Background
Telemedicine, or care provided across spatial and/or temporal distance, is often touted as a solution to the critical dilemma posed by a rapidly expanding aging population in countries with inadequate healthcare infrastructures. In ophthalmology, telemedicine is well-validated and widely accepted in diabetic retinopathy screening [
1], and more recently has found traction in glaucoma monitoring [
2‐
5], retinopathy of prematurity screening [
6,
7], macular degeneration screening [
8,
9], and comprehensive ophthalmology [
10]. Increasingly inexpensive and ubiquitous technologies, expanding computational power, and surging demand for limited healthcare resources are all pressures that have contributed its popularity. The SARS-CoV-2 pandemic has further accelerated popular use in part due to expanded reimbursement [
11], as well as encouragement on the part of governing bodies such as the American Academy of Ophthalmology.
Early data highlights teleophthalmology’s potential to reduce volume burden on clinics, travel burden on patients, and increase access to care for rural, impoverished, and otherwise vulnerable patients [
12‐
14]. Data also suggests teleophthalmology is well-accepted by patients and providers [
15‐
17]. Randomized controlled trials, while limited in number, suggest increased adherence to recommended frequency of diabetic eye exams [
18], improved attendance at follow-up visits [
19], and no significant difference in visual outcomes or delay to treatment compared to usual care [
20]. Pooled sensitivity and specificity for classification of diabetic retinopathy in teleophthalmology were found to be over 80% and 90% (respectively) by a meta-analysis [
21]. The United Kingdom successfully integrated store-and-forward telemedicine into its National Health Service Diabetic Eye Screening Programme in 2003. By 2010, Liew reported that diabetic retinopathy had been stripped of its 50-year reign as leading cause of blindness in working-aged adults [
22]. By 2018, nearly 83% of eligible individuals were being screened annually [
23].
Despite its promise, widespread adoption of teleophthalmology has yet to occur across the public and private sector in North America. This may be attributed more to practical realities of implementation and operation than to its potential utility. Organizational Readiness theory argues that implementation of novel models of healthcare delivery relies on a collective commitment to, and confidence in, the ability to create and sustain organizational change [
24‐
26]. Overcoming resistance and other barriers becomes particularly important as the technology in question reaches the “tipping point,” [
27] after which the most influential stakeholder is no longer an early adopter focused on and invested in the technology. Instead, the influence shifts to the public, who is most concerned with practical integration to real life [
12]. For this reason, understanding how key stakeholders perceive the innovation is critical to facilitate meaningful implementation and long-term sustainability [
28]. This effort to characterize individual determinants of implementation outcomes falls within what is known as a “determinant framework” of implementation science and is a potentially useful antecedent to successfully executed implementation strategies [
29]. Using a multilevel determinant framework [
29], this study elicited insight from patients, providers, and staff critical to the implementation and early operation of a comprehensive teleophthalmology clinic in an effort to identify remaining unmet needs and eventually facilitate long-term sustainability. At the time of publication, only one other study exploring obstacles perceived by teleophthalmology clinic staff existed [
30].
Discussion
As Lorenzi notes, the most effective, beneficial, cost-saving new technology can be “brought to its knees” by stakeholders with a low sense of ownership, confidence or investment in the new system [
43]. This study identified potential hindrances to teleophthalmology implementation through summative content analysis using a determinant framework of implementation science. Factors important to stakeholders included ongoing hands-on training with formative feedback, transparent organizational structure, clear bidirectional communication, and dedicated support staff.
Training was brought up extensively throughout interviews, marking the topic as critical to stakeholder investment. Technicians wished for more extensive hands-on training with formative feedback, administrators for clearer blueprints for operations, and physicians for clearer instructions. Ongoing training for all team members was also identified as a particularly important topic by Ramchandran et al. [
30] Substantial evidence supports the utility of formative feedback, defined as specific, timely, supportive, information conveyed to the learner in response to an action with the intent to modify the learner’s thinking or behavior, in the development of procedural and motor skills [
44]. Administrators whose responsibility included securing funding and space identified the need for “blueprints” for success, or advice from more experienced peers. This group may benefit from structured peer mentoring and support. Physicians wished for more guidance by way of a clear protocol to follow when uncertain. Similarly, administrators expressed need for a “super user” available to assist during site opening. Project managers remaining available during Go-Lives is a common feature of many health technology products.
Miscommunication and insufficient buy-in led to issues ranging from safety hazards to a hostile work environment. Stakeholders felt they could not identify how their role fit into the larger picture, and did not have a good understanding of the full clinical process. Better training, transparent organizational structure, and clear bidirectional communication may address these concerns. Fostering a culture which regularly seeks feedback and acts upon it is especially important to successful implementation; feeling heard and empowered is critical to buy-in [
45‐
47]. Although likely situational, others may still learn from the description of hostile sentiments towards TECS occupants of CBOC space for future planning. Interviews revealed misunderstanding and mistrust of TECS:
T350010: “The people on the frontlines … they don’t know who you are or what you’re doing or why. Get down to the grassroots…the people that are going to check [patients] in for you…[get] them on board before you start.”
Reaching out before site launch to let occupants of the incoming space know what the clinic is and how important the current occupants are to the mission of providing vision-preserving care to our vulnerable veteran population may ease misunderstandings.
Limitations
Limitations of this study include the use of convenience sampling, non-standardized questions across groups, and unequal numbers of participants in each stakeholder group. Similarly, demographic data was not collected thus limiting contextual grounding of our results. In addition, by following summative qualitative methods, the opportunity to perform a mixed methods or quantitative analysis was missed. The hostility felt by CBOC staff was unexpected, thus the authors were unable to secure interviews with non-TECS parties; however, other health professionals sharing CBOC space with TECS stakeholders should be included in future quality improvement research in order to better understand relational obstacles.
Conclusions
Using a determinant framework of implementation science, this study identified several factors important to stakeholders, including ongoing hands-on training with formative feedback, dedicated support staff, transparent organizational structure, and clear bidirectional communication. Looking forward, meeting these needs has the potential to increase access to screening, improve the quality of care provided, and facilitate sustainability of the innovation.
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