Background
Approximately 40 million people worldwide require palliative care each year, and yet, less than 15% of these individuals currently receive it [
1]. The increasing aging population and growing prevalence of chronic conditions will continue to drive demand for palliative services [
2,
3]. The COVID-19 pandemic has created a rapid surge in demand for remote palliative care services that will require rapid scale up [
4] and minimize both patients’ and providers’ exposure to the virus. Considering the urgent need and likely long-lasting impacts of the pandemic, the need for remote palliative services will exist both in the short- and long-term. Outside of a pandemic, meeting the palliative needs of the population is key to reducing prolonged suffering related to the burden of living with life-limiting illness [
5] and reduced quality of life [
6]. In light of the growing international demand for palliative care [
7] and the significant health and financial consequences associated with unmet palliative needs, health technologies have been explored as an opportunity to support palliative care delivery [
3]. The utilization of health technologies to enable and support the provision of health services and the transmission of health information is referred to broadly as telehealth [
3]. In this paper, the terms, “telehealth” and “health technologies” will be used interchangeably. Telehealth enables electronic modes of communication between patients and the care team (e.g. video visits, audio connections), and remote symptom monitoring and assessment [
3]. Research demonstrates that telehealth can help improve symptom management and quality of life, decrease health care costs [
8‐
11], and reduces risk of disease transmission due to decreasing direct contact [
12].
A number of systematic reviews of research on the application of telemedicine in palliative care have been conducted [
13‐
16]. Some studies demonstrated its feasibility [
15,
16] and provided some evidence of its effectiveness for improving quality of care, documentation, cost, and communication in palliative care [
13]. Others have focused on users’ information needs [
13], patient-reported health outcomes [
14], patient satisfaction, and health care use [
15]. Health technology
acceptance, however, has not been extensively explored within the context of palliative care specifically, despite the fact that studies have shown that acceptance acts as a key variable influencing technology adoption [
17,
18]. Given the emergence of new health technologies and evolving attitudes as health systems adapt to rapidly changing circumstances, it is important to understand the acceptance of current technology applications in palliative care in order to gain insight into how they can be rapidly scaled up. Nuances between palliative care settings across various regions, and important differences between hospice and palliative care provision in a number of countries raise the need to further develop the existing knowledge base to explore technology acceptance in additional palliative care contexts. Compared to hospice care, which focuses on the palliation of patients who are in their remaining months of life, palliative care is distinct in its aim to improve the quality of life among patients with life-limiting or serious illnesses who are not necessarily close to death [
19].
A limited number of studies have explored technology acceptance within palliative care. Some of the evaluated technologies allowed for monitoring and assessing symptoms [
7,
18,
20,
21], while others for video consultations, exclusively [
22]. Among these studies, factors supporting acceptance included demonstrated evidence that technology could enhance patient outcomes/experiences [
20,
21] and could act as an adjunct to in-person care [
7,
18]. Technologies that were tailored to meet the specific needs of different palliative care settings [
22] also supported provider acceptance. Conversely, perceived lack of clinical relevance (of aspects of the technology) [
20], lack of digital infrastructure to support technology [
7,
18], and privacy concerns [
22] were notable barriers to technology acceptance. Although health care providers were included in the palliative care studies previously mentioned, health administrator perspectives were excluded. Administrators are often closely involved in the procurement and/or coordination of health technologies and can potentially directly influence providers’ decision to use it on a regular basis. Therefore, health administrators’ perspectives are also important to consider to better understand technology acceptance in palliative care.
Our study sought to expand on previous research by providing a current and theoretically informed perspective on patients’ and providers’ acceptance of palliative care telehealth applications as viewed by health care providers and administrators in Ontario, Canada. We drew on the Technology Acceptance Model (TAM) [
23] to explore the usefulness and ease of using health technologies for both providers and patients in the palliative care context. To our knowledge, this is the first Canadian study that focuses on acceptance of technologies in palliative care from the perspectives of both health administrators and providers.
Methods
Theoretical framework: technology acceptance model
The TAM centers on two belief constructs that have been found to significantly influence an individual’s acceptance of (intention to engage) a technology: 1) perceived usefulness; and 2) perceived ease of use [
23]. This model contends that a strong relationship exists between one’s intention to use technology and their actual usage behavior [
24]. Perceived usefulness is characterized by an individual’s belief that engaging a technology improves their job performance while perceived ease of use refers to their belief that using a technology requires minimal effort [
23]. The TAM assumes that an individual’s perception of how easy a technology is to engage with impacts their evaluation of its usefulness [
23]. Thus, we explored these key variables in our study.
Study setting
We obtained ethical approval for the study from the Women’s College Hospital ethical review committee. Our study was a follow-up to two previous proof-of-concept (POC) implementations of patient- and provider-facing technologies in palliative care that were piloted by the Ontario Telemedicine Network (OTN) (a non-profit organization that facilitates virtually-enabled patient access to care, distance education, and remote meetings for health care providers and patients) in two regions in Ontario, Canada from September 2017 to March 2018. In one region, the piloted technology was a remote monitoring tool deployed as an adjunct to a home-based model of palliative care. The technology involved a set of survey instruments delivered on a tablet that was provided to and completed by patients or their caregiver(s) at home to capture routine information on their pain and symptom levels. Their data was then transmitted to a web-based database accessible by health administrators and providers to monitor patients for changes that potentially required either remote or in-person follow-up.
In the other region, the technology also supported a home-based model of palliative care. The technology consisted of a platform that acted as a central repository of information controlled by the patient and/or their caregiver(s). The technology supported self-management and could also act as a communication tool enabling video/audio touch-points between patients and the care team. The technology was designed as a personal electronic health record accessible to patients on their personal device. The personal electronic health record included goal-setting features, advance care and self-care planning, self-monitoring tools to track pain and symptoms, videoconferencing, and the potential to include other apps and features. The technology was intended to help support patients’ knowledge of their health status and engagement with their care.
While participants were recruited in the context of the two POC projects, participants were encouraged to consider their entire experience with the use of telehealth technologies in palliative care, even if this experience came from outside the POC projects. Some of the other technologies that participants spoke about included remote patient symptom assessment and monitoring tools, remote consultation tools, and digital decision support tools.
Participant recruitment
Participants were recruited using purposive and snowball sampling whereby the study funder (OTN) recommended potential participants (n = 4 health administrators) who were previously involved in the pilot projects. We then expanded our recruitment by drawing on our professional networks and existing study participants to refer health providers and administrators via word-of-mouth (n = 14), including individuals outside the pilot projects who had relevant experience implementing/using various technologies in palliative care. Participants were contacted through telephone or email for (or to schedule) an introductory telephone call whereby the study objectives and details of participation were explained and to provide an opportunity to build rapport. Of the 23 individuals we contacted, two refused to participate and three dropped out due to lack of availability. In total, our study included 18 participants (seven health care providers [three physicians in palliative consultation teams/centers, two family physicians, two registered nurses] and 11 health administrators). Nine participants were involved to various extents in the pilot projects (seven health administrators, two health care providers) while the remaining nine included those with relevant telehealth experience in palliative care outside the pilot projects (four administrators, five health care providers).
Data collection
We conducted 18 semi-structured, individual interviews with participants to explore their perceptions of the perceived usefulness and ease of using health technology in palliative care. Development of the interview guide was informed by the two belief constructs underlying the TAM (perceived usefulness and ease of use) as well as discussions with a family physician, a palliative care physician, and researchers with training and experience in qualitative methodologies and digital health evaluations. Questions centered on what supported the usefulness of health technologies (e.g. how technology could address current gaps in palliative care, positive impacts of using technology in palliative care, how technology could be integrated with workflow to optimize palliative care), and what improvements would be required to support their ease of utilization/adoption in palliative care (e.g. barriers or challenges that would need to be addressed). Semi-structured interview guides were used to provide a preliminary format for discussion, while enabling the exploration of common responses that emerged during interviews until data saturation was reached. Please see “Additional Files – Interview Guides”. Interviews were conducted by two female research assistants with masters and PhD training in qualitative methods and were conducted over the phone, lasting approximately 30 to 60 min. All interviews were audio-recorded and transcribed verbatim.
Data analysis
The study scientific lead and two research assistants analyzed the data using inductive thematic analysis – a systematic approach in which the identification of meaningful themes (commonalities, patterns within the data) were derived from the data set [
25]. We used (NVivo11) software to code (manage, organize, and categorize using descriptive labels) the data for subsequent analysis. In line with a theory-driven approach to thematic analysis [
25], the interview data were analyzed in terms of the TAM and the overarching aim of the proposed research. Thus, analysis was oriented to exploring the usefulness of technologies and what supports their ease of use in palliative care. First, we identified (at random) and independently coded five transcripts and then compared codes as a group before coding the remaining transcripts. We identified passages within the dataset that corresponded to a common idea and assigned codes to group these portions of the data together. Using an iterative approach, we continually revisited and refined the codes throughout the analysis. We then reviewed the codes to generate themes based on our theoretical approach and research objective.
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