Athletic Trainers’ Experiences and Perceptions Regarding Telemedicine

Study Design and Participants

We used a partially mixed sequential dominant status design²⁷ and recruited a convenience sample of credentialed athletic trainers from a national survey. Participants (N = 512) had to self-identify as a user (n = 214) or non-user (n = 298) of telemedicine based on a provided definition in the survey, which was explained as the “use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include video conferencing, the internet, store-and-forward imaging, streaming media, and wireless communications” (p. 2).²⁸ Data from this study are not provided in this article but did influence the sequential order for recruitment. The second phase of the study, the qualitative interview, was guided by interviewing the experiences of athletic trainers who self-identified as users of telemedicine from the provided definition. The telemedicine users were asked to participate in a follow-up interview in which 121 participants consented to do so. From this sample, 11 athletic trainers (females = 6, males = 5; age = 37 ± 12 years) responded to the email to schedule the interview and completed the one-on-one interview. Recruitment of additional participants was discontinued when we reached data saturation. Table 1 provides demographic characteristics for the participants. All participants initially provided electronic consent to participate in the survey and provided follow-up contact information in the first phase of the study for which the study was approved by the institutional review board of Indiana State University. All participants then provided verbal consent during the interview prior to enrollment in the second phase of the study that was approved by the University of South Carolina’s institutional review board.

Table 1: Participant Pseudonym and Descriptive Characteristics

Procedures

One researcher (ZKW) scheduled and completed one-on-one audio interviews using a web-based platform (Zoom Video Communications, Inc). Scripts were created by an athletic trainer with contemporary expertise in telemedicine (ZKW) and reviewed by a researcher with a background in qualitative methods and telemedicine (KEG). Interviews were recorded and lasted approximately 15 to 30 minutes. The interviews followed an interview protocol (Table A, available in the online version of this article) that sought to obtain demographic information, participants’ definition of telemedicine, and their perceptions related to telemedicine use in athletic training. Following the interview, automatic transcription was completed using features provided by Zoom and checked by members of the research team for accuracy. Trustworthiness was established with multiple researchers’ analyses, an external auditor, and transcription credibility checks by research team members who did not conduct the interviews.

Table A: Interview Protocol

Data Analysis

Data were analyzed using the consensual qualitative research tradition.²⁹ A three-person data analysis team (ZKW, ADM, MMK) convened to analyze data following a multi-phased approach to identify emergent domains and categories. Data analysis included external review by a fourth member of the data analysis team (KEG) with prior experience with consensual qualitative research and telemedicine research.²⁵ Data were analyzed to determine the frequency of the categories within the sample. A category was considered general if it applied to all cases, typical if it applied to more than half of the cases, and variant if it applied to more than one but less than half of the cases.²⁹

Impressionable State

Participants were in an impressionable state by which their perceptions of telemedicine were influenced by mentors, jobs, and third-party insurance companies. Individuals shared experiences with telemedicine and reflected on how they were introduced to it. Two categories presented during interviews. The first category involved influence via mentors, people, jobs, and past experiences. The second category involved curiosity and desire to know more. Participants’ perceptions of telemedicine were influenced by various experiences, including exposure in formal education, discussions with other professionals, and allotments of private health insurance companies. Two participants were influenced by a third-party payer for health insurance related to implementation. Participants expressed a desire to know more about telemedicine, including more training on its use. There was also curiosity regarding telemedicine being an avenue for growth in the profession. The lack of adoption at the current time was perceived to be driven by a social normative culture that is resistant to change.

Concerns With Implementation

Participants noted concerns with implementation of telemedicine in their practice including feasibility, thoughts on the end-user experience, and novice knowledge relative to telemedicine. There was concern with implementation feasibility and telemedicine use in athletic training, citing that it was not feasible for scenarios where hands-on patient care was typical. The lack of physical touch in post-surgical cases was a consistent concern.

The patient’s experience in using telemedicine was also a theme across participants (10 of 11). Administrative concerns such as information technology and ancillary staff support to assist with technology were noted. Participants identified needing to have technological support for day-to-day operations and in the event of a disruption of technology operation. The athletic trainers were concerned with privacy and patient preferences and noted their level of experience and access to technology influenced these thoughts. Fees associated with telemedicine and whether third-party payers would reimburse services was a concern, and the idea that patients may be negatively influenced in their decision to use telemedicine if health insurance companies did not reimburse services.

Finally, concerns with implementation also focused on a clinician’s skillset. There was a perception that more formal education is needed in all levels of the profession. The athletic trainer’s experience level as a health care provider was noted as important, with the perception that telemedicine providers would have to be skilled in interviewing patients to make up for a lack of hands-on patient evaluation. The need for education and training in telemedicine use was noted. There was also a concern about the barrier of time management for the clinician, with a novice user perceiving telemedicine as inefficient.

Connectedness

The connectedness domain incorporated education, collaboration, and immediacy of interactions that were completed using telemedicine. The category of education emerged throughout the interviews. Participants noted the importance of students and clinicians engaging in learning via telemedicine, and some described the use of video communication with expert clinicians performing surgery or lectures on patient care from a distance. Telemedicine was also described as a platform for patient education, and the ability to incorporate telemedicine in practice was thought to benefit the patient. The benefit of collaboration was noted throughout the interviews, in that athletic trainers felt they were able to connect with health care providers, including specialists, easier via telemedicine. Ease of access to care was consistently described as a benefit of telemedicine. It was thought to especially benefit patients with barriers to scheduling traditional medical care. Overall, perceived benefits of telemedicine expressed by participants included the ease of access to health care for patients, the ability to triage, and quicker determination of a care plan.

Clinician-Focused Concerns

The feasibility of providing quality care through telemedicine was the participants’ main concern. Specifically, respondents questioned the ability to perform orthopedic evaluations and health care services without hands-on care. Scenarios like a catastrophic event or post-surgical cases were given as examples where telemedicine feasibility would struggle. Additionally, accurate diagnosis was called into question due to the lack of physical touch that is common with face-to-face interactions. However, this concern may not hold true for orthopedic injuries. A previous investigation compared diagnostic findings of telemedicine to conventional physical therapy and found an 86% agreement between examination findings.³⁰ The concern of quality of care found in our study appeared to be dependent on the athletic trainers’ level of experience. It was noted that newly certified and young professionals may lack clinical interviewing skills needed to be successful when using telemedicine. Previous research reported a barrier of providers not being proficient in facilitating telemedicine consultations.³¹ Therefore, organizations looking to provide telemedicine services should consider the athletic trainer’s competency in subjective assessments. A framework for health care competence involves work experience, in-service training, and education.³² A neurovascular fellowship program provided physicians with telemedicine training for a minimum of 8 weeks.³³ Participants were oriented with the telemedicine network while shadowing interactions with stroke patients before conducting telemedicine consultations independently.³³ More than 62% of fellows reported that the telemedicine education and training they received was beneficial, and 81% of fellows reported that telemedicine training should be required for the accredited vascular neurology fellowship.³³ The current study also found that novice clinicians of telemedicine would be a barrier to implementing the service within a clinical practice. This concern could be addressed by organizations providing training like that of the neurovascular fellowship program.³³

There was also a perceived lack of resources for athletic training program educators and a desire to provide students with telemedicine experiences. Two participants stated they had not learned about telemedicine during their professional education or in clinical practice until pursuing a post-professional Doctor of Athletic Training degree. A previous investigation of telemedicine training for athletic training students demonstrated that a 2-week intervention improved the ease of use and perceived attitude toward telemedicine.²⁶ Therefore, we suggest that athletic trainers seek opportunities to learn telemedicine for consideration of use in clinical practice, because it may not be formally offered in continuing education planning or in professional athletic training programs.

Clinicians’ willingness to adopt telemedicine may be based on their level of education, training in telemedicine, and comfort level with technology. The perceived ease of use and usefulness of technology are two components in the theoretical framework for the acceptance of technology.³⁴ The current study demonstrated the perception that a younger clinician is comfortable with technology and may use telemedicine as a method to obtain a second opinion on a case. Although our study provided positive perceptions of telemedicine use by young clinicians, differing perceptions were seen in the findings of van Houwelingen et al,³⁵ where nursing students in Generation Z (individuals born between 1996 and 2010) were not interested in becoming trained in telehealth activities. Such findings may be explained because students were polled, and our study examined perceptions of practicing clinicians. It can be argued that students are focused on learning skills necessary for job acquisition, which does not include proficiency in telemedicine at the current time. However, practicing clinicians may be able to demonstrate a positive outlook on telemedicine if they see it as a simple addition to their clinical skillset.

Finally, athletic trainers reported concerns with the feasibility of implementation. Previous research noted the importance of the telecommunication network, including signal quality and reliability of connections, when implementing telemedicine services.⁴ Evidence from a systematic review listed low network bandwidth of a patient’s dwelling as something that would impede implementation.²³ Our study supports the notion that a strong network connection is important when considering the feasibility of implementing a telemedicine service.

Patient-Focused Concerns

Our study demonstrated concerns regarding the patient, including privacy, experience, and preferences. Ease of telemedicine use by the patient was also a perceived concern. Participants mentioned the possible difficulty for patients to obtain equipment needed for telemedicine visits and/or understand how to operate the equipment. A patient’s understanding of how to operate the technology used in telemedicine is one of the most common barriers discussed in the literature.³¹ Inability of patients to operate technology may lead to difficulty in clinical diagnosis if visual observation is required (ie, poor image clarity or real-time video³¹). Our results demonstrated the concern that older patients may not be technologically savvy, which was supported by a systematic review that identified age and computer literacy as factors impeding technology use.²³ Additionally, older patients may find decreased value in telemedicine encounters due to a lack of face-to-face interaction.³⁶

Another barrier identified was the potential fees for patients using telemedicine services. Participants reported the concern that telemedicine visits would not be reimbursed by health insurance companies. Therefore, patients may decide against a telemedicine visit if their insurance company declined service reimbursement. The main issue regarding insurance reimbursement is the requirement of a face-to-face consultation that involves the patient and provider physically being in the same room.⁴ However, in some states the use of real-time consultation between a provider and a patient is acceptable for reimbursement services.⁴ Third-party payers were found to not only potentially influence a patient’s decision to use telemedicine but also influence athletic trainers’ perceptions of telemedicine. One participant was involved in a discussion regarding telemedicine implementation at the worksite after a private health insurance company approached the health care organization in hope of providing consumers with lowered price points. Another participant’s perception of telemedicine was influenced by a health insurance company after learning that the insurance policy allowed access to care at a discounted rate. Both examples demonstrate the potential benefit of lowered health care costs using telemedicine. A systematic review found that, although there was evidence to support reduced health care costs through telemedicine, the limited amount of cost-effectiveness studies makes it impossible to formulate a conclusion regarding the financial benefit of telemedicine.³⁷

Perceived Benefits

Our study found that participants identified numerous benefits of telemedicine, including being a resource for patients who cannot attend a traditional appointment. Various reasons were given why it would be difficult to have a face-to-face appointment, including a conflicting work schedule, having young children, or being homebound. It has been estimated that for more than 2 million U.S. citizens, a barrier to receiving timely access to primary care was due to not having access to transportation.³⁸ Telemedicine allows for access to health care in patients’ homes, which could potentially influence their willingness to schedule appointments.

Our study illustrated the perception that there was increased adherence to follow-up appointments through telemedicine. One participant noted that prior to implementing telemedicine there was low adherence to follow-up appointments at their clinical setting because patients traveled considerable distances for surgery by an orthopedic physician. Although patients were willing to travel for surgery, they were less likely to travel for a follow-up appointment. However, when telemedicine visits were implemented, patients were more likely to attend follow-up appointments. A prior study that investigated telemedicine use in family practice found telemedicine a viable option for routine follow-up appointments.³⁹ Another participant in our study found benefit in time efficiency by scheduling telemedicine visits with a team physician instead of driving long distances for appointments. Telemedicine serves as an access point to health care while alleviating unnecessary emergency department visits and providing appropriate referral and patient education. A previous study highlighted that telemedicine access can potentially cut costs through the reduction of local emergency department visits.⁴⁰

Limitations and Future Research

The current study had the limitation of recruitment through self-identification as a telemedicine user in a national survey; however, it was unknown how frequently telemedicine was used or participants’ experience level with it. The perception that athletic trainers are novice in their education and experience with telemedicine demonstrates the need for future investigations to examine the prevalence of formal educational opportunities of telemedicine use at the professional and post-professional levels and within professional development opportunities specific to athletic training.