James D. Campbell, PhD

In 1995, in recognition of the need for trained family medicine researchers,^1-6 the North American Primary Care Research Group (NAPCRG) Committee on Building Research Capacity launched the Family Medicine Grant Generating Project (GGP) to help family medicine researchers successfully apply for their first major research grant. Between 1995 and the time of the evaluation, 23 faculty participants from 21 family medicine departments enrolled in this year-long “fellowship without walls” designed to permit participants to remain housed in their home department while working on their research proposal. Participants attended 3 GGP sessions held in conjunction with the annual meeting of the Society of Teachers of Family Medicine (STFM), and the NACPRG and the Primary Care Research Methods and Statistics meetings over the course of 1 year. Additionally, participants worked via e-mail, telephone, and postal mail with GGP faculty and research mentors during the year. Many participants met in person with mentors.

Although the program is referred to as a “fellowship” and participants as “fellows,” this is neither a traditional family medicine “fellowship” in which participants are housed for a designated time period (usually 2 years), nor an innovative fellowship in which individuals spend concentrated time at another institution. Traditional fellowships usually offer courses for academic credit in a variety of topics such as statistics and epidemiology and typically result in a master’s degree. GGP, however, is designed to train fellows in the design and writing of competitive external grant proposals: it does not offer courses or a degree. Over the fellowship year, fellows attend sessions that focus on the various tools, techniques, and methods required to produce a competitive proposal. These sessions include time devoted to concept paper development, conducting a literature review, development of specific aims, and elaboration of various research methodologies. GGP uses the term “fellowship” to identify the program as a special 1-year period with at least 25% of the time devoted to developing “grantsmanship skills” and producing a competitive proposal. This program is the only one of its kind in family medicine and therefore cannot be compared with more traditional fellowships programs. This article reports on the evaluation results.

Methods

From December 1999 through April 2000 we mailed surveys to 23 former GGP participants. Respondents were asked to evaluate the GGP’s components (statistics, concept paper, grant writing, mentoring) on a scale from “not at all helpful” to “very helpful.” Several open-ended questions were asked about their program expectations; what they considered GGP’s strengths and weaknesses; how participation contributed to their academic career and helped increase research capacity; the barriers encountered in achieving their research goals; the skills learned; suggestions for improving the program; and advice they would give to future applicants. Respondents were asked to indicate the grants/contracts that they submitted after their fellowship. In addition, demographic information was obtained on age, employment position, date of initiation of GGP, the year they graduated from medical school, and the year they participated in the GGP program.

Eighteen (78%) of the participants returned a completed survey. Reasons for not completing the survey, given either by the participants who chose not to complete the survey, or by their departments, included the participant now working outside research; the participant on leave; the participant in the middle of writing a research grant (R01) and therefore not having time to complete the survey; and lack of response (only 2 participants did not respond after 3 attempts to contact them). Of those who did not complete the survey, 1 was from the first-year class, 2 were from the second-year class, and 2 were from the third-year class.

Results

The average age of respondents was 43.8 years (range, 37-53 years). Most were at the assistant professor level. An additional 4 were at the associate professor level, 2 were research directors, 1 was a professor, 1 was a clinician investigator, and 1 was an interim chair. A total of 12 of the respondents were physicians, 5 had a PhD, and 1 had a Doctor of Public Health degree; 4 of the physicians also had a Masters in Public Health and 2 had a PhD. The average number of years since obtaining their terminal degree was 15.1 years (range, 4-26 years). Most respondents (11) had their terminal degree 15 years or more.

Evaluation of research activities

A total of 58 grants/contracts were submitted by the respondents, representing approximately US$19.3 million. These figures represent an underestimate because 1 first-year class respondent only mentioned having submitted more than 10 grants over the last 3 years ranging from $50,000 to more than $1 million, but did not elaborate further. Due to this lack of specification, this information could not be entered into the subsequent analysis. Seven (12%) of those submitted were training grants, representing approximately $1.7 million. Most (32, or 55%) of the submitted grants/contracts were to nonfederal organizations, whereas 19 (or -33%) were to federal agencies. Although 22 (38%) of the submitted grants/contracts were for less than $50,000, 11 (19%) (excluding training grants) were for more than $300,000. Nineteen (33%) of the submitted grants/contracts were funded including 4 training grants, representing approximately $1 million excluding training grants ($2.3 million including training grants).

Although 22 (38%) of the grant submissions were not funded (representing approximately $6.2 million), another 17 (29%) were pending, representing approximately $10.8 million, including training grants. Based on prior experience, approximately 46% of these pending grants may receive funding, which could result in an additional $4.8 million.

Table 1 shows the number of grants/contracts submitted, funded, not funded, and pending as Principal Investigator (PI) or Co-PI by class year of the GGP fellowship. Most (42, 72%) of the grants/contracts submitted were by the first- or second-year class fellows with 12 grants pending and 16 funded. The Figure 1 shows the number of grants/contracts submitted by submission date and fellowship class year. The number of submissions increased within 1 to 2 years of the fellowship.

Although the sample size was too small for statistical evaluation, some trends are noted. Only 3 of the 18 respondents indicated that they had not submitted a grant or contract as PI or Co-PI, whereas 1 respondent indicated being an evaluator or research director on 6 funded grants. The average number of grants submitted by participants was 4.4. Participants who had submitted a grant tended to be older and to have held their terminal degree for a longer time. Thirty-seven of the total grant/contract submissions were by respondents older than the mean age of 43 years, and 41 of the total grant/contract submissions were by respondents who had received their terminal degree more than 15 years ago. The latter respondents also accounted for 15 of the 19 funded grants. No difference was noted in the rate of grant submission by terminal degree type.

Several respondents also indicated the following grant roles: qualitative analyst on 2 grants; research writer, administrator, project director, or evaluator on 8 grants; co-investigator on 2 grants; and consultant on 4 grants. Twelve of these grants were funded, with 4 training grants representing approximately $1.7 million and 8 research grants representing approximately $1.3 million.

Evaluation of GGP components

Table 2 shows the evaluation of each GGP component. Most respondents indicated that the concept paper and the grant-writing components were very helpful. Additional components indicated as very helpful included networking, mock reviews, consultant mentoring, and peer groups. Compared with the concept paper and grant-writing components, the statistics and the mentoring components were rated as less helpful. Expectations of the GGP

Respondents were asked to describe their major expectations of the GGP. Most respondents replied that they expected to receive help in grant writing, to better understand the grant application process, and to develop helpful relationships with experienced researchers.

All of the respondents indicated that most of their expectations were met. However, respondents were mixed regarding the mentoring process. Although 8 indicated that the mentoring was very helpful, some respondents had difficulty in identifying a mentor or were never successful in finding a mentor, whereas others indicated problems with long distance mentoring.

Strengths of the GGP

Respondents indicated that program strengths include enhancing the value of family medicine research, receiving guidance and feedback, learning from the experiences of their peers, and developing grant-writing skills. Respondents specifically mentioned the focus on the NIH grant process and the mock study section as strengths.

With respect to how the GGP contributed to their career, 7 of the respondents said that the program helped them connect with other researchers and gave them confidence in grant writing. In other instances, the GGP program helped respondents to achieve a more secure position, obtain a promotion, start a career, or change academic departments/institutions. As one respondent mentioned, “I think more critically and more daringly . . . I [was] promoted after that from assistant to associate.”

Most respondents indicated that the GGP program enabled them to mentor, teach, and encourage other faculty members in their department in their grant-writing efforts. As one respondent mentioned, the GGP experience ”. . . has helped me to bridge the gap between clinicians and researchers.”

Challenges of the GGP

The most specific challenge of the GGP program mentioned by respondents was the variable commitment of mentors and the lack of having a mentor with expertise in a respondent’s area of research. The major barriers to respondents toward achieving their research goals were (1) the lack of a supportive research environment including a lack of financial support, few peers engaged in research, a lack of local mentoring, and infrastructural and administrative barriers (eg, no links to statisticians, confused priorities within department, and lack of diversity and foresight in department); (2) the lack of time to do research while participating in clinical duties and academic activities; and (3) the lack of information about funding opportunities at their institution. One respondent mentioned not having any external barriers but that the GGP experience “. . . did cause me to reevaluate and ultimately redefine my research goals.”

When asked what skills they learned during the GGP that helped them address these barriers, several respondents indicated (1) time management, including how to realistically organize the research process; (2) the ability to make connections with outside mentors and consultants; and (3) confidence development, such as contacting a program specialist despite poor information from their institution. However, respondents who mentioned the barrier of a nonsupportive research environment indicated that skills to address this barrier were not taught in the GGP program. Recommendations for improving the GGP

Suggestions for improving the GGP program included having 2 GGP entry levels (for beginning researchers and experienced researchers), continuing networking opportunities for “graduates,” addressing the need for female mentors, following up with consultations and mentoring, and having a mentor with expertise in participants’ area of research.

With respect to advice to future applicants, respondents mentioned being more aggressive in working with a mentor, having reasonable expectations, having long-term support from the department, using time efficiently to network, and reflecting on one’s motivation toward an intensive research career. As one participant said, “I would support the application 100% and notify them that it is one of the best investments of time they can make for their academic career.”

Discussion

The respondents’ comments made clear that the GGP is an “excellent place to start a career.” Most respondents appeared to regard the program as well worth the time and effort invested. Aside from some adjustments, such as consistency in mentoring and accommodating the research focus and skill level of participants, it is “. . . very important to continue [the] effort to train new researchers.” Interestingly, the GGP had a substantial impact on the extent to which many participants are now teaching and mentoring others to help develop the skills necessary for meaningful research.

Moreover, within 1 to 2 years of the program participants achieved a remarkable track record of grant submissions. Although for some participants “. . . breaking in [getting grant awards] still seems mysterious and forbidding,” they appreciated the opportunity to learn how to write a coherent concept paper, how to apply “good methods,” the importance of a track record, and to learn from experienced researchers.

As a result in large part of this evaluation, funding for the GGP has been continued with support from NAPCRG, the American Academy of Family Physicians, the STFM, the College of Family Physicians of Canada, and the home departments of participating academic departments and community-based residency programs.

Family medicine is poised to generate new knowledge through the development of its own research agenda-one that focuses on integrated, relationship-centered patient, family, and community health care.⁷ Young researchers, however, need to be nurtured, mentored, and organizationally supported.⁸ Research initiatives such as the GGP represent a collective enterprise, a building of coalitions toward the development of a culture of family medicine research. Continued research success requires commitments from both individuals and departments if family medicine research is to grow and prosper.

In 1995, in recognition of the need for trained family medicine researchers,^1-6 the North American Primary Care Research Group (NAPCRG) Committee on Building Research Capacity launched the Family Medicine Grant Generating Project (GGP) to help family medicine researchers successfully apply for their first major research grant. Between 1995 and the time of the evaluation, 23 faculty participants from 21 family medicine departments enrolled in this year-long “fellowship without walls” designed to permit participants to remain housed in their home department while working on their research proposal. Participants attended 3 GGP sessions held in conjunction with the annual meeting of the Society of Teachers of Family Medicine (STFM), and the NACPRG and the Primary Care Research Methods and Statistics meetings over the course of 1 year. Additionally, participants worked via e-mail, telephone, and postal mail with GGP faculty and research mentors during the year. Many participants met in person with mentors.

Although the program is referred to as a “fellowship” and participants as “fellows,” this is neither a traditional family medicine “fellowship” in which participants are housed for a designated time period (usually 2 years), nor an innovative fellowship in which individuals spend concentrated time at another institution. Traditional fellowships usually offer courses for academic credit in a variety of topics such as statistics and epidemiology and typically result in a master’s degree. GGP, however, is designed to train fellows in the design and writing of competitive external grant proposals: it does not offer courses or a degree. Over the fellowship year, fellows attend sessions that focus on the various tools, techniques, and methods required to produce a competitive proposal. These sessions include time devoted to concept paper development, conducting a literature review, development of specific aims, and elaboration of various research methodologies. GGP uses the term “fellowship” to identify the program as a special 1-year period with at least 25% of the time devoted to developing “grantsmanship skills” and producing a competitive proposal. This program is the only one of its kind in family medicine and therefore cannot be compared with more traditional fellowships programs. This article reports on the evaluation results.

Methods

From December 1999 through April 2000 we mailed surveys to 23 former GGP participants. Respondents were asked to evaluate the GGP’s components (statistics, concept paper, grant writing, mentoring) on a scale from “not at all helpful” to “very helpful.” Several open-ended questions were asked about their program expectations; what they considered GGP’s strengths and weaknesses; how participation contributed to their academic career and helped increase research capacity; the barriers encountered in achieving their research goals; the skills learned; suggestions for improving the program; and advice they would give to future applicants. Respondents were asked to indicate the grants/contracts that they submitted after their fellowship. In addition, demographic information was obtained on age, employment position, date of initiation of GGP, the year they graduated from medical school, and the year they participated in the GGP program.

Eighteen (78%) of the participants returned a completed survey. Reasons for not completing the survey, given either by the participants who chose not to complete the survey, or by their departments, included the participant now working outside research; the participant on leave; the participant in the middle of writing a research grant (R01) and therefore not having time to complete the survey; and lack of response (only 2 participants did not respond after 3 attempts to contact them). Of those who did not complete the survey, 1 was from the first-year class, 2 were from the second-year class, and 2 were from the third-year class.

Results

The average age of respondents was 43.8 years (range, 37-53 years). Most were at the assistant professor level. An additional 4 were at the associate professor level, 2 were research directors, 1 was a professor, 1 was a clinician investigator, and 1 was an interim chair. A total of 12 of the respondents were physicians, 5 had a PhD, and 1 had a Doctor of Public Health degree; 4 of the physicians also had a Masters in Public Health and 2 had a PhD. The average number of years since obtaining their terminal degree was 15.1 years (range, 4-26 years). Most respondents (11) had their terminal degree 15 years or more.

Evaluation of research activities

A total of 58 grants/contracts were submitted by the respondents, representing approximately US$19.3 million. These figures represent an underestimate because 1 first-year class respondent only mentioned having submitted more than 10 grants over the last 3 years ranging from $50,000 to more than $1 million, but did not elaborate further. Due to this lack of specification, this information could not be entered into the subsequent analysis. Seven (12%) of those submitted were training grants, representing approximately $1.7 million. Most (32, or 55%) of the submitted grants/contracts were to nonfederal organizations, whereas 19 (or -33%) were to federal agencies. Although 22 (38%) of the submitted grants/contracts were for less than $50,000, 11 (19%) (excluding training grants) were for more than $300,000. Nineteen (33%) of the submitted grants/contracts were funded including 4 training grants, representing approximately $1 million excluding training grants ($2.3 million including training grants).

Although 22 (38%) of the grant submissions were not funded (representing approximately $6.2 million), another 17 (29%) were pending, representing approximately $10.8 million, including training grants. Based on prior experience, approximately 46% of these pending grants may receive funding, which could result in an additional $4.8 million.

Table 1 shows the number of grants/contracts submitted, funded, not funded, and pending as Principal Investigator (PI) or Co-PI by class year of the GGP fellowship. Most (42, 72%) of the grants/contracts submitted were by the first- or second-year class fellows with 12 grants pending and 16 funded. The Figure 1 shows the number of grants/contracts submitted by submission date and fellowship class year. The number of submissions increased within 1 to 2 years of the fellowship.

Although the sample size was too small for statistical evaluation, some trends are noted. Only 3 of the 18 respondents indicated that they had not submitted a grant or contract as PI or Co-PI, whereas 1 respondent indicated being an evaluator or research director on 6 funded grants. The average number of grants submitted by participants was 4.4. Participants who had submitted a grant tended to be older and to have held their terminal degree for a longer time. Thirty-seven of the total grant/contract submissions were by respondents older than the mean age of 43 years, and 41 of the total grant/contract submissions were by respondents who had received their terminal degree more than 15 years ago. The latter respondents also accounted for 15 of the 19 funded grants. No difference was noted in the rate of grant submission by terminal degree type.

Several respondents also indicated the following grant roles: qualitative analyst on 2 grants; research writer, administrator, project director, or evaluator on 8 grants; co-investigator on 2 grants; and consultant on 4 grants. Twelve of these grants were funded, with 4 training grants representing approximately $1.7 million and 8 research grants representing approximately $1.3 million.

Evaluation of GGP components

Table 2 shows the evaluation of each GGP component. Most respondents indicated that the concept paper and the grant-writing components were very helpful. Additional components indicated as very helpful included networking, mock reviews, consultant mentoring, and peer groups. Compared with the concept paper and grant-writing components, the statistics and the mentoring components were rated as less helpful. Expectations of the GGP

Respondents were asked to describe their major expectations of the GGP. Most respondents replied that they expected to receive help in grant writing, to better understand the grant application process, and to develop helpful relationships with experienced researchers.

All of the respondents indicated that most of their expectations were met. However, respondents were mixed regarding the mentoring process. Although 8 indicated that the mentoring was very helpful, some respondents had difficulty in identifying a mentor or were never successful in finding a mentor, whereas others indicated problems with long distance mentoring.

Strengths of the GGP

Respondents indicated that program strengths include enhancing the value of family medicine research, receiving guidance and feedback, learning from the experiences of their peers, and developing grant-writing skills. Respondents specifically mentioned the focus on the NIH grant process and the mock study section as strengths.

With respect to how the GGP contributed to their career, 7 of the respondents said that the program helped them connect with other researchers and gave them confidence in grant writing. In other instances, the GGP program helped respondents to achieve a more secure position, obtain a promotion, start a career, or change academic departments/institutions. As one respondent mentioned, “I think more critically and more daringly . . . I [was] promoted after that from assistant to associate.”

Most respondents indicated that the GGP program enabled them to mentor, teach, and encourage other faculty members in their department in their grant-writing efforts. As one respondent mentioned, the GGP experience ”. . . has helped me to bridge the gap between clinicians and researchers.”

Challenges of the GGP

The most specific challenge of the GGP program mentioned by respondents was the variable commitment of mentors and the lack of having a mentor with expertise in a respondent’s area of research. The major barriers to respondents toward achieving their research goals were (1) the lack of a supportive research environment including a lack of financial support, few peers engaged in research, a lack of local mentoring, and infrastructural and administrative barriers (eg, no links to statisticians, confused priorities within department, and lack of diversity and foresight in department); (2) the lack of time to do research while participating in clinical duties and academic activities; and (3) the lack of information about funding opportunities at their institution. One respondent mentioned not having any external barriers but that the GGP experience “. . . did cause me to reevaluate and ultimately redefine my research goals.”

When asked what skills they learned during the GGP that helped them address these barriers, several respondents indicated (1) time management, including how to realistically organize the research process; (2) the ability to make connections with outside mentors and consultants; and (3) confidence development, such as contacting a program specialist despite poor information from their institution. However, respondents who mentioned the barrier of a nonsupportive research environment indicated that skills to address this barrier were not taught in the GGP program. Recommendations for improving the GGP

Suggestions for improving the GGP program included having 2 GGP entry levels (for beginning researchers and experienced researchers), continuing networking opportunities for “graduates,” addressing the need for female mentors, following up with consultations and mentoring, and having a mentor with expertise in participants’ area of research.

With respect to advice to future applicants, respondents mentioned being more aggressive in working with a mentor, having reasonable expectations, having long-term support from the department, using time efficiently to network, and reflecting on one’s motivation toward an intensive research career. As one participant said, “I would support the application 100% and notify them that it is one of the best investments of time they can make for their academic career.”

Discussion

The respondents’ comments made clear that the GGP is an “excellent place to start a career.” Most respondents appeared to regard the program as well worth the time and effort invested. Aside from some adjustments, such as consistency in mentoring and accommodating the research focus and skill level of participants, it is “. . . very important to continue [the] effort to train new researchers.” Interestingly, the GGP had a substantial impact on the extent to which many participants are now teaching and mentoring others to help develop the skills necessary for meaningful research.

Moreover, within 1 to 2 years of the program participants achieved a remarkable track record of grant submissions. Although for some participants “. . . breaking in [getting grant awards] still seems mysterious and forbidding,” they appreciated the opportunity to learn how to write a coherent concept paper, how to apply “good methods,” the importance of a track record, and to learn from experienced researchers.

As a result in large part of this evaluation, funding for the GGP has been continued with support from NAPCRG, the American Academy of Family Physicians, the STFM, the College of Family Physicians of Canada, and the home departments of participating academic departments and community-based residency programs.

Family medicine is poised to generate new knowledge through the development of its own research agenda-one that focuses on integrated, relationship-centered patient, family, and community health care.⁷ Young researchers, however, need to be nurtured, mentored, and organizationally supported.⁸ Research initiatives such as the GGP represent a collective enterprise, a building of coalitions toward the development of a culture of family medicine research. Continued research success requires commitments from both individuals and departments if family medicine research is to grow and prosper.

In 1995, in recognition of the need for trained family medicine researchers,^1-6 the North American Primary Care Research Group (NAPCRG) Committee on Building Research Capacity launched the Family Medicine Grant Generating Project (GGP) to help family medicine researchers successfully apply for their first major research grant. Between 1995 and the time of the evaluation, 23 faculty participants from 21 family medicine departments enrolled in this year-long “fellowship without walls” designed to permit participants to remain housed in their home department while working on their research proposal. Participants attended 3 GGP sessions held in conjunction with the annual meeting of the Society of Teachers of Family Medicine (STFM), and the NACPRG and the Primary Care Research Methods and Statistics meetings over the course of 1 year. Additionally, participants worked via e-mail, telephone, and postal mail with GGP faculty and research mentors during the year. Many participants met in person with mentors.

Although the program is referred to as a “fellowship” and participants as “fellows,” this is neither a traditional family medicine “fellowship” in which participants are housed for a designated time period (usually 2 years), nor an innovative fellowship in which individuals spend concentrated time at another institution. Traditional fellowships usually offer courses for academic credit in a variety of topics such as statistics and epidemiology and typically result in a master’s degree. GGP, however, is designed to train fellows in the design and writing of competitive external grant proposals: it does not offer courses or a degree. Over the fellowship year, fellows attend sessions that focus on the various tools, techniques, and methods required to produce a competitive proposal. These sessions include time devoted to concept paper development, conducting a literature review, development of specific aims, and elaboration of various research methodologies. GGP uses the term “fellowship” to identify the program as a special 1-year period with at least 25% of the time devoted to developing “grantsmanship skills” and producing a competitive proposal. This program is the only one of its kind in family medicine and therefore cannot be compared with more traditional fellowships programs. This article reports on the evaluation results.

Methods

From December 1999 through April 2000 we mailed surveys to 23 former GGP participants. Respondents were asked to evaluate the GGP’s components (statistics, concept paper, grant writing, mentoring) on a scale from “not at all helpful” to “very helpful.” Several open-ended questions were asked about their program expectations; what they considered GGP’s strengths and weaknesses; how participation contributed to their academic career and helped increase research capacity; the barriers encountered in achieving their research goals; the skills learned; suggestions for improving the program; and advice they would give to future applicants. Respondents were asked to indicate the grants/contracts that they submitted after their fellowship. In addition, demographic information was obtained on age, employment position, date of initiation of GGP, the year they graduated from medical school, and the year they participated in the GGP program.

Eighteen (78%) of the participants returned a completed survey. Reasons for not completing the survey, given either by the participants who chose not to complete the survey, or by their departments, included the participant now working outside research; the participant on leave; the participant in the middle of writing a research grant (R01) and therefore not having time to complete the survey; and lack of response (only 2 participants did not respond after 3 attempts to contact them). Of those who did not complete the survey, 1 was from the first-year class, 2 were from the second-year class, and 2 were from the third-year class.

Results

The average age of respondents was 43.8 years (range, 37-53 years). Most were at the assistant professor level. An additional 4 were at the associate professor level, 2 were research directors, 1 was a professor, 1 was a clinician investigator, and 1 was an interim chair. A total of 12 of the respondents were physicians, 5 had a PhD, and 1 had a Doctor of Public Health degree; 4 of the physicians also had a Masters in Public Health and 2 had a PhD. The average number of years since obtaining their terminal degree was 15.1 years (range, 4-26 years). Most respondents (11) had their terminal degree 15 years or more.

Evaluation of research activities

A total of 58 grants/contracts were submitted by the respondents, representing approximately US$19.3 million. These figures represent an underestimate because 1 first-year class respondent only mentioned having submitted more than 10 grants over the last 3 years ranging from $50,000 to more than $1 million, but did not elaborate further. Due to this lack of specification, this information could not be entered into the subsequent analysis. Seven (12%) of those submitted were training grants, representing approximately $1.7 million. Most (32, or 55%) of the submitted grants/contracts were to nonfederal organizations, whereas 19 (or -33%) were to federal agencies. Although 22 (38%) of the submitted grants/contracts were for less than $50,000, 11 (19%) (excluding training grants) were for more than $300,000. Nineteen (33%) of the submitted grants/contracts were funded including 4 training grants, representing approximately $1 million excluding training grants ($2.3 million including training grants).

Although 22 (38%) of the grant submissions were not funded (representing approximately $6.2 million), another 17 (29%) were pending, representing approximately $10.8 million, including training grants. Based on prior experience, approximately 46% of these pending grants may receive funding, which could result in an additional $4.8 million.

Table 1 shows the number of grants/contracts submitted, funded, not funded, and pending as Principal Investigator (PI) or Co-PI by class year of the GGP fellowship. Most (42, 72%) of the grants/contracts submitted were by the first- or second-year class fellows with 12 grants pending and 16 funded. The Figure 1 shows the number of grants/contracts submitted by submission date and fellowship class year. The number of submissions increased within 1 to 2 years of the fellowship.

Although the sample size was too small for statistical evaluation, some trends are noted. Only 3 of the 18 respondents indicated that they had not submitted a grant or contract as PI or Co-PI, whereas 1 respondent indicated being an evaluator or research director on 6 funded grants. The average number of grants submitted by participants was 4.4. Participants who had submitted a grant tended to be older and to have held their terminal degree for a longer time. Thirty-seven of the total grant/contract submissions were by respondents older than the mean age of 43 years, and 41 of the total grant/contract submissions were by respondents who had received their terminal degree more than 15 years ago. The latter respondents also accounted for 15 of the 19 funded grants. No difference was noted in the rate of grant submission by terminal degree type.

Several respondents also indicated the following grant roles: qualitative analyst on 2 grants; research writer, administrator, project director, or evaluator on 8 grants; co-investigator on 2 grants; and consultant on 4 grants. Twelve of these grants were funded, with 4 training grants representing approximately $1.7 million and 8 research grants representing approximately $1.3 million.

Evaluation of GGP components

Table 2 shows the evaluation of each GGP component. Most respondents indicated that the concept paper and the grant-writing components were very helpful. Additional components indicated as very helpful included networking, mock reviews, consultant mentoring, and peer groups. Compared with the concept paper and grant-writing components, the statistics and the mentoring components were rated as less helpful. Expectations of the GGP

Respondents were asked to describe their major expectations of the GGP. Most respondents replied that they expected to receive help in grant writing, to better understand the grant application process, and to develop helpful relationships with experienced researchers.

All of the respondents indicated that most of their expectations were met. However, respondents were mixed regarding the mentoring process. Although 8 indicated that the mentoring was very helpful, some respondents had difficulty in identifying a mentor or were never successful in finding a mentor, whereas others indicated problems with long distance mentoring.

Strengths of the GGP

Respondents indicated that program strengths include enhancing the value of family medicine research, receiving guidance and feedback, learning from the experiences of their peers, and developing grant-writing skills. Respondents specifically mentioned the focus on the NIH grant process and the mock study section as strengths.

With respect to how the GGP contributed to their career, 7 of the respondents said that the program helped them connect with other researchers and gave them confidence in grant writing. In other instances, the GGP program helped respondents to achieve a more secure position, obtain a promotion, start a career, or change academic departments/institutions. As one respondent mentioned, “I think more critically and more daringly . . . I [was] promoted after that from assistant to associate.”

Most respondents indicated that the GGP program enabled them to mentor, teach, and encourage other faculty members in their department in their grant-writing efforts. As one respondent mentioned, the GGP experience ”. . . has helped me to bridge the gap between clinicians and researchers.”

Challenges of the GGP

The most specific challenge of the GGP program mentioned by respondents was the variable commitment of mentors and the lack of having a mentor with expertise in a respondent’s area of research. The major barriers to respondents toward achieving their research goals were (1) the lack of a supportive research environment including a lack of financial support, few peers engaged in research, a lack of local mentoring, and infrastructural and administrative barriers (eg, no links to statisticians, confused priorities within department, and lack of diversity and foresight in department); (2) the lack of time to do research while participating in clinical duties and academic activities; and (3) the lack of information about funding opportunities at their institution. One respondent mentioned not having any external barriers but that the GGP experience “. . . did cause me to reevaluate and ultimately redefine my research goals.”

When asked what skills they learned during the GGP that helped them address these barriers, several respondents indicated (1) time management, including how to realistically organize the research process; (2) the ability to make connections with outside mentors and consultants; and (3) confidence development, such as contacting a program specialist despite poor information from their institution. However, respondents who mentioned the barrier of a nonsupportive research environment indicated that skills to address this barrier were not taught in the GGP program. Recommendations for improving the GGP

Suggestions for improving the GGP program included having 2 GGP entry levels (for beginning researchers and experienced researchers), continuing networking opportunities for “graduates,” addressing the need for female mentors, following up with consultations and mentoring, and having a mentor with expertise in participants’ area of research.

With respect to advice to future applicants, respondents mentioned being more aggressive in working with a mentor, having reasonable expectations, having long-term support from the department, using time efficiently to network, and reflecting on one’s motivation toward an intensive research career. As one participant said, “I would support the application 100% and notify them that it is one of the best investments of time they can make for their academic career.”

Discussion

The respondents’ comments made clear that the GGP is an “excellent place to start a career.” Most respondents appeared to regard the program as well worth the time and effort invested. Aside from some adjustments, such as consistency in mentoring and accommodating the research focus and skill level of participants, it is “. . . very important to continue [the] effort to train new researchers.” Interestingly, the GGP had a substantial impact on the extent to which many participants are now teaching and mentoring others to help develop the skills necessary for meaningful research.

Moreover, within 1 to 2 years of the program participants achieved a remarkable track record of grant submissions. Although for some participants “. . . breaking in [getting grant awards] still seems mysterious and forbidding,” they appreciated the opportunity to learn how to write a coherent concept paper, how to apply “good methods,” the importance of a track record, and to learn from experienced researchers.

As a result in large part of this evaluation, funding for the GGP has been continued with support from NAPCRG, the American Academy of Family Physicians, the STFM, the College of Family Physicians of Canada, and the home departments of participating academic departments and community-based residency programs.

Family medicine is poised to generate new knowledge through the development of its own research agenda-one that focuses on integrated, relationship-centered patient, family, and community health care.⁷ Young researchers, however, need to be nurtured, mentored, and organizationally supported.⁸ Research initiatives such as the GGP represent a collective enterprise, a building of coalitions toward the development of a culture of family medicine research. Continued research success requires commitments from both individuals and departments if family medicine research is to grow and prosper.

Telemedicine can be broadly defined as the use of telecommunications to provide medical information and services.¹ It includes a computer connected to the Internet and videoconferencing. The Internet, for example, could be used to improve patient care and enhance biomedical research by connecting practitioners to up-to-date information.² With nearly 110,000 American physicians routinely using the Internet in 1995,³ some believe that it will change the patterns of physician-patient relationships.⁴ A few physicians claim that communicating by E-mail with patients about nonemergent care and test results has saved time and money.^3,5,6

Videoconferencing can help physicians manage the medical and financial risks of providing care to rural and underserved patients.¹ It has been used successfully throughout the United States in such specialties as dermatology,^7-9 psychiatry,^10-15 pulmonary medicine,¹⁶ and cardiology.^17-19 Efforts to expand the use of telemedicine have contributed to making it a cheaper method of providing medical information and education.^20-22

Rural health providers face unique challenges in delivering care: isolation, lack of communication, and lack of access to current medical information and continuing medical education.^23-28 Although telemedicine promises to address these problems with computers and videoconferencing, rural physicians have been slow to accept it.^29-36

The Missouri Telemedicine Network (MTN) consists of 21 videoconferencing sites in 16 Missouri counties. We evaluated a demonstration project in 3 of the counties where a high-speed computer data infrastructure was installed in 10 outpatient practices in 4 communities with populations ranging from 3000 to 8000. The infrastructure included a computer workstation with E-mail, access to the World Wide Web, medical databases including MEDLINE, community-specific demographic information, a calendar, and access to a medical librarian. Important goals of the workstation included fostering networking and access to educational opportunities and current medical information. The videoconferencing facilities were located in the hospitals in the 3 demonstration counties, plus one large group practice clinic. Participation in the project was voluntary.

Because changing physician behavior has proved difficult,^31,36-40 we investigated how rural health care providers perceive the introduction of telemedicine (videoconferencing and a computer workstation) to their practices. We also wanted to create a framework for assessing the readiness of rural providers to adopt telemedicine and to develop a guide for fostering the adoption of this technology.

Methods

We collected qualitative data during semistructured interviews using questions developed from pilot interviews with information specialists and MTN participants. Data were gathered at 10 outpatient practices in the 4 communities with both a computer infrastructure and videoconferencing. Three of the out-patient practices were affiliated with a public tertiary care center; 7 were private practices; and 3 were group practices. Our sampling matrix included physicians, nurses, and administrative staff from all the clinics. Between March and August 1998 we individually interviewed all physicians at the site and at least 2 nurses and administrative staff from each clinic. All interviews were conducted by the second author.

After giving their consent, all participants responded to the following open-ended questions regarding both the video and computer components of telemedicine: (1) What do you perceive are the advantages and disadvantages of the telemedicine technology? (2) What do you perceive are the barriers and facilitators to using the telemedicine technology? (3) How do you use the telemedicine technology? (4) Can you describe the ways in which the telemedicine technology has changed your role? (5) How has the telemedicine technology affected the quality of care you deliver? (6) Do you have any suggestions for improving the telemedicine technology? In addition to these 6 questions, we collected demographic information on age, sex, length of practice, and provider status at the end of the interview.

To guard against any bias toward advocating telemedicine, we stated to respondents at the beginning of the interview that we wanted their honest observations about telemedicine and that their responses would be confidential. We confirmed their observations throughout the interview. Also, before analyzing the data we noted our own bias and preconceptions toward telemedicine, so we could consciously avoid them while reviewing the data.⁴¹

Study staff transcribed the interviews verbatim and entered them into a computer database program, Ethnograph, which was designed to help organize textual material.⁴² We divided interviews by technology type—videoconferencing versus the computer component—and made an initial template analysis to organize and code the data.⁴³ The investigators’ multiple readings of the interviews led to further revisions of the codes until consensus was reached on the identification of salient issues or themes.^44,45 The coding scheme and the salient themes were then reviewed independently by a panel of information specialists and health care providers from nursing and medicine who were familiar with the demonstration project. The panel represented individuals with expertise in informatics and qualitative methods.

Quantitative outcome data were also obtained for each participant. Between March 1998 and February 1999, file servers in each county automatically collected data on use of the Web (number of pages accessed) and E-mail (number sent and received) through the workstation. The content of E-mails remained confidential.

Results

We completed 57 interviews. Thirteen were with physicians (9 men, 4 women) averaging 52 years of age and 19 years in rural practice. Eight were family practice physicians; 4 were in internal medicine; and one physician was in general surgery. Twenty interviews were with nurses or nurse practitioners (17 women, 3 men) averaging 43 years of age and 15 years in rural practice. Twenty-four interviews were with the administrative staff (18 women, 6 men) averaging 45 years of age and 14 years in administration. Before the implementation of telemedicine, all of the participants had minimal experience with information technology.

Those practices that were affiliated with a public tertiary care center had higher telemedicine use than those in private practices, although the overall use level would be considered low. For example, the monthly average number of E-mail messages sent from practices that were affiliated with a public tertiary care center was 25.6, while for those in private practice the average was 11.3. For E-mail messages received, the monthly average was 48.8 and 20.2, respectively. Nine of the 13 physicians used the Web, and those affiliated with the tertiary care center used it far more than those in private practice. A yearly total of 8140 visits to a single Web page was recorded for those affiliated with the tertiary care center (mean = 22.3 per day) compared with a yearly total of 734 visits to a single Web page for those in private practice (mean = 2.01 per day; P=.111). Computer use was also higher for the 4 practice sites that had a nurse practitioner.

Data were systematically gathered on the use of the videoconferencing system. However, the majority of the data represent regular dermatology or psychiatric clinics that were conducted between university physicians and patients from the rural site. The rural physicians rarely participated.

Interviews and other data yielded 6 themes related to the care providers’ receptivity to technologic change: turf, efficacy, practice context, apprehension, time to learn, and ownership. Each of these themes applies to the computer and video components of telemedicine, and each may operate as a perceived barrier or facilitator of change, depending on the provider in question. Some providers saw telemedicine as a welcome opportunity to learn, and others were resistant. The themes inevitably overlap at times, because we were qualitatively assessing the social context in which technologic changes take place.

Turf

This theme summarizes our findings from care providers who perceived telemedicine as a threat to their livelihood or professional autonomy or both. Health care practices are enmeshed in networks of social relationships. Satellite practices with direct ties to larger health care systems employ patterns of referral and consultation as part of the larger system. Private practices are autonomous units that have relationships with other providers and systems based on patterns of referral and consultation initiated by the physician.

Purveyors of telemedicine may assume that simply making this technology available will somehow persuade providers to automatically accept it and use it successfully.⁴⁶ However, some rural physicians see telemedicine as an intrusion on their territory by the urban tertiary care center.⁴⁷

Although some participants affiliated with the tertiary center saw the technology as a “good thing…it was nice to be connected to a big university,” others, particularly those in private practice, saw it as a potential threat to their sense of competency, autonomy, and livelihood.³⁷ One office staff participant in a private practice remarked on the perception among the rural providers that they “are not seen as practicing their craft correctly, that they’re not up to speed, and that’s why this [telemedicine] has come out here.”

A nurse practitioner in a private practice alluded to telemedicine as a threat to professional autonomy when she said, “I have experienced times when, although the intentions were good, the community has rejected it hands down because they didn’t need help from the outside.”

Efficacy

This theme refers to the participants’ desire to know that telemedicine will fill a functional need in their practice before they invest time and money in making such a big change. Telemedicine has no track record of directly improving patient care outcomes. Unlike drug therapies or medical procedures, telemedicine exerts indirect effects on outcomes with its abilities to enhance, streamline, or improve the process of health care delivery.

Some physicians we interviewed saw no compelling reason to integrate telemedicine into their practices. One physician in private practice who rarely used the computer said, “It doesn’t really help a lot. I think computers are good for specialists, and in primary care you know basically most of the stuff…then the other 20% of it that’s more difficult, you look it up in routine journals.”

Although some physicians saw no reason to integrate the new technology, others simply “don’t think about it.” Still other physicians—mostly those affiliated with a tertiary care center where computer technology figured prominently in patient care—welcomed telemedicine and quickly saw capabilities that would enhance their practices.

Practice Context

This theme refers to barriers to adopting telemedicine that clinics may face because they practice in rural areas where technologic change moves at a slower pace than in urban communities. One nurse practitioner in a private practice said, “We got 911 [emergency] 3 years ago. Three years before that, we finally had a 7-digit phone number. So, I think that the expectations for the rate of change and the learning curve should be pretty generous.” However, several participants, particularly those affiliated with a tertiary center, were positive that telemedicine would eventually catch on.

Apprehension

In contrast to the practice context, this theme refers to the apprehension of individual providers. When it comes to adopting new technology, some participants were philosophical about what they described as a human aversion to change. “People are scared of technology,” said one physician. Another physician in private practice said, “We don’t want to change. Everybody’s just fine the way it is…. I’m not prepared for this.”

Some providers had little confidence in their ability to operate the technology, and one nurse feared that her ignorance would get her into legal trouble: “I’m always afraid I’ll push the wrong button and…something will come up and it will say ‘illegal action.’ It scares me. I think ‘Oh my gosh, I’ve done something against the law.’“

Participants were also concerned about whether the information they would get though the videoconferencing channel would be reliable. A similar concern applied to information on the Internet. A physician in a private practice who was reluctant to use the computer workstation said: “The biggest problem I have with it (the Internet) is you don’t know [what] you’re getting…. There’s a lot of stuff on the Internet that’s no good.”

Although several physicians, particularly those in private practice, were apprehensive about telemedicine, they were willing to let others in their practice learn and use the technology. Some physicians in private practice, however, reflected on the seeming inevitability of change and were resigned to having to learn the technology.

Time to learn

This theme refers to hesitancy among providers to take the time to learn a new technology and to persuade patients of its worth.

One nurse/office manager said, “If I’m looking up something in a book, maybe the book is old, but at least I could have it done in 5 minutes…until I get good at this [computer], it’s taking me much longer.”

One physician in private practice bemoaned spending his time persuading patients that this new technology could benefit them. In contrast, a physician affiliated with a tertiary center noted several advantages of videoconferencing.

Ownership

This theme refers to participants who were professionally and emotionally invested in the technology—stakeholders who acknowledged its benefits, adapted it to their needs, and tried to help others learn. Predictably, this higher level of investment was most common in administrators, because of their familiarity with computerized procedures and records. One administrator affiliated with a tertiary center offered an example of this keen interest: “Yeah, we developed our own policies. We took some of the training modules and modified them to match what we thought. And we really had…everybody buy into using the same policies.”

The stakeholders often encourage others to “buy in” to the new technology, as described by this administrator affiliated with a tertiary center: “I don’t worry about the members of this group using it in a negative way. I want them to use it more…. The more exposure that they have to it, the more accustomed they’re going to be to using it.”

Discussion

These 6 themes (turf, efficacy, practice context, apprehension, time to learn, and ownership) provide a framework for understanding some consequences of introducing telemedicine into a rural setting. Although these themes have been noted to varying degrees by others,^29-37,46,48 we grouped all of them as key contextual elements of the rural health environment. Aside from technical issues, such as the user-friendliness of the technology, the elemental themes that emerged from our data helped us explore this broader context.

Introducing telemedicine into a rural setting is analogous in many ways to introducing managed care into such areas. Some rural providers perceive managed care as an opportunity, while others see it as a threat to their practices, taking the local health care dollar away.⁴⁹ Similarly, providers’ perceptions of telemedicine range from seeing it as a chance to improve health care delivery, as nonessential technology, or, at worst, as a threat.

Those introducing telemedicine to these areas appear to be most likely to succeed if they begin with an understanding of how the new technology is perceived by rural providers. The 6 themes we identified provide some essentials for understanding the initial process of technological change in a rural health care practice. Based on our results, rural providers’ acceptance of telemedicine is most likely to occur when there is a greater organizational integration of the new technology, a perceived increase in time efficiency, greater affiliation with a tertiary care center, a perceived increase in ownership, an enhanced ability to accommodate the changes, a reduction in apprehension, and the realization of the slower pace of change in a rural community.

These themes can be considered core issues for developing a plan that can be used when introducing telemedicine. Specific questions can then be formulated to aid in this process, including: Is there a perceived need for the technology? (turf); Who is initiating the technological change, and how it that perceived? (efficacy); How is the rate of technologic change perceived in the community? (practice context); How flexible are the users toward technologic change? What is the level of anxiety about using the technology? (apprehension); How is the time expended to learn and use the technology perceived? (time to learn); and Who manages and supports the technology? (ownership). Answers to these questions can help those introducing telemedicine to structure specific strategies for implementation that are tailored to fit the needs and concerns of each practice.

Strategies for change

After acknowledging the variability of rural practices and practice behaviors and the environmental conditions of the 10 practices in our study, we grouped them into 3 categories according to their readiness for implanting telemedicine: fertile soil, somewhat fertile soil, and barren soil. For each of these conditions, we propose strategies for change that enhance the potential for the growth of telemedicine as illustrated in the Table 1.^50-52 For those practices that have been identified as fertile soil, it is important to include the physicians and administrators in the entire planning and implementation process.⁵³ They are more likely to use physician extenders, so it is important to facilitate team building with regard to new innovations, while at the same time building various coalitions with other affiliated physicians. Empowerment is also a key to making sure the innovation is successfully implemented. Appropriate resources need to be provided, such as space for the innovation (or technology) and adequate personnel, access, and training.⁵²

For practices identified as having partly fertile soil for change, it is important to establish a sense of urgency for the implementation of the new technology and to engage in coalition building within the community and with other specialty physicians. Help is needed to create a new vision for the practice, and this should be communicated to all employees. It also helps to provide for short-term incentives regarding the new technology.⁵²

Engaging barren soil types of practices in implementing new technologies is difficult. It is possible, however, to facilitate change in the practice by developing a perceived need for the technology through presenting the physician(s) with current evidence-based medical information, for example. All the physicians need to be included in the planning and implementing process,⁵³ and steps should be taken to facilitate coalition building within the community.⁵²

Implementation strategies need to be tailored to the environmental conditions of practice sites that are carefully chosen for their potential to cultivate telemedicine. Successful sites can become exemplars to others. Establishing relationships with a practice site, however, begins with diplomatic negotiation that is sensitive to local conditions. A commitment must be made to nurture the relationship.

Limitations

The strength of our study lies in the initial investigation of rural health care providers’ perceptions of telemedicine, and we are not aware of any similar qualitative studies in the literature. The results of our study are limited, however, to the recent introduction of telemedicine technologies into rural settings. We presented perceptions of providers who were just beginning to adjust to new technologies. Future research is needed to determine the extent of these perceptions among rural health care providers in general and in particular whether some of the negative perceptions of telemedicine of the providers in our study will change over time.

Conclusions

Rural health care providers and administrators consider a range of factors, including economic ramifications, efficacy, social pressure, and apprehension, in deciding whether and how fast to adopt telemedicine technology. Since adopting this technology can be a major change, agencies trying to introduce it into rural areas should take all these factors into account in their approach to rural health care providers, staff, and communities.

Acknowledgments

Our study was funded by the National Library of Medicine, contract number: NO1-LM-6-3538.

Related resources

• Telemedicine Information Exchange (TIE) A National Library of Medicine-funded web page which offers comprehensive information on telemedicine and telehealth. http://tie.telemed.org
• Telemedicine And Health Care Informatics Legal Issues Web site A resource for providers, lawyers, professionals or anyone interested in learning more about health care law and, more specifically, the regulatory and transactional aspects of health care. http://www.netreach.net

Telemedicine can be broadly defined as the use of telecommunications to provide medical information and services.¹ It includes a computer connected to the Internet and videoconferencing. The Internet, for example, could be used to improve patient care and enhance biomedical research by connecting practitioners to up-to-date information.² With nearly 110,000 American physicians routinely using the Internet in 1995,³ some believe that it will change the patterns of physician-patient relationships.⁴ A few physicians claim that communicating by E-mail with patients about nonemergent care and test results has saved time and money.^3,5,6

Videoconferencing can help physicians manage the medical and financial risks of providing care to rural and underserved patients.¹ It has been used successfully throughout the United States in such specialties as dermatology,^7-9 psychiatry,^10-15 pulmonary medicine,¹⁶ and cardiology.^17-19 Efforts to expand the use of telemedicine have contributed to making it a cheaper method of providing medical information and education.^20-22

Rural health providers face unique challenges in delivering care: isolation, lack of communication, and lack of access to current medical information and continuing medical education.^23-28 Although telemedicine promises to address these problems with computers and videoconferencing, rural physicians have been slow to accept it.^29-36

The Missouri Telemedicine Network (MTN) consists of 21 videoconferencing sites in 16 Missouri counties. We evaluated a demonstration project in 3 of the counties where a high-speed computer data infrastructure was installed in 10 outpatient practices in 4 communities with populations ranging from 3000 to 8000. The infrastructure included a computer workstation with E-mail, access to the World Wide Web, medical databases including MEDLINE, community-specific demographic information, a calendar, and access to a medical librarian. Important goals of the workstation included fostering networking and access to educational opportunities and current medical information. The videoconferencing facilities were located in the hospitals in the 3 demonstration counties, plus one large group practice clinic. Participation in the project was voluntary.

Because changing physician behavior has proved difficult,^31,36-40 we investigated how rural health care providers perceive the introduction of telemedicine (videoconferencing and a computer workstation) to their practices. We also wanted to create a framework for assessing the readiness of rural providers to adopt telemedicine and to develop a guide for fostering the adoption of this technology.

Methods

We collected qualitative data during semistructured interviews using questions developed from pilot interviews with information specialists and MTN participants. Data were gathered at 10 outpatient practices in the 4 communities with both a computer infrastructure and videoconferencing. Three of the out-patient practices were affiliated with a public tertiary care center; 7 were private practices; and 3 were group practices. Our sampling matrix included physicians, nurses, and administrative staff from all the clinics. Between March and August 1998 we individually interviewed all physicians at the site and at least 2 nurses and administrative staff from each clinic. All interviews were conducted by the second author.

After giving their consent, all participants responded to the following open-ended questions regarding both the video and computer components of telemedicine: (1) What do you perceive are the advantages and disadvantages of the telemedicine technology? (2) What do you perceive are the barriers and facilitators to using the telemedicine technology? (3) How do you use the telemedicine technology? (4) Can you describe the ways in which the telemedicine technology has changed your role? (5) How has the telemedicine technology affected the quality of care you deliver? (6) Do you have any suggestions for improving the telemedicine technology? In addition to these 6 questions, we collected demographic information on age, sex, length of practice, and provider status at the end of the interview.

To guard against any bias toward advocating telemedicine, we stated to respondents at the beginning of the interview that we wanted their honest observations about telemedicine and that their responses would be confidential. We confirmed their observations throughout the interview. Also, before analyzing the data we noted our own bias and preconceptions toward telemedicine, so we could consciously avoid them while reviewing the data.⁴¹

Study staff transcribed the interviews verbatim and entered them into a computer database program, Ethnograph, which was designed to help organize textual material.⁴² We divided interviews by technology type—videoconferencing versus the computer component—and made an initial template analysis to organize and code the data.⁴³ The investigators’ multiple readings of the interviews led to further revisions of the codes until consensus was reached on the identification of salient issues or themes.^44,45 The coding scheme and the salient themes were then reviewed independently by a panel of information specialists and health care providers from nursing and medicine who were familiar with the demonstration project. The panel represented individuals with expertise in informatics and qualitative methods.

Quantitative outcome data were also obtained for each participant. Between March 1998 and February 1999, file servers in each county automatically collected data on use of the Web (number of pages accessed) and E-mail (number sent and received) through the workstation. The content of E-mails remained confidential.

Results

We completed 57 interviews. Thirteen were with physicians (9 men, 4 women) averaging 52 years of age and 19 years in rural practice. Eight were family practice physicians; 4 were in internal medicine; and one physician was in general surgery. Twenty interviews were with nurses or nurse practitioners (17 women, 3 men) averaging 43 years of age and 15 years in rural practice. Twenty-four interviews were with the administrative staff (18 women, 6 men) averaging 45 years of age and 14 years in administration. Before the implementation of telemedicine, all of the participants had minimal experience with information technology.

Those practices that were affiliated with a public tertiary care center had higher telemedicine use than those in private practices, although the overall use level would be considered low. For example, the monthly average number of E-mail messages sent from practices that were affiliated with a public tertiary care center was 25.6, while for those in private practice the average was 11.3. For E-mail messages received, the monthly average was 48.8 and 20.2, respectively. Nine of the 13 physicians used the Web, and those affiliated with the tertiary care center used it far more than those in private practice. A yearly total of 8140 visits to a single Web page was recorded for those affiliated with the tertiary care center (mean = 22.3 per day) compared with a yearly total of 734 visits to a single Web page for those in private practice (mean = 2.01 per day; P=.111). Computer use was also higher for the 4 practice sites that had a nurse practitioner.

Data were systematically gathered on the use of the videoconferencing system. However, the majority of the data represent regular dermatology or psychiatric clinics that were conducted between university physicians and patients from the rural site. The rural physicians rarely participated.

Interviews and other data yielded 6 themes related to the care providers’ receptivity to technologic change: turf, efficacy, practice context, apprehension, time to learn, and ownership. Each of these themes applies to the computer and video components of telemedicine, and each may operate as a perceived barrier or facilitator of change, depending on the provider in question. Some providers saw telemedicine as a welcome opportunity to learn, and others were resistant. The themes inevitably overlap at times, because we were qualitatively assessing the social context in which technologic changes take place.

Turf

This theme summarizes our findings from care providers who perceived telemedicine as a threat to their livelihood or professional autonomy or both. Health care practices are enmeshed in networks of social relationships. Satellite practices with direct ties to larger health care systems employ patterns of referral and consultation as part of the larger system. Private practices are autonomous units that have relationships with other providers and systems based on patterns of referral and consultation initiated by the physician.

Purveyors of telemedicine may assume that simply making this technology available will somehow persuade providers to automatically accept it and use it successfully.⁴⁶ However, some rural physicians see telemedicine as an intrusion on their territory by the urban tertiary care center.⁴⁷

Although some participants affiliated with the tertiary center saw the technology as a “good thing…it was nice to be connected to a big university,” others, particularly those in private practice, saw it as a potential threat to their sense of competency, autonomy, and livelihood.³⁷ One office staff participant in a private practice remarked on the perception among the rural providers that they “are not seen as practicing their craft correctly, that they’re not up to speed, and that’s why this [telemedicine] has come out here.”

A nurse practitioner in a private practice alluded to telemedicine as a threat to professional autonomy when she said, “I have experienced times when, although the intentions were good, the community has rejected it hands down because they didn’t need help from the outside.”

Efficacy

This theme refers to the participants’ desire to know that telemedicine will fill a functional need in their practice before they invest time and money in making such a big change. Telemedicine has no track record of directly improving patient care outcomes. Unlike drug therapies or medical procedures, telemedicine exerts indirect effects on outcomes with its abilities to enhance, streamline, or improve the process of health care delivery.

Some physicians we interviewed saw no compelling reason to integrate telemedicine into their practices. One physician in private practice who rarely used the computer said, “It doesn’t really help a lot. I think computers are good for specialists, and in primary care you know basically most of the stuff…then the other 20% of it that’s more difficult, you look it up in routine journals.”

Although some physicians saw no reason to integrate the new technology, others simply “don’t think about it.” Still other physicians—mostly those affiliated with a tertiary care center where computer technology figured prominently in patient care—welcomed telemedicine and quickly saw capabilities that would enhance their practices.

Practice Context

This theme refers to barriers to adopting telemedicine that clinics may face because they practice in rural areas where technologic change moves at a slower pace than in urban communities. One nurse practitioner in a private practice said, “We got 911 [emergency] 3 years ago. Three years before that, we finally had a 7-digit phone number. So, I think that the expectations for the rate of change and the learning curve should be pretty generous.” However, several participants, particularly those affiliated with a tertiary center, were positive that telemedicine would eventually catch on.

Apprehension

In contrast to the practice context, this theme refers to the apprehension of individual providers. When it comes to adopting new technology, some participants were philosophical about what they described as a human aversion to change. “People are scared of technology,” said one physician. Another physician in private practice said, “We don’t want to change. Everybody’s just fine the way it is…. I’m not prepared for this.”

Some providers had little confidence in their ability to operate the technology, and one nurse feared that her ignorance would get her into legal trouble: “I’m always afraid I’ll push the wrong button and…something will come up and it will say ‘illegal action.’ It scares me. I think ‘Oh my gosh, I’ve done something against the law.’“

Participants were also concerned about whether the information they would get though the videoconferencing channel would be reliable. A similar concern applied to information on the Internet. A physician in a private practice who was reluctant to use the computer workstation said: “The biggest problem I have with it (the Internet) is you don’t know [what] you’re getting…. There’s a lot of stuff on the Internet that’s no good.”

Although several physicians, particularly those in private practice, were apprehensive about telemedicine, they were willing to let others in their practice learn and use the technology. Some physicians in private practice, however, reflected on the seeming inevitability of change and were resigned to having to learn the technology.

Time to learn

This theme refers to hesitancy among providers to take the time to learn a new technology and to persuade patients of its worth.

One nurse/office manager said, “If I’m looking up something in a book, maybe the book is old, but at least I could have it done in 5 minutes…until I get good at this [computer], it’s taking me much longer.”

One physician in private practice bemoaned spending his time persuading patients that this new technology could benefit them. In contrast, a physician affiliated with a tertiary center noted several advantages of videoconferencing.

Ownership

This theme refers to participants who were professionally and emotionally invested in the technology—stakeholders who acknowledged its benefits, adapted it to their needs, and tried to help others learn. Predictably, this higher level of investment was most common in administrators, because of their familiarity with computerized procedures and records. One administrator affiliated with a tertiary center offered an example of this keen interest: “Yeah, we developed our own policies. We took some of the training modules and modified them to match what we thought. And we really had…everybody buy into using the same policies.”

The stakeholders often encourage others to “buy in” to the new technology, as described by this administrator affiliated with a tertiary center: “I don’t worry about the members of this group using it in a negative way. I want them to use it more…. The more exposure that they have to it, the more accustomed they’re going to be to using it.”

Discussion

These 6 themes (turf, efficacy, practice context, apprehension, time to learn, and ownership) provide a framework for understanding some consequences of introducing telemedicine into a rural setting. Although these themes have been noted to varying degrees by others,^29-37,46,48 we grouped all of them as key contextual elements of the rural health environment. Aside from technical issues, such as the user-friendliness of the technology, the elemental themes that emerged from our data helped us explore this broader context.

Introducing telemedicine into a rural setting is analogous in many ways to introducing managed care into such areas. Some rural providers perceive managed care as an opportunity, while others see it as a threat to their practices, taking the local health care dollar away.⁴⁹ Similarly, providers’ perceptions of telemedicine range from seeing it as a chance to improve health care delivery, as nonessential technology, or, at worst, as a threat.

Those introducing telemedicine to these areas appear to be most likely to succeed if they begin with an understanding of how the new technology is perceived by rural providers. The 6 themes we identified provide some essentials for understanding the initial process of technological change in a rural health care practice. Based on our results, rural providers’ acceptance of telemedicine is most likely to occur when there is a greater organizational integration of the new technology, a perceived increase in time efficiency, greater affiliation with a tertiary care center, a perceived increase in ownership, an enhanced ability to accommodate the changes, a reduction in apprehension, and the realization of the slower pace of change in a rural community.

These themes can be considered core issues for developing a plan that can be used when introducing telemedicine. Specific questions can then be formulated to aid in this process, including: Is there a perceived need for the technology? (turf); Who is initiating the technological change, and how it that perceived? (efficacy); How is the rate of technologic change perceived in the community? (practice context); How flexible are the users toward technologic change? What is the level of anxiety about using the technology? (apprehension); How is the time expended to learn and use the technology perceived? (time to learn); and Who manages and supports the technology? (ownership). Answers to these questions can help those introducing telemedicine to structure specific strategies for implementation that are tailored to fit the needs and concerns of each practice.

Strategies for change

After acknowledging the variability of rural practices and practice behaviors and the environmental conditions of the 10 practices in our study, we grouped them into 3 categories according to their readiness for implanting telemedicine: fertile soil, somewhat fertile soil, and barren soil. For each of these conditions, we propose strategies for change that enhance the potential for the growth of telemedicine as illustrated in the Table 1.^50-52 For those practices that have been identified as fertile soil, it is important to include the physicians and administrators in the entire planning and implementation process.⁵³ They are more likely to use physician extenders, so it is important to facilitate team building with regard to new innovations, while at the same time building various coalitions with other affiliated physicians. Empowerment is also a key to making sure the innovation is successfully implemented. Appropriate resources need to be provided, such as space for the innovation (or technology) and adequate personnel, access, and training.⁵²

For practices identified as having partly fertile soil for change, it is important to establish a sense of urgency for the implementation of the new technology and to engage in coalition building within the community and with other specialty physicians. Help is needed to create a new vision for the practice, and this should be communicated to all employees. It also helps to provide for short-term incentives regarding the new technology.⁵²

Engaging barren soil types of practices in implementing new technologies is difficult. It is possible, however, to facilitate change in the practice by developing a perceived need for the technology through presenting the physician(s) with current evidence-based medical information, for example. All the physicians need to be included in the planning and implementing process,⁵³ and steps should be taken to facilitate coalition building within the community.⁵²

Implementation strategies need to be tailored to the environmental conditions of practice sites that are carefully chosen for their potential to cultivate telemedicine. Successful sites can become exemplars to others. Establishing relationships with a practice site, however, begins with diplomatic negotiation that is sensitive to local conditions. A commitment must be made to nurture the relationship.

Limitations

The strength of our study lies in the initial investigation of rural health care providers’ perceptions of telemedicine, and we are not aware of any similar qualitative studies in the literature. The results of our study are limited, however, to the recent introduction of telemedicine technologies into rural settings. We presented perceptions of providers who were just beginning to adjust to new technologies. Future research is needed to determine the extent of these perceptions among rural health care providers in general and in particular whether some of the negative perceptions of telemedicine of the providers in our study will change over time.

Conclusions

Rural health care providers and administrators consider a range of factors, including economic ramifications, efficacy, social pressure, and apprehension, in deciding whether and how fast to adopt telemedicine technology. Since adopting this technology can be a major change, agencies trying to introduce it into rural areas should take all these factors into account in their approach to rural health care providers, staff, and communities.

Acknowledgments

Our study was funded by the National Library of Medicine, contract number: NO1-LM-6-3538.

Related resources

• Telemedicine Information Exchange (TIE) A National Library of Medicine-funded web page which offers comprehensive information on telemedicine and telehealth. http://tie.telemed.org
• Telemedicine And Health Care Informatics Legal Issues Web site A resource for providers, lawyers, professionals or anyone interested in learning more about health care law and, more specifically, the regulatory and transactional aspects of health care. http://www.netreach.net

Telemedicine can be broadly defined as the use of telecommunications to provide medical information and services.¹ It includes a computer connected to the Internet and videoconferencing. The Internet, for example, could be used to improve patient care and enhance biomedical research by connecting practitioners to up-to-date information.² With nearly 110,000 American physicians routinely using the Internet in 1995,³ some believe that it will change the patterns of physician-patient relationships.⁴ A few physicians claim that communicating by E-mail with patients about nonemergent care and test results has saved time and money.^3,5,6

Videoconferencing can help physicians manage the medical and financial risks of providing care to rural and underserved patients.¹ It has been used successfully throughout the United States in such specialties as dermatology,^7-9 psychiatry,^10-15 pulmonary medicine,¹⁶ and cardiology.^17-19 Efforts to expand the use of telemedicine have contributed to making it a cheaper method of providing medical information and education.^20-22

Rural health providers face unique challenges in delivering care: isolation, lack of communication, and lack of access to current medical information and continuing medical education.^23-28 Although telemedicine promises to address these problems with computers and videoconferencing, rural physicians have been slow to accept it.^29-36

The Missouri Telemedicine Network (MTN) consists of 21 videoconferencing sites in 16 Missouri counties. We evaluated a demonstration project in 3 of the counties where a high-speed computer data infrastructure was installed in 10 outpatient practices in 4 communities with populations ranging from 3000 to 8000. The infrastructure included a computer workstation with E-mail, access to the World Wide Web, medical databases including MEDLINE, community-specific demographic information, a calendar, and access to a medical librarian. Important goals of the workstation included fostering networking and access to educational opportunities and current medical information. The videoconferencing facilities were located in the hospitals in the 3 demonstration counties, plus one large group practice clinic. Participation in the project was voluntary.

Because changing physician behavior has proved difficult,^31,36-40 we investigated how rural health care providers perceive the introduction of telemedicine (videoconferencing and a computer workstation) to their practices. We also wanted to create a framework for assessing the readiness of rural providers to adopt telemedicine and to develop a guide for fostering the adoption of this technology.

Methods

We collected qualitative data during semistructured interviews using questions developed from pilot interviews with information specialists and MTN participants. Data were gathered at 10 outpatient practices in the 4 communities with both a computer infrastructure and videoconferencing. Three of the out-patient practices were affiliated with a public tertiary care center; 7 were private practices; and 3 were group practices. Our sampling matrix included physicians, nurses, and administrative staff from all the clinics. Between March and August 1998 we individually interviewed all physicians at the site and at least 2 nurses and administrative staff from each clinic. All interviews were conducted by the second author.

After giving their consent, all participants responded to the following open-ended questions regarding both the video and computer components of telemedicine: (1) What do you perceive are the advantages and disadvantages of the telemedicine technology? (2) What do you perceive are the barriers and facilitators to using the telemedicine technology? (3) How do you use the telemedicine technology? (4) Can you describe the ways in which the telemedicine technology has changed your role? (5) How has the telemedicine technology affected the quality of care you deliver? (6) Do you have any suggestions for improving the telemedicine technology? In addition to these 6 questions, we collected demographic information on age, sex, length of practice, and provider status at the end of the interview.

To guard against any bias toward advocating telemedicine, we stated to respondents at the beginning of the interview that we wanted their honest observations about telemedicine and that their responses would be confidential. We confirmed their observations throughout the interview. Also, before analyzing the data we noted our own bias and preconceptions toward telemedicine, so we could consciously avoid them while reviewing the data.⁴¹

Study staff transcribed the interviews verbatim and entered them into a computer database program, Ethnograph, which was designed to help organize textual material.⁴² We divided interviews by technology type—videoconferencing versus the computer component—and made an initial template analysis to organize and code the data.⁴³ The investigators’ multiple readings of the interviews led to further revisions of the codes until consensus was reached on the identification of salient issues or themes.^44,45 The coding scheme and the salient themes were then reviewed independently by a panel of information specialists and health care providers from nursing and medicine who were familiar with the demonstration project. The panel represented individuals with expertise in informatics and qualitative methods.

Quantitative outcome data were also obtained for each participant. Between March 1998 and February 1999, file servers in each county automatically collected data on use of the Web (number of pages accessed) and E-mail (number sent and received) through the workstation. The content of E-mails remained confidential.

Results

We completed 57 interviews. Thirteen were with physicians (9 men, 4 women) averaging 52 years of age and 19 years in rural practice. Eight were family practice physicians; 4 were in internal medicine; and one physician was in general surgery. Twenty interviews were with nurses or nurse practitioners (17 women, 3 men) averaging 43 years of age and 15 years in rural practice. Twenty-four interviews were with the administrative staff (18 women, 6 men) averaging 45 years of age and 14 years in administration. Before the implementation of telemedicine, all of the participants had minimal experience with information technology.

Those practices that were affiliated with a public tertiary care center had higher telemedicine use than those in private practices, although the overall use level would be considered low. For example, the monthly average number of E-mail messages sent from practices that were affiliated with a public tertiary care center was 25.6, while for those in private practice the average was 11.3. For E-mail messages received, the monthly average was 48.8 and 20.2, respectively. Nine of the 13 physicians used the Web, and those affiliated with the tertiary care center used it far more than those in private practice. A yearly total of 8140 visits to a single Web page was recorded for those affiliated with the tertiary care center (mean = 22.3 per day) compared with a yearly total of 734 visits to a single Web page for those in private practice (mean = 2.01 per day; P=.111). Computer use was also higher for the 4 practice sites that had a nurse practitioner.

Data were systematically gathered on the use of the videoconferencing system. However, the majority of the data represent regular dermatology or psychiatric clinics that were conducted between university physicians and patients from the rural site. The rural physicians rarely participated.

Interviews and other data yielded 6 themes related to the care providers’ receptivity to technologic change: turf, efficacy, practice context, apprehension, time to learn, and ownership. Each of these themes applies to the computer and video components of telemedicine, and each may operate as a perceived barrier or facilitator of change, depending on the provider in question. Some providers saw telemedicine as a welcome opportunity to learn, and others were resistant. The themes inevitably overlap at times, because we were qualitatively assessing the social context in which technologic changes take place.

Turf

This theme summarizes our findings from care providers who perceived telemedicine as a threat to their livelihood or professional autonomy or both. Health care practices are enmeshed in networks of social relationships. Satellite practices with direct ties to larger health care systems employ patterns of referral and consultation as part of the larger system. Private practices are autonomous units that have relationships with other providers and systems based on patterns of referral and consultation initiated by the physician.

Purveyors of telemedicine may assume that simply making this technology available will somehow persuade providers to automatically accept it and use it successfully.⁴⁶ However, some rural physicians see telemedicine as an intrusion on their territory by the urban tertiary care center.⁴⁷

Although some participants affiliated with the tertiary center saw the technology as a “good thing…it was nice to be connected to a big university,” others, particularly those in private practice, saw it as a potential threat to their sense of competency, autonomy, and livelihood.³⁷ One office staff participant in a private practice remarked on the perception among the rural providers that they “are not seen as practicing their craft correctly, that they’re not up to speed, and that’s why this [telemedicine] has come out here.”

A nurse practitioner in a private practice alluded to telemedicine as a threat to professional autonomy when she said, “I have experienced times when, although the intentions were good, the community has rejected it hands down because they didn’t need help from the outside.”

Efficacy

This theme refers to the participants’ desire to know that telemedicine will fill a functional need in their practice before they invest time and money in making such a big change. Telemedicine has no track record of directly improving patient care outcomes. Unlike drug therapies or medical procedures, telemedicine exerts indirect effects on outcomes with its abilities to enhance, streamline, or improve the process of health care delivery.

Some physicians we interviewed saw no compelling reason to integrate telemedicine into their practices. One physician in private practice who rarely used the computer said, “It doesn’t really help a lot. I think computers are good for specialists, and in primary care you know basically most of the stuff…then the other 20% of it that’s more difficult, you look it up in routine journals.”

Although some physicians saw no reason to integrate the new technology, others simply “don’t think about it.” Still other physicians—mostly those affiliated with a tertiary care center where computer technology figured prominently in patient care—welcomed telemedicine and quickly saw capabilities that would enhance their practices.

Practice Context

This theme refers to barriers to adopting telemedicine that clinics may face because they practice in rural areas where technologic change moves at a slower pace than in urban communities. One nurse practitioner in a private practice said, “We got 911 [emergency] 3 years ago. Three years before that, we finally had a 7-digit phone number. So, I think that the expectations for the rate of change and the learning curve should be pretty generous.” However, several participants, particularly those affiliated with a tertiary center, were positive that telemedicine would eventually catch on.

Apprehension

In contrast to the practice context, this theme refers to the apprehension of individual providers. When it comes to adopting new technology, some participants were philosophical about what they described as a human aversion to change. “People are scared of technology,” said one physician. Another physician in private practice said, “We don’t want to change. Everybody’s just fine the way it is…. I’m not prepared for this.”

Some providers had little confidence in their ability to operate the technology, and one nurse feared that her ignorance would get her into legal trouble: “I’m always afraid I’ll push the wrong button and…something will come up and it will say ‘illegal action.’ It scares me. I think ‘Oh my gosh, I’ve done something against the law.’“

Participants were also concerned about whether the information they would get though the videoconferencing channel would be reliable. A similar concern applied to information on the Internet. A physician in a private practice who was reluctant to use the computer workstation said: “The biggest problem I have with it (the Internet) is you don’t know [what] you’re getting…. There’s a lot of stuff on the Internet that’s no good.”

Although several physicians, particularly those in private practice, were apprehensive about telemedicine, they were willing to let others in their practice learn and use the technology. Some physicians in private practice, however, reflected on the seeming inevitability of change and were resigned to having to learn the technology.

Time to learn

This theme refers to hesitancy among providers to take the time to learn a new technology and to persuade patients of its worth.

One nurse/office manager said, “If I’m looking up something in a book, maybe the book is old, but at least I could have it done in 5 minutes…until I get good at this [computer], it’s taking me much longer.”

One physician in private practice bemoaned spending his time persuading patients that this new technology could benefit them. In contrast, a physician affiliated with a tertiary center noted several advantages of videoconferencing.

Ownership

This theme refers to participants who were professionally and emotionally invested in the technology—stakeholders who acknowledged its benefits, adapted it to their needs, and tried to help others learn. Predictably, this higher level of investment was most common in administrators, because of their familiarity with computerized procedures and records. One administrator affiliated with a tertiary center offered an example of this keen interest: “Yeah, we developed our own policies. We took some of the training modules and modified them to match what we thought. And we really had…everybody buy into using the same policies.”

The stakeholders often encourage others to “buy in” to the new technology, as described by this administrator affiliated with a tertiary center: “I don’t worry about the members of this group using it in a negative way. I want them to use it more…. The more exposure that they have to it, the more accustomed they’re going to be to using it.”

Discussion

These 6 themes (turf, efficacy, practice context, apprehension, time to learn, and ownership) provide a framework for understanding some consequences of introducing telemedicine into a rural setting. Although these themes have been noted to varying degrees by others,^29-37,46,48 we grouped all of them as key contextual elements of the rural health environment. Aside from technical issues, such as the user-friendliness of the technology, the elemental themes that emerged from our data helped us explore this broader context.

Introducing telemedicine into a rural setting is analogous in many ways to introducing managed care into such areas. Some rural providers perceive managed care as an opportunity, while others see it as a threat to their practices, taking the local health care dollar away.⁴⁹ Similarly, providers’ perceptions of telemedicine range from seeing it as a chance to improve health care delivery, as nonessential technology, or, at worst, as a threat.

Those introducing telemedicine to these areas appear to be most likely to succeed if they begin with an understanding of how the new technology is perceived by rural providers. The 6 themes we identified provide some essentials for understanding the initial process of technological change in a rural health care practice. Based on our results, rural providers’ acceptance of telemedicine is most likely to occur when there is a greater organizational integration of the new technology, a perceived increase in time efficiency, greater affiliation with a tertiary care center, a perceived increase in ownership, an enhanced ability to accommodate the changes, a reduction in apprehension, and the realization of the slower pace of change in a rural community.

These themes can be considered core issues for developing a plan that can be used when introducing telemedicine. Specific questions can then be formulated to aid in this process, including: Is there a perceived need for the technology? (turf); Who is initiating the technological change, and how it that perceived? (efficacy); How is the rate of technologic change perceived in the community? (practice context); How flexible are the users toward technologic change? What is the level of anxiety about using the technology? (apprehension); How is the time expended to learn and use the technology perceived? (time to learn); and Who manages and supports the technology? (ownership). Answers to these questions can help those introducing telemedicine to structure specific strategies for implementation that are tailored to fit the needs and concerns of each practice.

Strategies for change

After acknowledging the variability of rural practices and practice behaviors and the environmental conditions of the 10 practices in our study, we grouped them into 3 categories according to their readiness for implanting telemedicine: fertile soil, somewhat fertile soil, and barren soil. For each of these conditions, we propose strategies for change that enhance the potential for the growth of telemedicine as illustrated in the Table 1.^50-52 For those practices that have been identified as fertile soil, it is important to include the physicians and administrators in the entire planning and implementation process.⁵³ They are more likely to use physician extenders, so it is important to facilitate team building with regard to new innovations, while at the same time building various coalitions with other affiliated physicians. Empowerment is also a key to making sure the innovation is successfully implemented. Appropriate resources need to be provided, such as space for the innovation (or technology) and adequate personnel, access, and training.⁵²

For practices identified as having partly fertile soil for change, it is important to establish a sense of urgency for the implementation of the new technology and to engage in coalition building within the community and with other specialty physicians. Help is needed to create a new vision for the practice, and this should be communicated to all employees. It also helps to provide for short-term incentives regarding the new technology.⁵²

Engaging barren soil types of practices in implementing new technologies is difficult. It is possible, however, to facilitate change in the practice by developing a perceived need for the technology through presenting the physician(s) with current evidence-based medical information, for example. All the physicians need to be included in the planning and implementing process,⁵³ and steps should be taken to facilitate coalition building within the community.⁵²

Implementation strategies need to be tailored to the environmental conditions of practice sites that are carefully chosen for their potential to cultivate telemedicine. Successful sites can become exemplars to others. Establishing relationships with a practice site, however, begins with diplomatic negotiation that is sensitive to local conditions. A commitment must be made to nurture the relationship.

Limitations

The strength of our study lies in the initial investigation of rural health care providers’ perceptions of telemedicine, and we are not aware of any similar qualitative studies in the literature. The results of our study are limited, however, to the recent introduction of telemedicine technologies into rural settings. We presented perceptions of providers who were just beginning to adjust to new technologies. Future research is needed to determine the extent of these perceptions among rural health care providers in general and in particular whether some of the negative perceptions of telemedicine of the providers in our study will change over time.

Conclusions

Rural health care providers and administrators consider a range of factors, including economic ramifications, efficacy, social pressure, and apprehension, in deciding whether and how fast to adopt telemedicine technology. Since adopting this technology can be a major change, agencies trying to introduce it into rural areas should take all these factors into account in their approach to rural health care providers, staff, and communities.

Acknowledgments

Our study was funded by the National Library of Medicine, contract number: NO1-LM-6-3538.

Related resources

• Telemedicine Information Exchange (TIE) A National Library of Medicine-funded web page which offers comprehensive information on telemedicine and telehealth. http://tie.telemed.org
• Telemedicine And Health Care Informatics Legal Issues Web site A resource for providers, lawyers, professionals or anyone interested in learning more about health care law and, more specifically, the regulatory and transactional aspects of health care. http://www.netreach.net