Attitudes Toward Telemedicine in Urban, Rural, and Highly Rural Communities

Vaughn R.A. Call, PhD,1 Lance D. Erickson, PhD,1 Nancy K. Dailey, MSN, RN,2 Bret L. Hicken, PhD, MSPH,2 Randall Rupper, MD,2,4 Jeremy B. Yorgason, PhD,3 and Byron Bair, MD, MBA2 1

Department of Sociology, Brigham Young University, Provo, Utah. Veterans Rural Health Resource Center—Western Region, VHA Office of Rural Health, Salt Lake City, Utah. 3 School of Family Life, Brigham Young University, Provo, Utah. 4 Salt Lake VA Geriatrics Research Education and Clinical Center, Salt Lake City, Utah.

Hence, few have used telemedicine, and key innovation adoption criteria—trialability and observability—are low. Increased attention to public awareness in the adoption process is needed to increase willingness to embrace telemedicine as a convenient way to obtain quality healthcare services.

2

The views expressed herein do not necessarily represent the views of the Veterans Administration or the U.S. government.

Abstract Introduction: The rate of telemedicine adoption using interactive video between patient and provider has not met expectations. Technology, regulations, and physician buy-in are cited reasons, but patient acceptance has not received much consideration. We examine attitudes regarding telemedicine to better understand the subjective definitions of its acceptability and utility that shape patients’ willingness to use telemedicine. Materials and Methods: Using the Montana Health Matters study (a random, statewide survey [n = 3,512]), we use latent class analysis to identify groups with similar patterns of attitudes toward telemedicine followed by multinomial logistic regression to estimate predictors of group membership. Results: Although only 5% are amenable to telemedicine regardless of circumstance, 23% would be comfortable if it could be convenient, whereas 29% would be situationally amenable but uncomfortable using telemedicine. Still, a substantial percentage (43%) is unequivocally averse to telemedicine despite the inconvenience of in-person visits. Educational attainment, prior Internet use, and rural residence are main predictors that increase the likelihood of being in an amenable group. Conclusions: From the patient’s perspective, the advantages of reduced travel and convenience are recognized, but questions remain about the equivalence to physician visits. Many people are averse to telemedicine, indicating a perceived incompatibility with patient needs. Only 1.7% of the respondents reported using telemedicine in the previous year; about half were veterans.

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Key words: telemedicine, military medicine, policy, telehealth

Introduction

T

he rapid increase in Internet adoption and the expansion of mobile connectivity over the last decade have altered global communications, access to information, commerce, and the delivery of services. Although this shift has become almost ubiquitous, the financial sustainability of telemedicine and the scope of adoption into the mainstream healthcare system remain uncertain.1 Significant advances have occurred in the underlying technology supporting online healthcare services, resulting in evidence of telemedicine’s feasibility as a clinically effective equivalent to in-person medical care for many health problems.2–4 Yet there remain nontechnological barriers (e.g., implementation leadership, operating costs, physician buy-in, regulatory/legal restrictions, community support, and patient acceptance) that are frequently cited as undermining the adoption of telemedicine.5,6 Consequently, despite the benefits of telemedicine, its adoption has been slow and below expectations.1,7 Physicians, hospital administrators, and healthcare payers are considered the largest barriers to telemedicine adoption, with patients as largely passive participants in the process.8 Many companies have developed innovative solutions to address a perceived need in the marketplace only to discover that they misjudged consumer willingness to embrace it. Because telemedicine is a contingent process, physicians and hospitals may provide telemedicine as a service-delivery option, but the general public (patients/customers) can use other providers if telemedicine’s quality of service does not match in-person visits. Despite the convenience of telemedicine, people consistently report that they prefer seeing their doctor in-person.7,9 Thus hospitals and physicians may not invest financial resources into a product that patients might reject.

DOI: 10.1089/tmj.2014.0125

ATTITUDES TOWARD TELEMEDICINE

More consideration must be given to the public’s role as the ‘‘adopter’’ in the innovation-adoption process.10,11 Broadly defined, telemedicine involves the use of various communication technologies to deliver or support direct medical care to patients and to promote collaboration between physicians regardless of physical distance.8 In this study, telemedicine is limited to direct physician–patient consultations using video communication over the Internet. Although many studies suggest that patients who use telemedicine are satisfied with it12 and that exposure to telemedicine influences patients to have more favorable attitudes toward it,13 little existing research sheds light on perceptions about telemedicine among the general or minority populations.14 With a few notable exceptions,9,15 studies tend to include small samples with limited population coverage, and study designs limit the generalizability of findings.16 The lack of understanding of public perceptions of telemedicine may be an important impediment to its broader acceptance.7,17 We addressed this gap in the literature by examining public perceptions of telemedicine using latent class analysis (LCA) in a state-representative sample of Montana.

Materials and Methods

replacement, and 100 households were randomly selected without replacement to achieve the desired stratum size (1,000 urban, 2,000 rural, and 2,000 highly rural). We used a multimethod, five-wave mail/telephone survey protocol,22 and a $2 honorarium was included in the original mailing to maximize survey response. Of the 5,000 in the target sample, 3,512 responded to the 2010 survey (493 urban [comparison group], 1,391 rural, and 1,628 in highly rural). About 18% of the respondents were veterans. Telemedicine attitude questions come from a 1-year follow-up survey that had a mortality-adjusted 77% response rate (n = 2,659; 355 urban, 1,042 rural, and 1,262 highly rural); all other measures come from the original 2010 survey. Only respondents who had at least five nonmissing responses to the eight questions (n = 2,399; 312 urban, 947 rural, and 1,142 highly rural) were included in these analyses. Weights used take into account nonresidential addresses in the Delivery Sequence File, the multistage cluster sampling design, and survey nonresponse so results are representative of the state of Montana. The study was approved by Brigham Young University’s Institutional Review Board. MEASURES Telemedicine attitudes were assessed using eight survey items. The survey defined ‘‘telehealth’’ as ‘‘an Internet service that uses video cameras and specialized equipment to permit physicians and medical specialists to consult with patients and to conduct some medical examinations over the Internet. Physicians and patients can talk and see each other without

This study was based on survey data from the 2010–2012 Montana Health Matters study, a state-representative survey of Montana. These data are highly suited for this study of telemedicine as Montana has the fourth highest proportion of its population living in rural areas.18 Furthermore, MonTable 1. Rho and Gamma Values for Groups Derived from Latent Class Analysis tana has a long history of Using Telemedicine Attitudes telemedicine use. The Montana SITUATIONALLY SITUATIONALLY AVERSE AMENABLE COMFORTABLE UNCOMFORTABLE Healthcare Telecommunications Alliance was formed in Gamma 0.43 0.05 0.23 0.29 1995 and has four active Rho telemedicine networks.19,20 In I prefer to see my doctor in-person. 0.97 0.28 0.51 0.92 addition, the Veterans Health People get better care in-person. 0.90 0.00 0.46 0.83 Administration (VHA) has a Telemedicine is better than traveling long distances. 0.03 0.00 0.86 0.72 telemedicine network for enrolled veterans. Telemedicine is better than traveling in weather. 0.23 0.10 0.96 0.95 The sampling frame included I would use telemedicine to save traveling time. 0.05 0.06 0.92 0.55 all Montana households in the I prefer telemedicine with my specialist than 0.19 0.05 0.72 0.43 U.S. Postal Service’s computwith another physician in person. erized Delivery Sequence File. With telemedicine I would miss fewer appointments. 0.03 0.00 0.44 0.12 The target sample was stratified I would be comfortable with telemedicine visits. 0.04 0.18 0.85 0.18 using the VHA urban, rural, and highly rural designations.21 Data are from the 2010–2012 Montana Health Matters study (n = 2,399). Gamma is the estimated proportion of the sample in each group. Rho is the proportion of group members who agreed with the telemedicine question. Zip codes within each stratum were randomly selected with

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the patient having to travel to the doctor’s office.’’ This description most accurately defines telemedicine, but the survey applied the term ‘‘telehealth’’ because of its broader public recognition. Respondents were asked to indicate their level of agreement or disagreement with the following items: a. I prefer to see my doctor in person rather than using a video system on the Internet. b. Using a telehealth system to meet with my doctor would be better than traveling long distances to see my doctor. c. Using a telehealth system to meet with my doctor would be better than traveling during bad weather conditions to see my doctor. d. People are likely to receive better-quality care when they see their doctor in-person rather than over an interactive video system. e. I would use telehealth if it allowed me to significantly reduce the time I spend traveling to other communities to see my doctor. f. I would prefer a telehealth visit with my own specialist over an in-person visit with another physician. g. Having telehealth services in my community would mean that I would miss fewer appointments. h. I would feel comfortable having telehealth visits with my doctor. Response options were 1 = ‘‘strongly agree,’’ 2 = ‘‘agree,’’ 3 = ‘‘neither agree nor disagree,’’ 4 = ‘‘disagree,’’ and 5 = ‘‘strongly disagree.’’ ‘‘Strongly agree’’ and ‘‘agree’’ were coded as 1, and all other response options were coded as 0. This not only allows a clear substantive interpretation of the analyses but also facilitates the LCA model estimates.17 LCA: MODEL SELECTION LCA estimates probabilities of membership in unobserved classes or groups. Because the groups estimated in LCA are not observed in the population, identifying them is a nontrivial issue. In many statistical applications, likelihood ratio tests can be used to identify an appropriate model. However, models that estimate different numbers of groups are not nested. The Bayesian information criterion (BIC) is a common alternative to compare non-

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Table 2. Descriptive Profiles of Groups of Telemedicine Attitudes: Means and Proportions SITUATIONALLY SITUATIONALLY AVERSE AMENABLE COMFORTABLE UNCOMFORTABLE Demographics Femalea

0.54

0.52

0.64

0.58

Age (years)

58.40

59.14

56.65

58.57

Income (in $1,000)

56.65

53.02

62.49

61.20

2.99

3.18

3.21

3.24

Married

0.77

0.69

0.73

0.74

Divorced or separated

0.09

0.12

0.12

0.12

Widowed

0.07

0.13

0.08

0.06

0.07

0.06

0.07

0.07

Nonveteran

0.78

0.80

0.87

0.82

Enrolled veteran

0.07

0.09

0.06

0.07

Nonenrolled veteran

0.15

0.11

0.07

0.11

0.81

0.78

0.86

0.84

Self-rated health

3.53

3.66

3.59

3.57

Number of chronic conditions

4.05

4.32

4.03

3.69

SF-12 physical

47.69

48.68

47.97

48.31

SF-12 mental

44.86

44.89

43.62

44.32

Depression

3.18

3.69

4.27

3.43

Pain

1.59

1.50

1.66

1.60

Doctor visits in last 60 days

1.09

0.93

1.08

0.98

Internet use

1.28

1.60

1.76

1.53

Prior telehealth use

0.01

0.02

0.04

0.01

External locus of control

2.29

2.42

2.36

2.38

Community satisfaction

5.74

5.56

5.67

5.67

Urban

0.12

0.17

0.08

0.18

Rural

0.41

0.35

0.38

0.38

Highly rural

0.46

0.48

0.54

0.44

Distance to PCP

19.30

20.20

20.59

16.96

Educational attainment a

Marital status

Never married a

Veteran status

Has Internet at home Health

Personality

Accessibility Ruralitya

continued/

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Table 2. Descriptive Profiles of Groups of Telemedicine Attitudes: Means and Proportions continued SITUATIONALLY SITUATIONALLY AVERSE AMENABLE COMFORTABLE UNCOMFORTABLE Transportation is easy

6.57

6.20

6.50

6.52

Drive self to PCP

0.86

0.83

0.88

0.88

Prescriptions in community

0.60

0.50

0.57

0.61

1.57

1.52

1.53

1.55

Availability PCP availability Overnight visits

2.41

2.49

2.64

2.55

a

0.31

0.35

0.28

0.36

Appointments with PCP

5.61

5.58

5.50

5.54

Appointments with specialist

5.21

4.97

5.10

5.07

Fill prescriptions

6.57

6.32

6.46

6.55

Complete paperwork

5.80

5.54

5.62

5.73

Doesn’t stay overnight Accommodation

venience is ‘‘assigned’’ to the group for which his or her probability of membership is greatest. Groups are then given substantive names based on the patterns of responses to the telemedicine items for respondents classified in each group. Only a small proportion of the sample has attitudes generally ‘‘amenable’’ to telemedicine use (5%); this group is less predisposed to say they want to see their doctor in person than are the other groups. Another 23% of the sample is amenable to telemedicine when inperson visits are perceived as inconvenient. We refer to this group as being ‘‘situationally comfortable’’ with telemedicine. In contrast, the ‘‘situationally uncomfortable’’ group (29%) reports a willingness to use telemedicine when in-person visits are inconvenient, but they feel uncomfortable with telemedicine. The remainder of the sample (43%) appears totally ‘‘averse’’ to using telemedicine services regardless of its potential convenience.

Results

Affordability

Missing values on independent variables were treated using multiple imputation. Given the large Money for care 2.54 2.71 2.49 2.57 number of variables in this exploratory analysis, a we examined for multicolinearity but found no Has insurance 0.90 0.86 0.89 0.91 evidence for it. The means and proportions for Data are from the 2010–2012 Montana Health Matters study (n = 2,399). Variables were coded study variables for each telemedicine group are so that higher values represent more of the concept. Groups were identified using latent class analysis. presented in Table 2. a Proportions. Being averse to telemedicine is not a result of the PCP, primary care provider; SF-12, 12-item Short Form. absence of home Internet—there is very little difference in Internet access across the four groups (Table 2). The averse group, however, is less likely nested models. Smaller BIC values indicate better model fit. to use the Internet across a range of common uses (Table 3). The final consideration is the ability of the estimated models to Subsequent multivariate analyses confirm that the propensity identify unique patterns in the data.23 If an estimate with addito not use the Internet for everyday activities does impact tional groups produces substantively similar patterns in reattitudes about telemedicine. sponses to the measured items used to estimate the classes, the Relative risk ratios from multinomial logistic regression model with fewer classes is the one selected based on the prinanalyses are presented in Table 4. The averse group is ciple of parsimony.17 Missing responses on the eight telehealth omitted, serving as a referent for each of the remaining three questions were treated in the estimation of the LCA model as groups. The first column compares the amenable to the 24 missing at random using full information maximum likelihood. averse group. Using the Internet for daily activities (1.40, Based on the BIC, the optimal number of groups of attitudes p < 0.01) and having an external locus of control (1.52, was five, but two groups were substantively similar. Consep < 0.05) modestly increase the likelihood of being amenable quently, we present results for the four-group solution. Estito telemedicine rather than averse. Worrying about finances mates of gamma, the proportion of the sample in each group, reduces the likelihood (0.78, p < 0.05) and having money to and rho, the proportion of respondents in each group who pay for healthcare increases the likelihood (2.12, p < 0.01) agreed with a particular attitude, are presented in Table 1. of being amenable. Having health insurance (0.28, p < 0.01) Because the groups are unobserved, each respondent has a and easily obtaining transportation for doctor appointnonzero probability of belonging in each group but for conments (0.77, p < 0.05) and prescriptions in one’s community Worries about finances

2.90

2.61

2.93

2.89

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Table 3. Internet Use (Days During the Week) in Full Sample and Telemedicine Groups SITUATIONALLY SITUATIONALLY FULL AVERSE AMENABLE COMFORTABLE UNCOMFORTABLE Online banking

1.55

1.41c

1.82

1.87a,d

1.47c

Local businesses

0.19

0.15b,c

0.36a,d

0.25a

0.19b

Nonlocal businesses

1.13

0.98c

1.25

1.46a,d

1.10c

0.10b,c

0.30a,d

0.24a,c

0.10b,d

group. Being older increases the likelihood of being situationally uncomfortable (1.02, p < 0.001). Living in rural (0.61, p < 0.01) and highly rural (0.71, p < 0.05) communities decreases the likelihood of being in the situationally uncomfortable group relative to the averse group.

Discussion

After a half century of telemedicine development, the realization of its benefits remains Check news 3.18 2.87 3.52 3.47 3.39 elusive. Although reasons for its slow adoption Local events 1.18 0.99b–d 1.55a 1.31a 1.33a are not clear, insurance coverage, doctor reimNonlocal events 1.91 1.66b–d 2.33a 2.23a 2.01a bursement, regulatory restrictions, and technolGeneral information 3.86 3.46b–d 4.24a 4.31a 4.07a ogy issues are common explanations.1 Despite a substantial focus on developing technologies Health information 1.45 1.17b–d 1.80a 1.91a,d 1.47a,c and enhancing physician buy-in, the current c,d a a Social networking 2.01 1.73 1.90 2.45 2.12 analysis suggests that consideration of public Gaming 1.05 1.03 1.23 0.95 1.12 acceptance is needed for telemedicine to receive 0.86 0.90a 0.65 Movies or TV 0.67 0.55c less conditional and more widespread acceptance among the general public. A key considData are from the 2010–2012 Montana Health Matters study (n = 2,399). Groups were identified using latent class analysis. eration is that telemedicine is a mode of service a Significantly different than the Averse group at p < 0.05. delivery and is potentially more sensitive to b Significantly different than the Amenable group at p < 0.05. patients’ preferences than a medical-treatment c Significantly different than the Situationally Comfortable group at p < 0.05. option where patients might rely more heavily d Significantly different than the Situationally Uncomfortable group at p < 0.05. on physicians’ judgments. Although some funders of medical care, like the VHA or health maintenance organizations, can dictate how care is delivered, most patients choose their physicians and their (0.58, p < 0.05) reduce the likelihood of being amenable to method of accessing healthcare. Because patient satisfactelemedicine. tion determines the financial viability of a doctor’s practice, In the second column of Table 4, the situationally comthe adoption of telemedicine is a collective decision where fortable group is compared with the averse group. Females are both doctors and patients must favor the innovation.10 more likely to be situationally comfortable with telemedicine (1.31, p < 0.05). Higher levels of education (1.13, p < 0.05) and Results from multinomial logistic regression analysis indiincreased Internet use (1.40, p < 0.001) modestly increase cated that the small amenable group has the Internet skills to the likelihood of being situationally comfortable. Living in use telemedicine and the financial resources to obtain the care highly rural communities doubles the likelihood of memberthey want and are less inclined to feel that quality care requires face-to-face care. Like the amenable group, people in ship in this group (1.97, p < 0.01). Better mental functioning (RAND-12 mental subscale) decreases the likelihood of being the situationally comfortable group use Internet-based sersituationally comfortable relative to the averse group (0.97, vices more extensively and have higher levels of education. p < 0.05). Being a nonenrolled veteran also decreases the This group seems to appreciate the convenience of telelikelihood of being situationally comfortable with telemedicine in part because of physician access issues that come medicine (0.50, p < 0.01). Prior telemedicine use had a strong from living in highly rural communities. Why being a nonepositive relationship with membership in the situationally nrolled veteran lowers the odds of being in the situationally comfortable group (6.22, p < 0.001). comfortable group and no others is unclear and requires more The final column in Table 4 compares the situationally in-depth investigation. This finding is unexpected given that the VHA is not limited by private-sector physician reimuncomfortable group with the averse group. Increased education (1.17, p < 0.01), daily Internet use (1.24, p < 0.001), bursement issues, has developed an extensive telemedicine network,25 and has aggressively developed telemedicine serand increased external locus of control (1.30, p < 0.01) increase the odds of being in this group relative to the averse vices for physical and mental healthcare of rural veterans.26–28 Groceries, etc.

0.14

c,d

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a

a

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Although the amenable and situationally comfortable groups have similar levels of education and Internet use, the situationally uncomfortable group has some specific differences. First, being older somewhat increases the odds of being in this group. Older people may be accustomed to seeing a doctor in-person and less comfortable with technology.15 Or, older respondents’ attitudes could be informed by existing physical limitations, such as impaired vision or manual dexterity.29 Second, living in rural and highly rural communities significantly reduces the odds of being in the situationally uncomfortable group. Thus, living in rural and highly rural areas produces a context where people will be situationally amenable to telemedicine given the difficulty of face-to-face doctor visits, but one group (i.e., younger people) will be more comfortable than the other using the technology. Although Montana may be very different from other states in terms of economic conditions, physician availability, and rurality, these factors should have promoted favorable attitudes toward telemedicine use, particularly given the greater physical and mental healthcare needs in rural areas.30 But they did not. Thus, there remains a significant divide between the perceptions of benefits by telemedicine advocates and attitudes toward this medical innovation by the general public. Consequently, our results provide important context for discussions of the benefits of the technology, clinical applications, and changes in business models that occur in the telemedicine literature because little emphasis is placed on key human dimensions that impact telemedicine adoption by patients. Contingent innovation decisions are always slow,10 and the relative advantage of telemedicine versus seeing a doctor in person is difficult to demonstrate to the public. The convenience of telemedicine enhances its public perception, but this is largely limited to those who have access barriers. Most people (70%) are still concerned about the quality of care available through telemedicine; part of this concern may be discomfort with virtual relationships. As Skype (Google, Mountain View, CA) and FaceTime (Apple, Cupertino, CA) gain more acceptance for personal contacts among family members, discomfort with virtual ‘‘visits’’ should lessen, just as

Table 4. Predictors of Membership in Groups of Telehealth Attitudes: Relative Risk Ratios from Multinomial Logistic Regression SITUATIONALLY SITUATIONALLY AMENABLE COMFORTABLE UNCOMFORTABLE Demographics Female

0.77

1.31a

1.09

Age (years)

1.02

1.01

1.02c

Income (in $1,000)

1.00

1.00

1.00

1.26

1.13

1.17b







Divorced or separated

1.20

1.26

1.23

Widowed

1.88

1.31

0.97

Never married

0.50

1.09

1.15







Educational attainment

a

Marital status Married

Veteran status Nonveteran Enrolled veteran

0.98

Nonenrolled veteran

a

0.89

b

0.51

0.58

0.52

0.72

0.86

1.23

1.06

Self-rated health

1.10

1.10

0.94

Number of chronic conditions

1.00

1.00

0.99

RAND-12 physical

1.02

1.00

1.02

Home Internet access Health

a

RAND-12 mental

1.01

0.97

0.99

Depression

1.04

1.03

1.00

Pain

1.05

1.07

1.06

Doctor visits in last 60 days

0.91

0.97

0.94

Internet use

1.40b

1.40c

1.24c

Prior telemedicine use

1.16

6.22c

1.09

Personality

a

External locus of control

1.52

1.20

1.30b

Community satisfaction

0.97

1.04

1.00

Urban







Rural

0.67

1.49

0.61b

Highly rural

0.82

1.97b

0.71a

Distance to PCP

1.00

1.00

1.00

1.01

0.98

Accessibility Rurality

Transportation is easy

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b

0.75

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option for follow-up and other routine office visits, highlighting its convenience in a context where direct patient–doctor contact is deemed less critiSITUATIONALLY SITUATIONALLY AMENABLE COMFORTABLE UNCOMFORTABLE cal. This could dispel perceptions of telemedicine Drive self to PCP 0.87 1.11 1.08 as inferior care that is only useful for accommoa dating patients with extensive travel or other acPrescriptions in community 0.58 0.81 0.91 cess issues. Availability In sum, although physician acceptance and PCP availability 1.15 0.98 0.96 other financial and technical barriers to teleOvernight visits 1.12 1.08 1.08 medicine undoubtedly remain, extensive telemedicine networks have been in place in some Doesn’t stay overnight 1.50 1.05 1.21 areas for over a decade. Yet the sustainability and Accommodation future of telemedicine are still uncertain.1 In this Appointments with PCP 1.19 1.00 1.06 study, perceptions of the general public toward Appointments with specialist 0.84 1.02 0.93 telemedicine are largely negative—most still want to see their doctor in-person despite the conveFill prescriptions 0.92 0.95 1.02 nience of telemedicine and the ubiquitous use of Complete paperwork 1.00 0.98 0.98 the Internet to obtain health information.27,32 Affordability Consequently, we suggest, as does a recent study in Worries about finances 0.78a 0.91 0.98 Germany,9 that a neglected consideration in the b slow telemedicine adoption process is public acMoney for care 2.12 0.94 1.03 ceptance. Most other digital patient-engagement b Has insurance 0.28 0.89 1.06 tools are facing similar adoption problems, leading Data are from the 2010–2012 Montana Health Matters study (n = 2,399). Groups were identified marketing specialists to suggest that the major using latent class analysis. Results are from 20 multiple imputation datasets and are relative risk problem is that the various technologies may not ratios are the risk compared with the Averse group. Dashes indicate the reference group. a be addressing the right patient-focused questions p < 0.05, bp < 0.01, cp < 0.001. or needs.33 Does telemedicine allow patients to feel as informed and confident about their health status as they do talking face to face with their physician? Do pae-mail and Facebookª (Menlo Park, CA) innovations have tients feel that online experience provides the same level of altered family communication patterns. service quality they would receive in their doctor’s office? To enhance acceptance, more emphasis must be placed on Under what conditions and to what extent is telemedicine increasing experience with telemedicine and communicating acceptable for various types of primary care and specialized information to the public documenting its quality, convemedical services? Although past research finds that patients nience, and ease of use.26 Media efforts could specifically address two of the most critical issues that affect the adoption who use various telemedicine applications are satisfied with it12 and our results indicate they are more comfortable with it, rate of new technologies—observability (being able to see telemedicine in use) and trialability (being able to talk to the overwhelming majority of the general public has yet to be people who have used it, or try it themselves). Policies must convinced about the quality of telemedicine compared with an allow the public to assess the quality of telemedicine relative actual physician visit. Making the general public more aware to actual physician visits. For example, expanding teleof its benefits should increase customer willingness to emmedicine to the entire Veterans Administration healthcare brace telemedicine as a convenient way to obtain quality system has increased trialability and observability, although healthcare services. this is limited to veterans.31 In addition, pilot projects in highly rural areas that engage the community-as-a-partner to Acknowledgments facilitate the provision of telemedicine services not only meet The Veterans Health Administration Office of Rural Health the needs of veterans living in the local area but also provide reviewed this manuscript prior to submission to Telemedicine other community members the ability to directly observe the and e-Health. This research was supported by the Veterans benefits of telemedicine.26 Perhaps most important is that Health Administration Office of Rural Health and Brigham Young University. telemedicine could be mainstreamed as a service-delivery Table 4. Predictors of Membership in Groups of Telehealth Attitudes: Relative Risk Ratios from Multinomial Logistic Regression continued

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Disclosure Statement No competing financial interests exist.

19. Zauher J. Telehealth in Montana. Paper presented at Rural Health Care in Japan and the United States: Shared Challenges and Solutions, held July 1, 2001, in Bozeman, MT.

REFERENCES

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Address correspondence to: Vaughn R.A. Call, PhD Department of Sociology Brigham Young University 2027 JFSB Provo, UT 84602

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E-mail: [email protected] Received: June 20, 2014 Revised: October 13, 2014 Accepted: October 16, 2014

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ª M A R Y A N N L I E B E R T , I N C .  VOL. 21

NO. 8  AUGUST 2015

TELEMEDICINE and e-HEALTH 651

Attitudes Toward Telemedicine in Urban, Rural, and Highly Rural Communities.

The rate of telemedicine adoption using interactive video between patient and provider has not met expectations. Technology, regulations, and physicia...
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