By

Paul Kleinjan - s1921126 Esther Nijboer - s2398176 Alice van Riel - s2280310

University of Groningen Faculty of Economics and Business

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Abstract

The objective of this thesis is to contribute to the academic field of knowledge with regard to the attitude of using telemedicine. The study consists of a combination of literature and field research focussing on the social causes of resistance towards the use of new distance oriented healthcare technology. The social causes of resistance are split into three elements of attitude development: concerns about competences, concerns about personal reputation and concerns about perceived usefulness. The goal of the study is to find solutions to increase the use of telemedicine by changing the attitude of physicians in the rural areas of Tanzania. The chosen methodology for the field study is semi-structured interviewing. The key finding is that all three mentioned social causes are related to a form of reluctance with regard to using the new technology. Lacking certain competences, the fear of damaging ones personal reputation as and a lack of perceived usefulness all effect the utilisation of telemedicine tools in a negative way.

Keywords:

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Acknowledgements

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1. Introduction

In Tanzania, many people live in rural areas, having limited access to healthcare. The epicentre of healthcare expertise and resources remains in the cities. The rural areas are isolated from the rest of the medical world. This isolation causes a lack of up to date reference materials and a lack of consultation possibilities resulting in low quality healthcare and diagnosis in clinics and health centres in these areas. (IICD, 2010)

One of the strategies to get specialist care to rural areas is by means of telemedicine. Telemedicine refers to the use of Information Technology to provide healthcare service and activities via the internet with necessary information or expertise in order to improve service effectiveness or resource allocation. The focus is often on geographically dispersed areas. (Chau & Hu, 2002)

After a roundtable workshop on ‘ICT for Health’, held in Tanzania in February 2005 the Evangelical Lutheran Church Tanzania (ELCT) supported by International Institute for Communication and Development (IICD) and Cordaid started a project to build a telemedicine based medical service support system. The first implementation stage of this project took place in January 2008.

The evaluation report of this first phase (IICD, 2010) indicated positive effects of the use of telemedicine. Telemedicine saves time, costs, and supports physicians in treating their patients. There are however still many challenges to overcome. One of the main objectives of the telemedicine project in Tanzania was to have an online consultation network up and running with around 100 consultations taking place on a weekly base. Unfortunately, only a couple hundred medical cases was submitted in two years time. The evaluation reports of IICD showed that the main cause is the prevailing attitude of physicians towards the use of telemedicine.

The objective of this thesis is to contribute to the field of knowledge on how to implement telemedicine programs in rural areas, specifically Tanzania. Evaluation reports show that the prevailing attitude of physicians is a major cause of implementation problems. Therefore, this thesis will be focussing mainly on this issue.

The thesis research question is as follows: How to improve the attitude of physicians in the

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The concept of prevailing attitude is split into three determinants, which influence the use of telemedicine:

 Concerns about competence

 Concerns about personal reputation

 Concerns about the perceived usefulness

The goal of this study is to find solutions to change the attitude of physicians in order to increase the use of telemedicine.

Key findings are that a lack of competences does effect the utilisation of telemedicine tools. The fear of damaging a personal reputation and a lack of perceived usefulness cause reluctance in use. The study reveals that a thorough integration of telemedicine tools in the daily routines of hospitals will improve adoption. In addition, the study showed that the creation of awareness of the benefits of telemedicine tools for all stakeholders is required.

The remainder or this thesis begins with a literature review split into three parts. The review will focus on the elements competences, personal reputation and perceived usefulness. In the subsequent chapter, the research design will be set out with special attention to the methodology and data collection. Subsequently a field research in the form of semi-structured interviews will be conducted and the results will be discussed. Finally, the thesis will conclude.

2. Research framework

2.1. Conceptual framework

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Figure 1: Problem statement, the three attitude related problems.

2.2. Concepts & definitions

In this section, the most important concepts are being defined in order to clearly limit the concepts and scope of the thesis.

 Competences: The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served (Epstein & Hundert, 2005).

 Perceived usefulness: The degree to which a person believes that using a particular system would enhance his or her job performance (Davis, 1989).’

 Personal reputation: The extent to which individuals are perceived by others, over time, as performing their jobs competently, and being helpful towards others in the workplace (Zinko et al., 2011)

 Physicians: Physicians in rural areas

 Rural area: A geographic area that is located far outside the cities and towns

 Specialists: Specialists (which mostly live in urban areas), who have to provide physicians with their medical knowledge

 Telemedicine: IT to support healthcare service and activities via electronic transmission of the necessary information or expertise among geographically

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dispersed parties, including physicians and patients, in order to improve service effectiveness or resource allocation/utilization efficiency (Chau & Hu, 2002).

2.3. Research questions

In this section, the main research question and sub-questions for literature and field research are determined.

The main research question

How to improve the attitude of physicians in the rural areas of Tanzania in order to increase the use of telemedicine?

Sub-questions Literature

1. How do concerns about competences play a role in the development of a reluctant attitude towards the use of telemedicine according to the literature?

2. How do concerns about personal reputation play a role in the development of a reluctant attitude towards the use of telemedicine according to the literature?

3. How do concerns about perceived usefulness play a role in the development of a reluctant attitude towards the use of telemedicine according to the literature?

4. How can, according to literature, these problems be solved?

Sub-questions field research

1. How do concerns about competences play a role in the development of a reluctant attitude towards the use of telemedicine according to the experts?

2. How do concerns about personal reputation play a role in the development of a reluctant attitude towards the use of telemedicine according to the experts?

3. How do concerns about perceived usefulness play a role in the development of a reluctant attitude towards the use of telemedicine according to the experts?

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2.4. Literature review

This literature review is a summary of the current knowledge in academic literature on the topic of telemedicine and the reluctant attitude of physicians toward using this new technology. The focus is on the three elements that influence attitude towards implementation: concerns about competences, concerns about personal reputation and concerns about perceived usefulness.

2.4.1. Competences and the implementation of telemedicine

Evaluations of telemedicine projects show that many adult healthcare workers experience severe challenges in using the telemedicine tools (Themistocleous, Koumaditis, Mantzana, & Morabito, 2010). Many healthcare workers experience problems caused by a lack of user training on the systems, a lack of online health resources awareness and poor research skills in finding authoritative information online. Additional support for this conclusion can be found in a study of Taurai Chikotie et al. The authors argue that the limited educational background is to blame for the slackness in ICT skills.

Tornatzky and Klein (1982) argue that effective education facilities could increase the effectiveness and appreciation of the benefits of the health project and could take away barriers. They urge the need for more rigorous research to identify advantages and disadvantages of specific uses of ICT in medical education. Sargant (2007) argues that it is vital that the crew is trained on ICT use to ensure maximum effectiveness and efficiency for support in the process of rendering health services to patients.

According to van Dijk (1999) a limited educational background refers to only one of the four barriers on the way to using the internet society. Van Dijk (1999) differentiates between five kinds of barriers:

1. Lack of any digital experience caused by lack of interest, computer fear and unattractiveness of the new technology (‘psychological access’)

2. No possession of computers and network connections (‘material access’) 3. Lack of digital skills caused by insufficient user-friendliness and inadequate 4. education or social support (‘skills access’)

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With regard to telemedicine projects, the barrier ‘no possession of computers’ should be omitted as at the start of the different telemedicine projects computers will be provided. The other three barriers could possibly play a role in the adoption of telemedicine tools.

Noe, Hollenbeck, Gerhart and Wright (2012), show several factors that affect the motivation to learn. One of them are the need for ‘basic skills’. People must have prerequisite skills before they engage in training for understanding and learning the training content. These factors or motivation are comparable to the ‘psychological access’ barrier as mentioned by Van Dijk.

Sedoyeka (2012) studied the hurdles in bridging the ‘digital divide’ in Tanzania, stated that at an individual level, there is still no aspiration to embrace ICT and occasions that come with it. Stories about accepting western ways of life and what it involves make some people sceptical about technology, particularly the internet. (Sedoyeka, 2012)

Based on previous research we can conclude that different access related barriers exist to the use of the ICT tools. This could result in reluctance toward developing new competences in the area of telemedicine. To bridge this usage gap and diminish the digital divide, special training programs related to the field of computer skills and language skills and community gatherings could help overcome these problems.

2.4.2. Personal Reputation and the implementation of telemedicine

‘Knowledge is Power’ is worldwide a well-known statement that applies to telemedicine in Tanzania as well. When physicians have to ask for information from the more knowledgeable specialists, a so-called power distance barrier arises. As the country has the lowest Gross Domestic Product in the region and provides limited opportunities knowledge is a valuable asset resulting in a tendency to withhold information, countering networking and knowledge sharing. Physicians asking a second opinion to a specialist are rather unusual. Physicians are supposed to be knowledgeable themselves. Asking for advice is can be considered as a failure.

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Gordon and Grant’s (2005) study of knowledge management literature reveals that journal articles that do mention power, treat it as unproblematic and conceptualize power as a resource which people may acquire and utilize to influence others. As mentioned in the evaluation report of IICD, several physicians felt discouraged in the way some of the specialists communicate. For example, specialists can react offensively if a physician forgets to include some important details about the medical case, which could prevent them from using the telemedicine tool again.

Next to this power barrier, cultural influences can also influence the individuals’ willingness to share. Holden (2002) states that the attitude towards knowledge sharing as well as actual knowledge sharing behaviour depends on the conditions that vary across cultural contexts. It differs from culture to culture how easy people are sharing with others.

In order to improve the sharing process and increase the amount of the shared medical files physicians and specialists have to collaborate and communicate actively about their activities. Carlile et al. (2002) argues that the practice based view of knowledge in organizations suggests that knowledge is localized, embedded and invested in practice. Based on this view, it is argued that knowledge is shared more easily when individuals collaborate in communities and networks around similar practices (e.g. Brown and Duguid 2001; Wenger et al., 2002).

2.4.3. Perceived usefulness and the implementation of telemedicine

A major challenge for the telemedicine projects in Tanzania is to overcome the fear of the unknown. At the same time, physicians are hesitating in taking up the new system because of the extra workload. This corresponds with the perceived usefulness determinant, which is especially important to the influence of the use of telemedicine. (Davis, 1989)

Hu et al. (1999) carried out a study to explain a physicians‘decision to accept the telemedicine technology in a health-care context. This research revealed that perceived usefulness has a significant and strong influence on physicians’ attitude towards the use of telemedicine.

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To encourage the use of telemedicine by individual physicians, the organizations management should emphasize the usefulness of telemedicine to the physicians (Chrismar & Wiley-Patton, 2003). The management should emphasize the benefits and should shore the physicians that the use of telemedicine would enhance the job performance. This could be done by showing that telemedicine could improve both the physicians’ daily work as well as the care they deliver.

2.4.4. Conclusion literature review

Literature revealed that the competences of physicians, fear about their personal reputation and the usefulness they perceive all affect the attitude towards the use of telemedicine. With regard to the concerns about competences, several causes influence the reluctance. Examples are a lack of any digital experiences or a limited educational background. Special training programs could help to overcome these problems. With regard to concerns about personal reputation, academic literature discusses a so-called power distance barrier. Physicians feel that they are supposed to be knowledgeable themselves. Asking for advice is often considered a failure. To overcome this fear it is important that individuals collaborate in communities and networks around similar practices to share knowledge more easily. Finally, with regard of the perceived usefulness, literature emphasizes that management should show physicians that the use of telemedicine will enhance job performance as well as the quality of their care.

3. Research design

In this section the methodology, data collection and limitations of this research are set out. The criteria reliability and validity are of great importance to safeguard the validly and reliability of the conclusions of this study.

3.1. Methodology

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3.2. Interview guide

The interview questions are prepared through a roadmap assuring that the interview questions are prepared in a structured and responsible way improving reliability and validity of the research. (Emans, 2004) Open questions in the interview is linked to the main research questions of the thesis ensuring that all data that needs to be collected is considered in the interview. The interview is in phases: Introduction, Explanation of the research and problem, Interview questions and Closure. The most important definitions of the research are elaborated on during the interview. The interview guide contributes to a uniform approach towards each interview.

3.3. Transcript analysis methodology

It is important to ensure that the input from the respondents is managed and stored well. Voice data is recorded and converted into a transcript. The data is converted into a data collection and analysis template. In the template, the respondents’ details are collected. The transcript will be analysed by colour coding. Colour coding takes place by two persons to bring a fresh perspective as this may confirm the themes. Information that is not relevant is discarded. Relevant answers are colour coded and transferred into the relevant cells of the collection template spreadsheet. After patterns are identified conclusions are defined. The results show up in a table showing the answers per theme using quotes of the respondents where possible.

3.4. Validity

A main advantage of this type of semi-structured interviews is that feelings and emotions can easily be observed. The internal validity is very high as respondents are able to talk about a topic in detail and in-depth. Discussed and clarification of complex issues is easy. External validity is less strong mainly caused by the small sample size. Justified generalization of findings is therefore not possible.

3.5. Reliability

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3.6. Data collection

The data collection takes place through three semi-structured interviews with experts in the field of telemedicine. Purposive sampling was used to identify the respondents. Selected took place based on their unique experiences in the field of telemedicine. IICD and Dr. Sol introduced them. The experts have years of experiences in several cases of telemedicine. Recording of the interviews takes place digitally.

3.7. Sample size

Academic literature offers several different opinions with regard to the exact number of interviews needed for a safe diagnosis in semi-structured interviews. In this study, a sample size of three structured interviews is used. Literature however shows that if semi-structured interviews are the sole source of information, a larger sample is required. Time and other resource constraints limit us.

3.8. Limitations

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4. Analysis and discussion

In this section, a discussion takes place about the results of literature review and field study. The next page contains a table that summarizes the results. A Discussion follows on the subsequent pages. The field data is based on interviews with field experts: Mr. John Paul Kaswija, Mr. Nic Moens, Mrs. Hilde Eugelink and Mr. Per Hasvold. The colours of the table rows are related to the highlighting in the interview transcriptions.

Colour / # Question / part

0 introduction / ending

1 Do concerns about competences play a role in the development of a reluctant attitude towards the use of telemedicine?

2 Do concerns about personal reputation play a role in the development of a reluctant attitude towards the use of telemedicine?

3 Do concerns about perceived usefulness play a role in the development of a reluctant attitude towards the use of telemedicine?

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4.1. Analysis

The questions that need to be answered in this paper are how concerns about competences, personal reputation and perceived usefulness play a role in the development of a reluctant attitude towards the use of telemedicine and how these attitude problems can be eliminated. In this section, the results of the literature review and field study will be adequately analysed and discussed. The table below displays the results of the research. The first column shows the number of the sub question and the relating colour to that question. In the transcripts of the interviews, the colours can be found back. The second column contains the four sub-questions. The third column shows the outcomes from the literature review. The outcomes of the literature review are compared with the outcomes of the field research. Columns four, five and six contain the outcomes from the three interviews with field experts.

Color

/ # Question

What makes physicians reluctant to use telemedicine according to

literature?

expert 1?

expert 2?

expert 3?

Nic Moens/Hilde Eugelink John Paul Kaswija Per Hasvold

1

How do concerns about competences play a role in the development of a reluctant attitude towards the use of telemedicine?

Limited educational background of physicians in remote areas

Introduce telemedicine to students, Use e-learning modules as a catalyst for other telemedicine tools. Integrate telemedicine in the daily routine. Include knowledge about telemedicine in the curriculum of universities to create more awareness for the need of teamwork in medicine. The fact that things are less organized gives room for experiments, but its makes embedding difficult. Emphasize on the concept of life-long learning.

They do not learn using computers at medical school. It is not part of the curriculum

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Page 19 of 49 Lack of digital basic skills.

The system is not very difficult to use. Sometimes, the typing skills are not sufficient, but that can improve over time.

Physicians can often use the computer, but system not easy to use.

People that are directly involved are skilled enough to use the system. When things go well, the actual services are not the problem, but whenever there are small problems, if something needs an update, or if something is not working then there is a lack of IT support and people simply stop using the tools. The day to day access to computers and day to day chance of gaining of general knowledge and gaining experience with computers is often missing

Lack of user training on the systems.

If people are trained to use the system, it is not difficult to use. The projects are very depending on the individuals involved. When the individuals leave or new people get brought in, they need to be trained too.

Often physicians do not receive a formal training.

2

How do concerns about personal reputation play a role in the development of a reluctant attitude towards the use of telemedicine?

Power distance between physicians and specialists.

Tension between specialists and physicians causes reluctance to ask for advice.

No problem with hierarchical power. Consultation is one of the routines in the medical profession

Dangerous to blame only culture, similar problem arise in Europe. It is difficult to distinguish between what is perhaps cultural and what is just a result of the way things are organized. Basic level of trust required

Feelings of embarrassment when asking for advice.

Ashamed of the way diagnoses are written. Asking for help is not conceived as a sign of strength by patients. Need to reconfigure identity

Physicians are not ashamed when asking for advice, consultations are routines

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Page 20 of 49 Cultural influences on the

willingness to share.

Acceptance of asking consultancy depends often on the subject on the level of difficulty. Consults from western physicians is less subject to attitude problems due to high personal involvement.

Physicians behave like professionals, they follow professional ethics.

In general, people are positive towards the new technology. In cultures where you do not have a basic form of trust, you need more time to establish trust between parties to share experiences.

3

How do concerns about perceived usefulness play a role in the development of a reluctant attitude towards the use of telemedicine?

Time limitations, heavy workload in hospitals

The system is in general perceived as useful; however, physicians should invest time in gaining experience using it. Often there is not enough time available to become familiar with the system.

Sometimes writing is more convenient then typing into the computer. There is not enough time to type information about every the patient in the computer.

The local hospitals have relatively extra work and investments, while the benefits lie at the specialists’ side. We often ignore the importance and the amount of time required and the number of cases that benefit.

Physicians perceive telemedicine as useful

The system is in general perceived as useful, but not everyone is exposed to the system.

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Page 21 of 49 Physicians perceive that

telemedicine improve the care they deliver

Benefit is often for the patient, less for the physician. Telemedicine does not yet fit into the existing organization of hospitals and the remuneration structure of physicians.

Often physicians do not know about the potential benefits. Physicians are not all exposed to see the benefits of the system. Not all parties involved benefit from the system equally.

The groups that bring sacrifices are often not the groups that benefit. Projects need to be maintained. It is important to establish not just trust, but also understanding of the totality of who would benefit and why it would be useful to establish such a service. Creating awareness of who benefits and who needs to do some extra work and why is important.

4 How can these attitude problems be _eliminated?

Training and education

Make IT skills part of the medical school curriculum. Introduce telemedicine to students. Use e-learning modules as a catalyst for other telemedicine tools. Integrate telemedicine in the daily routine. Include knowledge about telemedicine in the curriculum of universities. The projects are very depending on the individuals involved. When the individuals leave or new people get brought in, they need to be trained too.

Put computers usage and telemedicine into the school curriculum. Physicians should get training on using the computer tools.

Collaboration of individuals.

Teamwork is not enough part of the curriculum of medical Universities. Improve cooperation; create networks to share knowledge (Start with Study friends, old teachers, etc.).

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Page 22 of 49 Emphasize the usefulness of

telemedicine

Management should learn what the impact of telemedicine is on hospital performance. Telemedicine should be part of the existing organization of hospitals and the remuneration structure of physicians.

The management should learn what the impact of telemedicine is on hospital performance. If they know the importance of telemedicine, they will facilitate the implementation and they will promote it. Implementing a telemedicine system requires support from all parties. Therefore, they should target not only the users but also the decision makers. They all should benefit.

The groups that bring sacrifices are often not the groups that benefit. Therefore it is important that physicians get understanding of the totality of who would benefit and why it would be useful to establish such a service. Creating awareness why this system is important and why they should use it.

Telemedicine does not yet fit into the existing organization of hospitals and the remuneration structure of physicians. Introduce (financial) incentives.

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4.2. Discussion

In this section shows a comparison between the outcome of the literature review and field study. The question in what way concerns about competences, personal reputation and perceived usefulness play a role in the development of a reluctant attitude towards the use of telemedicine and how these attitude problems can be eliminated will be answered. Answers to the questions came initially from the literature review and formed the base for the semi-structured interviews.

How do concerns about competences play a role in the development of a reluctant attitude towards the use of telemedicine?

With regard to competences three issues play a major role in the formation of attitude toward telemedicine in literature: The limited educational background of physicians and nurses in remote areas, lack of digital basic skills and finally, lack of user training on computers. The field experts consider not all of these issues a problem. Experts argue that one important cause of a reluctant attitude towards telemedicine is the lack of IT education in the curriculum of the medical universities in the past. Secondly, physicians in remote areas are exposed less to computers and IT technology than their counterparts in more leading city hospitals. Experts argue that there is a gap of knowledge between international specialists in high-tech academic clinics and the physicians in local hospitals.

The lack of digital basic skills is a problem according to literature, but field experts considered it a smaller issue. According to the experts, telemedicine systems are not very difficult to use. Experts mention that the typing skills are often not sufficient, but that these improve over time. According to the field experts, physicians in remote areas are often very well able to use the computer. A main challenge mentioned by field experts are the lack of general IT support personnel in remote areas. If something needs an update, or if something is not working well then there is a lack of IT support and people stop using the tools.

Experts argue that lack of user training on the systems is depending on the individuals involved, but also on the accessibility to computers. The day-to-day access to computers and day-to-day chances for gaining general knowledge and gaining experience with computers is often missing. Experts see in the fact that things are less organized an opportunity that gives room for experiments, but it also makes embedding of the tools in daily routines more difficult.

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How do concerns about personal reputation play a role in the development of a reluctant attitude towards the use of telemedicine?

With regard to the fear for personal reputation damage, three issues play a major role in the formation of attitude toward the introduction of telemedicine according to literature: The power distance between physicians and specialists, the feelings of embarrassment when asking for advice and the cultural influences on the willingness to share. Experts do not consider all of these problems a real issue. Experts particularly do not share the opinion of literature with regard to the tensions between specialists and physicians as a cause for reluctance to ask for advice. Some argue that there are no problems at all with hierarchical power and that consultation is one of the routines in the medical profession. Others claim that patients do not conceive asking for help as a sign of strength and that this is the reason why physicians are therefore reluctant to ask for advice in some cases. Reluctance because of fear for personal reputation damage all seems to depend on the way things are organised. Some local physicians are ashamed of the way they formulate diagnoses, but it is difficult to distinguish between what is perhaps cultural and what is just a result of the way things are organized. All experts think that the establishment of confidence between the partners is required first. There should be a clear understanding on how to make use of each other’s skills. A basic level of trust is required. Acceptance of asking consultancy depends often on the subject of the level of difficulty. Sharing information and collaboration between the different levels of health care is less common and more difficult in many developing countries. In cultures where a basic form of trust is missing, there is need for more time to establish trust between parties to share experiences. Experts argue that the way physicians see themselves as all-knowing does not contribute to the use of telemedicine. To improve knowledge sharing physicians have to see themselfes as part of a larger team instead of operating indendently. Collaboration between different levels of healthcare is required and the awareness that physicians are not all-knowing individuals but part of a larger multi-disciplined team starts at university.

How do concerns about perceived usefulness play a role in the development of a reluctant attitude towards the use of telemedicine?

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However, experts argue that the lack of exposure to the system reduces the perceived usefulness. Although the system is in general perceived as useful, it is clear that physicians should invest time in gaining experience using it. Sometimes writing is simply more convenient than typing data into the computer. There is not enough time to type information about every the patient in the system. According to the experts, the amount of time required and the number of cases that really benefits is often ignored.

Literature claims that it is important that physicians are aware of the fact that telemedicine improve the care they deliver. Experts see that there is not enough involvement of all relevant parties to acknowledge the proposed benefits. The groups that bring sacrifices are often not the groups that benefit. Not all parties involved benefit from the system equally. Implementing a telemedicine system requires support from all parties targeting not only the users but also the decision makers. It is important to establish not just trust, but also understanding of the totality of who would benefit and why it would be useful to establish such a service. Creating awareness of who benefits and who needs to do some extra work and why is important.

How can these attitude problems be eliminated?

Academic literature offered a number of solutions to how to change attitude in a way that reduces reluctance with regard to telemedicine. Although some of the solutions may sound self-evident, they can be very effective. Literature argues that arranging training and education, organizing collaboration of individuals and emphasize the usefulness of telemedicine will help to implement the telemedicine project to a next level.

Most experts in the field acknowledge the effect of these solutions. With regard to the educational background and training experts, agree that developing IT skills should be part of the medical school curriculum. In addition, training on the telemedicine system of physicians is required. Experts argue that these skills need to be maintained within the hospital. When individuals leave or new people are brought in, they need to be trained too.

Experts argued that bringing people together, collaboration and creating networks would affect the use of telemedicine in the positive way. In addition, champions are needed; people who are brave enough to start sharing. Moreover, all experts mention that exposure to the system is very important to perceived usefulness of telemedicine.

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5. Conclusions, recommendations and limitations

The purpose of this research is to find solutions to reduce the reluctant attitude of physicians in the rural areas of Tanzania in order to increase the use of telemedicine. In this section, we conclude. Recommendations will be done to improve the attitude of physicians with regard to telemedicine. Finally, the limitations of this research are described and recommendations for further research are mentioned.

5.1. Conclusion

Three major aspects influence the attitude of physicians: concerns about competences, concerns about personal reputation and concerns about perceived usefulness.

Firstly, regarding to concerns about competences the major obstacle as stated in the literature and mentioned by experts is the limited educational background with telemedicine systems. Physicians in remote hospitals are not exposed to using e-health systems at medical school. It has not been part of the curriculum. Although, the telemedicine system is not difficult to use, user training on the system is required.

With regard to concerns about personal reputation, it can be concluded that a power barrier exist between physicians and specialists. Some physicians are embarrassed to ask for advice and patients do not conceive asking for help as a sign of strength. Culture influences can also affect the physicians willingness to share, but it is difficult to distinguish what is cultural and what is a result of the way things are organized. A change of the position of physicians within the healthcare system is required, which includes a change in the way physicians see themselves as a part of a larger team.

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5.2. Recommendations

In this chapter, recommendations to improve the attitude of physicians to increase the use of telemedicine are proposed. Because challenges exist at different organizational levels, recommendations are not limited to the position of a physician.

In order to make more use of the telemedicine, physicians need to be competent enough in using the system. Working with telemedicine systems should be integrated in the medical school curriculum. Physicians need to be trained in using the system. It is important that the knowledge about the system is maintained. If physicians are leaving, or new people are brought in, the knowledge of using the system should be handed over.

Physicians need to be more exposed to telemedicine to improve the perceived usefulness. In addition, it is recommended to make physicians aware why they have to put some extra time and effort in their job and what are the benefits of this. Since the benefit is often not for the physician, the introduction of (financial) incentives may help to stimulate the use of telemedicine.

Telemedicine should be integrated in the daily routines of physicians to improve the adoption. In order to make it a success, telemedicine should be made part of the system. Apart from more exposure, the developers of the system should make sure that all parties involved benefit from the system to get full support for the implementation. Implementing a telemedicine system requires support from all parties. A change of the position of physicians within the healthcare system is required, which includes a change in the way physicians see themselves as a part of a larger team. Their position should change from an ‘all-knowing physician’ to a member of a larger team of multiple disciplines. The emphasize should be on cooperation and integration.

The focus should be on bringing people together and let individuals collaborate in networks in order to increase the willingness to share. At the same time, telemedicine should be integrated in the daily routines of the hospital.

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5.3. Limitations and recommendations for further research

The study does have several limitations. Apart from earlier mentioned issues with regard to internal and external validity as well as reliability, the study is limited in scope. Making general conclusions on how telemedicine projects should be implemented remains very difficult. Differences arise among countries, cultures and projects. There was no opportunity to actually visit projects on site. All information was second or even third hand. At the same time, the number of interviewed experts was rather low. Internal en external validity as well as reliability can be improved with more respondents and the use of special software tools to evaluate qualitative interviews in a more structured way.

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6. References

1. Brown, J.S., & Duguid, P. 2001. Local Knowledge: Innovation in the networked age.

University of California.

2. Østerlund, C., & Carlile, P. 2002. How Practice Matters: A Relational View of Knowledge Sharing.

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Appendix Interview 1

Color / # Question / part

2 Do concerns about personal reputation play a role in the development of a reluctant attitude towards the use of telemedicine?

3 Do concerns about perceived usefulness play a role in the development of a reluctant _{attitude towards the use of telemedicine?} 4 How can these attitude problems be eliminated?

Name: John Paul Kaswija

Position: Master in Internal Medicine, Muhimbili University, Dar es Salaam, Tanzania Date: 06/05/2013 – 19.30h

Good evening, do you hear us? Yes, I can hear you! We are Paul and Esther from the University of Groningen, and we are doing a project with Dr. Sol, He introduced us to you, because we are doing a research thesis in the field of telemedicine and he said that you are very experienced in this field. Yes! Did you read our mail about our project?

Yes I’ve seen it! We are wondering what your experiences are in the field of

telemedicine. Not Much! But sometimes I do consolations through mobile phone. What is your position in the field of telemedicine? Are you a physician, specialist or consultant? I’m a specialist. We will ask you a number of questions about telemedicine. We don’t know if you are familiar with everything, but if you have questions, please let us know. Yes ok. I know something about it. I think telemedicine can help improving

medical services in terms of quality, efficiency, effectiveness if well planned. Do you

know IICD, the organization that introduced a telemedicine program in Tanzania? Yes,

I read about it and I know about it through professor Henk. It is a project for Tanzania en Zimbabwe, I think. There are various experiments in various hospitals in Arusha, in Kwanza, Kagera in Tanzania. They are implementing things like health information services, medical information systems. Can you maybe tell something about what your

own experiences are with regard to telemedicine? Experience, not much. I’m not that

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are advanced in terms of having digital medical records also, they can access lab results via the computer. Clinics in the world can access this data. The remote hospitals cannot access it. In the other remote centers, they are however using electronic health reports in Tanzania. In a leading hospital in Dar Es Salam, there is a pilot program in collaboration with two universities in the U.S. They are implementing a system with which you can send x-rays from remote hospitals to specialists. After analysis by a specialist or a radiologist, the results are sent back and the patient is treated.

What are your experiences with the use of this system? This is a good service.

Especially for people that can only access hospitals with few specialists. What kind of

problems did you discover with regard to the use of these systems? Sometimes there are

failures. Like there is no internet connection? Like technical problems? Yes, if there is no internet connection, the requests cannot be transferred. Sometimes you cannot reach the specialist. Does every physician have the competences to use the system? No, very few. Is it that complicated? Well, they can use the computer, but the system is not easy to use. In the university hospital, all physicians know how to use it, but that is a university hospital in Dar Es Salam. Even the nurses know how to use the system over there. But in the other centers, I don’t know. What about the attitude of the physicians?

Are they willing to use the system? Alternatively, do they prefer just to use the traditional way? That depends on the situation. For instance, if the physician looks for

specific patient information, when they see a patient in the clinic, instead of writing a lot, they can find the information in the computer. But sometimes writing is more convenient then typing into the computer.

Why do you think that they prefer the normal way sometimes? First of all they are not

used to this. They do not learn using computers at medical school. It is not part of the curriculum. But they are trying to put it into the curriculum.

Some know how to use it, because they know how to use the computer. They should get training in that. If you work in the clinic, it is very busy. There is not enough time to type the information about every the patient in the computer.

Do you also think that physicians in the rural areas feel ashamed to ask specialist for advice? No, I do not think so. Consultation is one of the routines in the medical

profession. So you don’t think that there is a hierarchical power between specialists and

physicians? No, I think it is not there. Physicians behave like professionals. They teach

you ethics in medical school. They should follow professional ethics. But if they don’t

feel ashamed, and they are competent, so why do physicians don’t use it that much?

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But in most cases they are trained to use the telemedicine system. In the project of IIDC, they trained the physician’s right? Yes in areas where they use the IICD program, yes, I

think they train them. But in your example that the physicians were not trained? Well, for instance, even in my case, I never got any training on using the information system. Sometimes I’m writing proposals about this subject, but that is because of my personal interest. I don’t have any formal training in that

Do you think that physicians know that telemedicine can enhance their job performance?

Only few know that. Because if somebody is exposed to telemedicine, yes then they know that. But if someone doesn’t know anything about it, how can he know.

What do you think governments and hospital management can do to improve the situation with regard to the use of telemedicine?

The management should be oriented. When I say oriented, I mean, they should be informed and get more information on telemedicine. They should learn what the impact of telemedicine is on hospital performance. If those medical administrators know the importance of telemedicine, they will facilitate the implementation. Then it will be promoted. But, people are never exposed to telemedicine, than they cannot make any correct decision about it.

What about the technical problems: the internet, and usage?

Well, internet is not that much of a problem. The national government tries to get fiber optic cabling in every region now. This will make high speed internet available. In Tanzania, the goal is to get internet available through fiber optic connections. This is currently underway. Sometimes when the internet is not working well, they can access the internet though their smart phones. In most of the health centers, and hospitals, they have wireless internet though a modem now. Access is possible through various service providers. With regard to internet accessibility, you cannot compare the situation now, with three years ago. It is relatively well available. Accept for some rural areas. There is no electricity over there. That is a main challenge.

Summarized: When people are exposed to telemedicine, and they know that it can improve their job performance then they will use telemedicine that is the most important thing? Yes, that is very important

But I thought that some physicians did not use the internet, because it is too time consuming for them? Yes, as I said, if you are treating many patients, there is no time to

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But again, information will only help you if it is useful. For example, an electronic health care record system should help the physicians and nurses, not only the administrators. The developers of the system should make sure that all parties involved are supported by the system to get full support for implementation. Implementing a telemedicine system requires support from all parties. So they should target not only the users but also the decision makers. All should benefit. Do you have any questions to us?

Our research is about the attitude of physicians towards the use of telemedicine in terms of personal reputations, perceived usefulness and competences. We are doing interviews with a number of experts in the field of telemedicine and analyze the data and then we make some recommendations for improvement. Maybe we can email the final report to you if you like. Yes, that would be ok. If we have any more questions, can we send you a quick email? Yes, no problem.

If you look at the concerns about the perceived usefulness, as I said, if someone is exposed to the telemedicine, they will see the advantages. But, you talk to a lot of physicians. I think it would be good idea to try to speak and get information from hospital administrations or managers to get views from their perspectives. It is important to find out if they speak the same language with regard to telemedicine as the operators. That would be nice,

That is possible I think. Yes, you should ask for their views. When you ask if

telemedicine will increase productivity then I’m wondering here, what is meant in terms of productivity? It’s more that the physicians and specialists think whether their job

performance will be better if they use telemedicine. That’s with regard to perceived usefulness. Productivity is more abstract. We focus on the perspective of the physicians and the specialist. We wonder if they consider the telemedicine as an advantage. Ok,

that’s nice, that is about the operations. We don’t expect that the conclusion of our thesis

will be that productivity will be higher with telemedicine. Ok, but the challenge is what

is productivity. Are you meaning that productivity is seeing more patients, doing more consultations, how do you measure for productivity? I mean, do you measure how many entries are made into the computer? That is the challenge. How to measure productivity? Because you need to measure the quality of the service provided.

You should not just look at the number, but at the actual service that is provided to the patient. From a telemedicine perspective, how do we improve this productivity now with telemedicine? But I also think, if you are competent to use the system and the computer,

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help and for your time, and if we have finished our thesis, then we will send you a copy

of the report to you. If we have any more questions, we will send you an email ok? Yes that will be fine. Feel free to contact me any time. Ok, thanks for your time. Have a nice

evening. Same to you, hopefully, this information will help you to make the best thesis.

Appendix Interview 2

Color / # Question / part

2 Do concerns about personal reputation play a role in the development of a reluctant _{attitude towards the use of telemedicine?} 3 Do concerns about perceived usefulness play a role in the development of a reluctant _{attitude towards the use of telemedicine?} 4 How can these attitude problems be eliminated?

Name: Nic Moens & Hilde Eugelink

Position: IICD, Principal Advisor, Manager eHealth programs, Lecturer, Sector Developer Health / Community Relations at IICD

Date: 06/05/2013- 14.00h

Met betrekking tot de fase waar het project zich nu in bevindt geeft de heer Moens het volgende aan: Er gebeuren twee dingen:

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Vaak als ‘champions’ rondgaan voor een project dan zie je het aantal consulten weer omhoog gaan. Mensen worden weer enthousiast. Als dat dan weer een tijdje geduurd heeft zie je dat terugzakken. Dus dat is het eerste probleem met deze hele setup.

Een tweede punt is hoe je dat dan beter geïntegreerd krijgt. Denken aan oplossingen om een betere referral chain te krijgen. Dus dat betekent dat je het met een kliniek of met een gespecialiseerd ziekenhuis. Dat vereist nogal wat organisatorische activiteiten. Voorbeeld is om het ziekenhuis bij Kilimanjaro als gespecialiseerde unit nemen. Dit proces loopt echter nog steeds wat moeilijk omdat er een aantal issues zijn. Één daarvan is omdat de verwachting van het ziekenhuis bij Telemedicine en veel klassieke modellen is dat je een verbinding hebt tussen bijvoorbeeld Groningen en Amsterdam en daartussen wissel je informatie uit en dat is vaak high-level, dat zijn specialisten die met elkaar praten. Je kunt daar meekijken met die operaties en dat is een beetje het beeld wat er is. Dit project is precies het omgekeerde. Dit is klein, kleinschalig. Dus dat past niet altijd bij de verwachtingen van specialisten op high level. Tweede issue: ziekenhuis is groot, organisatorische vragen. Speelt enorme spanning tussen geneesheer-directeur en andere directeuren. Daar is een aantal mensen ontslagen. Veel gedoe. Dat stopt ook eigenlijk dit proces.

Derde ding dat lastig is en veel tijd kost is om het goed geïntegreerd te krijgen in het national health insurance fund. En dat is niet zozeer omdat dit fund absoluut niet wil, maar ze vragen zich af wat het is, wat het gaat betekenen voor hen. Het type kosten dat een dergelijk fund voor zich heeft en voor zijn rekening neemt zijn patiënt behandelingen en dat soort zaken. Met Telemedicine, als je dat zou betalen, blijft dat dus hetzelfde, daar schiet je niet zoveel mee op. Voor de patiënt echter een groot voordeel: minder reizen. Maar dat betaalt de verzekering niet. Op die manier heb je allemaal van dat soort dingen, los van allerlei regelgeving etc. Een kleine groep in Tanzania is maar verzekerd, maar dit zet het signaal. Het geeft het signaal voor het ziekenhuis van hoe het zou kunnen werken.

Een tweede beweging die je er in zou kunnen maken is dat je het onderdeel maakt van het functioneren van het ziekenhuis zelf, ook financieel en dan heb je daar twee of drie groepen. Private ziekenhuizen, met koopkrachtige mensen en een goede manier van service. Daar zou dat passen

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Artsen gaan wel één keer in de twee weken minimaal van gespecialiseerd ziekenhuis naar een ander hospitaal. Daar helpen zij een bepaald soort gevallen. Dat zou zich lenen voor Telemedicine binnen het bestaande systeem. Dat betekent dan dat je eigenlijk die mensen van het bezoek aan het ziekenhuis weer weghaalt om Telemedicine te doen, wat natuurlijk wel handig is voor die artsen. Maar minder goed voor het hele systeem. Dus dat is allemaal niet zo makkelijk. Al dit soort mens-dingetjes maken het lastig. En je moet het allemaal onderdeel maken van de organisatie, van het ziekenhuis, het management, van het beloningsbeleid. Artsen zijn vooral in de publieke ziekenhuizen vrij strak. Ze werken in shifts van 8 tot 3, en dan zijn ze om drie uur ook weg. Want als je langer blijft komt alles wat er nog over is allemaal naar jou toe en je hebt geen recht op overuren. Ben je eenmaal weg en ze halen je terug, dan moeten ze je betalen. Een aantal van dat soort dingen.

Ik denk wel dat ons onderzoek zich richt op het eerste probleem dat u schetst, op het daadwerkelijke gebruik van ipath. Want wij richten ons voornamelijk op de attitude van artsen en misschien heeft u het al gezien, hebben we een driesplitsing gemaakt. De perceived usefulness wat u zei, over het bewustzijn van het daadwerkelijke nut ervan. En competent zijn met het gebruik van het systeem en de personal reputation van artsen. Drie problemen die we uit de rapporten hebben gehaald, waardoor het toch minder gebruikt wordt. Want jullie wilden 100 consults per week, dit is niet gelukt. Ik weet niet hoe het nu staat? Nee weet ik ook niet precies. Het zijn er zeker geen 100 per week. Dat is ook heel lastig, op een gegeven moment loopt het bijvoorbeeld tussen een kliniek en een ziekenhuis, want dat is hun kliniek en dat is handig voor het gebruik. Maar om dat allemaal op te lossen, moet je eigenlijk die factoren die ik net schetste, oplossen.

Het enige wat echt helpt, is het aantal structurele, financiële, organisatorische en beleidsdingen aanpakken. Dan komt het op gang. Dan is het onderdeel van het systeem. En daarbinnen houd je natuurlijk deze beperkingen. Dit is naar mijn idee de context.

Zoals u al zei, was ICT niet het grootste probleem? Nee, techniek is niet echt het probleem. Ow, want wij hadden wel anders begrepen uit de rapporten. Dat mensen niet

eens konden typen. Nou dan krijg je dus, dat zijn puur technische problemen, met

verbinding etc, maar dat is niet het grootste obstakel. Een ander verhaal is natuurlijk als je type skills niet geschikt zijn, dan kost dat veel tijd. Je moet er echt achter gaan zitten, je moet toegang hebben tot de computer , je moet ook wil laten zien aan anderen. Al dat soort dingen. Maar strikt technisch genomen is de techniek ok. En de competenties met

het gebruik van de techniek van ICT, is dat ook ok? Ja dat gaat goed, je moet ze even

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mensen zeggen dat ze het niet doen omdat ze het lastig vinden dan kost het teveel tijd en

dan doen ze het uiteindelijk niet. Ja dat kan liggen aan de toegang die je hebt tot de

computer, het gemak ervan. Of hoe goed je kunt typen natuurlijk. Als een computer natuurlijk een uitzondering is, in jouw hele werkstroom, dan maak je er natuurlijk veel minder gebruik van.

Maar is het ook niet zo dat we met een iets jongere generatie artsen werken? Ja dat gaat wat makkelijker, maar dat loopt ook wel door elkaar heen. Want die champions zijn ook eigenlijk wel de oudere artsen. Ja want werken jullie op die manier? Één iemand die

traint en die moet dan stokje doorgeven aan de rest van de dokters? De wijze waarop ze

het doen is ze gaan naar ziekenhuizen, ze praten daar, en degenen die het interessant vinden komen naar voren. Het idee is heel mooi van het stokje doorgeven, maar het gebeurt nauwelijks. ja want die champions werden echt ingezet in de tweede fase toch? Ja omdat het het gevoel had van dat praat makkelijker. Het zijn artsen zelf, die doen dat en dan horen ze van collega’s hoe die dat doen. En dat werkt wel wat beter.

Merkt u ook dat artsen niet altijd bereid zijn om andere artsen advies te vragen? Ja daar word verschillend over gedacht. Één gedachte is dat ‘ik heb daar voor geleerd, ik hoor dat te weten’, dus dat is niet zo handig als ik een ander vraag. Sommigen vinden dat ook in de perceptie van de patiënt. Als de dokter een boek pakt is dat een beetje dom. Anderen zeggen ja dat kan wel heel goed zijn. Het is heel dubbel eigenlijk. Ik denk over het algemeen dat het eerste het sterkste is. Als artsen zeggen ‘ik weet het eigenlijk niet, ik ga het eens vragen’, komt iets minder over. Ik denk ook dat het aan omgeving ligt, aan bijvoorbeeld urbane gebieden, met rijkere mensen die meer educated zijn, komt dit makkelijker over. Want is er zeg maar een power barrier tussen dokters die in die rural

areas zitten en de specialisten die ze dan eventueel om advies moeten vragen? Ik denk

het wel. In Nederland beschouwt een specialist een huisarts toch als een kneusje, eerlijk gezegd en dat zal daar exact hetzelfde verhaal zijn.

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Het is een kwestie van attitude. Ook een kwestie van voorbeelden die men noemt is, als ze iets hebben bellen ze een collega, een vriend, of een oud – docent van een universiteit. Dat soort netwerken heb je dan. Dat is trouwens een andere vorm van Telemedicine omdat het artsen met een gratis telefoon, of gratis air-time gekregen. Dan kunnen artsen elkaar makkelijker consulteren. Is wel een aardige vraag om naar te kijken, gaat dat makkelijker met sms’jes. Ik kan me wel voorstellen dat dokters zich een

beetje schamen en daardoor minder vaak hulp inschakelen. Ja, dat kan, maar dat zal niet

met iedereen zijn dus je zit steeds weer met gradaties, en wie en waarom, doet men iets.

Ik had ook gelezen dat specialisten zich onbehoorlijk opstellen tegenover die dokters dan, alsof ze minder zijn. Daar heb ik niet zo veel over gehoord. Wel dat men soms

komt met bepaalde therapieën die gewoon niet haalbaar zijn in die context. Dus dat je een medicijn voorschrijft waar een lokale arts gewoon niets mee kan, want die heb je daar niet. Dat soort adviezen. En dat hoort een specialist dan ook te weten? Ik denk het wel, en in dit soort netwerken, de voorkeur gaat dan ook naar artsen, Amerikanen of Nederlanders bijvoorbeeld die dat doen, dat die ook zelf in die landen gewerkt hebben. Die inzichten in wat speelt daar allemaal, wat gebeurt daar, en wat is reëel. Ja ik denk ook wel dat er een verschil is tussen specialisten in Tanzania en in het westen. Ja ik denk niet qua vakkennis, in het westen heb je toch vaker mensen die wat meer tijd hebben, bijvoorbeeld die in hun studententijd een tijdje daar gezeten hebben, grote mate van betrokkenheid voelen en daar graag iets mee willen doen. En die dat leuk vinden en die dat leuk vinden ja, die daar structureel tijd voor maken. Want het is geheel vrijwillig

toch. attitudes en dergelijke is toch een vrij ondergeschikt ding, maar waar wel aandacht

aan besteed moet worden in het change management proces. Maar uiteindelijk, als het iets geaccepteerds is als idee, dan zie je het change management proces snel gaan. Wat wel zo is, is dat wanneer je dit soort systemen vrijblijvend houdt, want dat is natuurlijk leuk voor die mensen, kunnen ze beetje proeven enzo.. ideeën over opbouwen. maar als je het gaat verplichten moet je de opleiding van artsen, welke toch een relatief klassiek ding is, met veel nadruk op procedures, als men met ICT op deze wijze gaat werken dan krijg je wel dat artsen heel anders naar hun eigen vak moeten gaan kijken. Dan krijg je heel veel vragen waar jullie mee bezig zijn, die heel relevant worden. want wat is dan de attitude. En hoe vervang ik dan het idee van ik ben een one-stop physician die alles weet naar ik ben toch een team work en ik moet het best geven aan de patiënt. Dat zijn natuurlijk ander soort gedachten die niet standaard in het onderwijs zit. Maar als je het

Telemedicine in Rural Areas

Telemedicine in Rural Areas

Finding solutions to change the attitude towards the use of

telemedicine

Telemedicine in Rural Areas

Finding solutions to change the attitude towards the use of telemedicine

Abstract

Keywords:

Acknowledgements

Table of Contents

1. Introduction

2. Research framework

2.1. Conceptual framework

2.2. Concepts & definitions

2.3. Research questions

2.4. Literature review

2.4.1. Competences and the implementation of telemedicine

2.4.2. Personal Reputation and the implementation of telemedicine

2.4.3. Perceived usefulness and the implementation of telemedicine

2.4.4. Conclusion literature review

3. Research design

3.1. Methodology

3.2. Interview guide

3.3. Transcript analysis methodology

3.4. Validity

3.5. Reliability

3.6. Data collection

3.7. Sample size

3.8. Limitations

4. Analysis and discussion

4.1. Analysis

4.2. Discussion

5. Conclusions, recommendations and limitations

5.1. Conclusion

5.2. Recommendations

5.3. Limitations and recommendations for further research

6. References

Appendix Interview 1

Appendix Interview 2