1. Opinion Leaders’ Perspective of the Benefits and Barriers in Telemedicine:
A Grounded Theory Study of Telehealth in the Midwest
by
Shelley Brown Cooper
An Applied Dissertation Submitted to the
Abraham S. Fischler School of Education
in Partial Fulfillment of the Requirements
for the Degree of Doctor of Education
Nova Southeastern University
2014

2. ii
Approval Page
This applied dissertation was submitted by Shelley Brown Cooper under the direction of
the persons listed below. It was submitted to the Abraham S. Fischler School of
Education and approved in partial fulfillment of the requirements for the degree of
Doctor of Education at Nova Southeastern University.
Michael Simonson, PhD Date
Committee Chair
Linda Yopp, PhD Date
Committee Member
Ronald J. Chenail, PhD Date
Interim Dean

3. iii
Statement of Original Work
I declare the following:
I have read the Code of Student Conduct and Academic Responsibility as described in the
Student Handbook of Nova Southeastern University. This applied dissertation represents
my original work, except where I have acknowledged the ideas, words, or material of
other authors.
Where another author’s ideas have been presented in this applied dissertation, I have
acknowledged the author’s ideas by citing them in the required style.
Where another author’s words have been presented in this applied dissertation, I have
acknowledged the author’s words by using appropriate quotation devices and citations in
the required style.
I have obtained permission from the author or publisher—in accordance with the required
guidelines—to include any copyrighted material (e.g., tables, figures, survey instruments,
large portions of text) in this applied dissertation manuscript.
Signature
Shelley Brown Cooper
Name
Date

4. iv
Acknowledgments
Thanks to my dissertation chair Michael Simonson, PhD, and committee member
Linda Yopp, PhD, for their guidance and expertise. A special note of appreciation to Dr.
Simonson for his encouragement and no-nonsense advice: It helped me “get off my duff
and finish this thing.”
To my friends, thank you for your continued support. Thanks also for your
understanding when I was AWOL at numerous gatherings. To my family, thank you for
allowing me to disappear into my office night after night. I am grateful to you for
withholding your complaints to fast food and backed-up laundry.
Most important, thank you to my husband, Mitch. You listened to my ideas,
wiped away my tears, quelled my anxiety attacks, and shared my excitement during this
life-changing journey.
In Memoriam
Gloria McShann-Blue
Carl Vernon Hubbell
William Miles Brown, Jr.
Silla
Philippians 4:13 I can do all things through Christ who strengthens me.

5. v
Abstract
Opinion Leaders’ Perspective of the Benefits and Barriers in Telemedicine: A Grounded
Theory Study of Telehealth in the Midwest. Shelley Brown Cooper, 2014: Applied
Dissertation, Nova Southeastern University, Abraham S. Fischler School of Education.
ERIC Descriptors: Diffusion of Innovations Theory, Telemedicine, Opinion Leaders,
Grounded Theory, Hospitals
This applied dissertation provided a better understanding of how opinion leaders
influence the adoption of innovative programming, such as telemedicine, among hospital
administrators in the Midwestern region of the United States. Rogers’ (2003) Diffusion of
Innovations theory was applied to gather a better understanding of the adoption of
telemedicine at the Midwest hospitals. An exploration into the effects of opinion leaders’
influence on administrators provided a focus into this process. As a result of providing a
better understanding of this adoption process, additional innovative medical methods
such as electronic health records, mobile devices, and other forms of medical technology
might be more easily accepted by hospitals.
A demographic protocol instrument gathered personal data on the chief executive officers
and other administrators at 18 hospitals and health care organizations within the Greater
Kansas City Area. In addition, the Innovativeness Scale and Perceived Organizational
Innovativeness Survey (PORGI) were administered to measure individual and
organizational innovativeness. Face-to-face interviews and telephone interviews with the
chief administrative officers using open-ended questions provided rich data regarding the
origins of telemedicine development within each organization. Advantages and
challenges of telemedicine efforts were explored.
An analysis of the data revealed that a modest relationship exists between the key
telemedicine leaders’ level of innovativeness and the perceived level of organizational
innovativeness. The most successful activities were those that involved interviews with
hospital administrators. These interviews resulted in five themes related to Rogers’
(2003) Diffusion of Innovations theory: financial feasibility; resistance to change and
acceptance of new technology; access to specialists or subspecialists; collaborative
governance; and champion or opinion leader roles in the adoption process. Drawbacks
from this study included limited sample size and narrow geographical area. As a result of
this study, it was discovered that additional research on this topic is needed that should
include interviews and focus groups consisting of legislative bodies, vendors, and a
variety of health care professionals to obtain a deeper understanding of external factors
related to telemedicine adoption.

6. vi
Table of Contents
Page
Chapter 1: Introduction........................................................................................................1
Phenomenon of Interest ...........................................................................................2
Background and Justification...................................................................................3
Deficiencies in the Evidence....................................................................................6
Audience ..................................................................................................................7
Definition of Terms..................................................................................................7
Purpose of the Study..............................................................................................10
Chapter Summary ..................................................................................................13
Chapter 2: Literature Review.............................................................................................14
Purpose Statement..................................................................................................14
Distance Education ................................................................................................15
History of Telemedicine ........................................................................................17
Factors That Contribute to Telemedicine Implementation....................................17
Needs for Telemedicine .........................................................................................17
Barriers to Telemedicine in the United States .......................................................20
Telemedicine in the Midwest.................................................................................22
Kansas....................................................................................................................23
Diffusion of Innovations........................................................................................27
International Telemedicine ....................................................................................33
Benefits and Barriers Identified by Literature (International) ...............................42
Theoretical Framework–Diffusion of Innovations ................................................45
Additional Diffusion Literature .............................................................................47
Importance of Opinion Leaders .............................................................................54
Characteristics of Opinion Leaders........................................................................56
Research Questions................................................................................................64
Limitations.............................................................................................................65
Chapter 3: Methodology ....................................................................................................67
Aim of the Study....................................................................................................67
Qualitative Research Approach .............................................................................67
Rationale for Grounded Theory Study...................................................................68
Participants.............................................................................................................69
Data Collection Tools ............................................................................................71
The Innovative Survey...........................................................................................72
The Perceived Organizational Innovativeness Survey ..........................................72
Procedures..............................................................................................................73
Data Analysis.........................................................................................................74
Conducting the Interview.......................................................................................74
Ethical Considerations ...........................................................................................75
Trustworthiness......................................................................................................76
Data Collection ......................................................................................................80
Potential Research Bias..........................................................................................82

7. vii
Limitations.............................................................................................................82
Chapter Summary ..................................................................................................82
Chapter 4: Findings............................................................................................................84
Overview................................................................................................................84
Participants.............................................................................................................84
Interviews...............................................................................................................86
Interview Questions ...............................................................................................86
Data Collection Instruments and Reliability..........................................................88
Results of Data Collection Instruments .................................................................91
Normative Group Innovativeness Scale.................................................................93
IS............................................................................................................................94
PORGI Scale..........................................................................................................95
Comparison of Normative Group PORGI and IS Results to Participants’
Results....................................................................................................................96
Qualitative Data .....................................................................................................99
Grouping by Question............................................................................................99
Data Analysis.......................................................................................................104
Discussion............................................................................................................106
Chapter 5: Discussion ......................................................................................................107
Approach..............................................................................................................107
Meanings and Understandings.............................................................................110
Implications of the Study.....................................................................................112
Relevance of the Study ........................................................................................117
Recommendations Based on the Results of the Study ........................................118
Conclusions and Recommendations for Further Research ..................................119
References........................................................................................................................121
Appendices
A Interview Protocol for Hospital Administrators ...........................................141
B Demographic Information Document ..........................................................143
C Innovativeness Scale.....................................................................................146
D Organizational Innovativeness Scale............................................................148
E Interview Questions......................................................................................150
F Telephone Interview Guide ..........................................................................152
Tables
1 Methods, Techniques, Advantages, Disadvantages, and Instruments Used for
Identifying Opinion Leaders...........................................................................39
2 Key Leaders’ Age Descriptions......................................................................92
3 Key Leaders’ Gender Classifications .............................................................92
4 Key Leaders’ Ethnic Descriptions..................................................................92
5 Key Leaders’ Educational Attainment............................................................92
6 Key Leaders’ Professional Status Descriptions..............................................94

8. viii
7 IS Scores .........................................................................................................98
8 PORGI Scale Scores.......................................................................................98
9 Pearson Correlation Matrix Among PORGI, IS, and Age..............................98
10 Top Five Themes in Order of Frequency .....................................................118
Figures
1 Adopter Categorization on the Basis of Innovativeness ................................94
2 Distribution of Normative Population Scores: Individual Innovativeness
Scale Scores for the Normative Group ...........................................................95
3 Telemedicine Leaders’ Distribution of IS Scores...........................................96
4 Distribution of Normative PORGI Scale Scores ............................................97
5 Telemedicine Leaders’ Distribution of PORGI Scale Scores.........................97

9. 1
Chapter 1: Introduction
Statement of the Problem
Should your address determine whether you live or die (Christopher, 2013)? Even
though medical innovations have had an enormous effect on society, there continue to be
areas where health care is not readily available. When a Nigerian mother of four dies
shortly after giving birth because postpartum medical care and education were
unavailable to her, it is a tragedy for her family and friends (Oyedepo Olukayode,
personal communication, July 20, 2014). Telemedicine provides a needed service by
connecting patients and health care providers who are separated by distance, time and
accessibility. Miller (2001) detailed, “the advantages of telemedicine in improving rural
access to high quality specialist care” (p. 1). It will provide health care education,
increase doctor-patient interactions, and bring specialty services to underserved areas. It
is clear: telemedicine can save lives.
Meanwhile, when on the other side of the world, elderly patients in rural towns
vie for access to physicians who are scarce and specialists who are seldom obtainable,
unnecessary medical conditions often result (Craig, 2013). The medically unserved,
underserved, and technologically disenfranchised do not have equal access to equitable
medical attention. Providing health care services and medical education from a distance
could decrease the gap in services among populations. The purpose of this qualitative
study was to explore the opinion leaders’ perspective of the benefits and barriers in
telemedicine and their influence on the adoption of such innovative medical processes by
administrators at hospitals and health care facilities within the Greater Metropolitan
Kansas City area (GMKCA).

10. 2
Phenomenon of Interest
Telemedicine is a promising technology that can reduce physical and monetary
burdens of patients traveling to distant hospitals in order to have medical consultations
and increase educational sessions in a local area. Telemedicine consists of medical
services delivered from a distance. Specifically, it is the “delivery of health care and the
exchange of health care information across distances, including tele-education and
distance treatment” (Wootton, Craig, & Patterson, 2011, p. 4). Early uses of telemedicine
occurred over 50 years ago; one involved distance and the second concerned traveling
through city traffic. The first took place in 1959 between the Nebraska Psychiatric
Institute in Omaha and the state mental hospital in Norfolk, 112 miles away.
Telepsychiatry was achieved when consultations between general practitioners and
consultants used closed circuit television to care for psychiatric patients (Norris, 2002).
Another example occurred in Boston, Massachusetts between Massachusetts General
Hospital and Logan International Airport Medical Station in 1968. Air passengers
received emergency care and air employees got occupational health services using
telemedicine (Norris, 2002). In addition, telemedicine has benefited isolated, underserved
populations that do not routinely attract medical service providers, such as rural
inhabitants, Native Americans, and prison inmates. Teleradiology took place during the
same timeframe in a collaborative effort between Lockheed, the U.S. Public Health
Service, and the National Aeronautics and Space administration (NASA). Medical care
was given to Papago Indian in Arizona through a project called Space Technology
Applied to Rural Papago Advanced Health Care (STARPAHAC). Specialists provided
assistance by interpreting electrocardiographs and X-ray (Norris, 2002). The military has

11. 3
been another frequent user as telemedicine has been a part of large-scale coordination
efforts required for international disaster relief.
Background and Justification
According to the U.S. Census Bureau, the GMKCA, also known as delineation
number 28140, Kansas City, MO-KS Metropolitan Statistical Area, includes the
following cities: Kansas City, Missouri; Overland Park, Kansas; and Kansas City,
Kansas. It is comprised of six counties in Kansas (Franklin, Johnson, Leavenworth, Linn,
Miami, and Wyandotte) and nine counties in Missouri (Bates, Caldwell, Cass, Clay,
Clinton, Jackson, Lafayette, Platte, and Ray) (U.S. Census Bureau, 2013, p. 36). This
area covers approximately 5,506 square miles with an average of 329 people per square
mile and a population of approximately 2,035,334, 0.7% of the total U.S. population. The
median age is between 35 and 39 years old. There are 96.7 to 99.9 males for every 100
females. The racial composition of Kansas City is as follows: 76.9% White; 12.7%
African American; 7.0% of Hispanic or Latino origin; and 3.4% from other minority
groups. The median household income is $53,508, which is above the national average of
$50,740. The percentage of people living in poverty is 10.2%. The percentage of the
population who graduated from high school is 90.1%, while only 31.5% have a
bachelor’s degree or higher (U.S. Census Bureau, 2012).
There are 52 hospitals and health care facilities in the GMKCA. Of these 52, five
have been ranked on the U.S. News and World Reports “Best Hospitals” list. The
rankings are based on number of specialties, patient satisfaction, latest advances in
innovative medical procedures, and accreditation. Hospitals are both privately and
publicly funded (U.S. News and World Reports, 2013).

12. 4
While innovative medical processes such as telemedicine and telehealth services
can bring national attention to hospitals, several barriers to developing and accepting
telemedicine have been noted in the literature. Yellowlees (1997) examined 11 reasons
why clinicians fail to accept new information systems such as telemedicine. These
barriers can impede successful implementation of telemedicine programming:
1. Too much change (‘change toxicity’)
2. Failure to begin with an adequate physician base of support
3. Lack of a user-friendly interface
4. Concern regarding the information collected
5. Failure to collect the most important information
6. Physician technophobia
7. Excluding physician involvement from the financial analysis
8. Failure to include marketing to physicians in the implementation plan
9. Inadequate training of physicians to use the system
10. Lack of strong, centralized information systems leadership respected by
physicians
11. Lack of control by the organization over physician practices. (pp. 20–24)
In addition, Yellowlees (1997) provided seven core principles to developing a successful
telemedicine program:
1. Telemedicine applications and sites should be selected pragmatically, rather
than philosophically
2. Clinician drivers and telemedicine users must own the systems
3. Telemedicine management and support should follow best-practice business
principles
4. The technology should be as user-friendly as possible
5. Telemedicine users must be well trained and supported, both technically and
professionally
6. Telemedicine applications should be evaluated and sustained in a clinically
appropriate and user-friendly manner
7. Information about the development of telemedicine must be shared. (pp. 215–
22)
Telemedicine affects current caregivers, underserved populations in the city and
surrounding areas, along with patients needing specialized services not available in their
local areas (Maheu, Whitten, & Allen, 2001; Norris, 2002; Spaulding, Russo, Cook, &

13. 5
Doolittle, 2005; Stanberry, 1998; Wootton et al., 2011). Hospitals have commonalities in
designing telemedicine/telehealth and health care learning programming based on
demographics, location, Health Insurance Portability and Accountability Act (HIPAA)
requirements, budget constraints, and state technology goals. The intent of this study was
to provide guidance in developing a set of best practices or an established body of
knowledge in overcoming barriers leading toward implementing a telehealth or health
care distance education program in hospitals or health care organizations. The results of
this study will be of assistance to future efforts of hospitals and health care organizations
implementing a telemedicine programs.
The benefits of telemedicine are numerous. Darkins and Cary (2000) reported
several of the benefits, including (a) reduced cost of health care delivery; and (b) greater
access to health care services and education for the general, rural, prison, and
underserved populations. Military settings, tribal communities, and space research
operations such as NASA’s Telemedicine Spacebridge have benefitted from the
advantages of telehealth (Karinch, 1994; Maheu et al., 2001). Pozgar (2007) noted that
worldwide telemedicine offers several health-related solutions that enable establishing
nations around the world the opportunity to perform tele-consultations, patient studies,
and constant access to up-to-date professional medical information along with decreased
travelling challenges for its affected individuals.
Lastly, telehealth allows health care-related distance education to take place in
areas not readily available to its inhabitants (Bauer & Ringel, 1999). Moore (2007) noted
that distance education facilitates continuous medical education allowing for medical
professionals to stay current with changing profession-specific information and expertise.

14. 6
In addition, distance education provides the platform for medical professionals to retain
and enhance their particular specialized skills from amateur to expert specialist, while
advancing their employment opportunities.
However, barriers exist that impede the successful implementation of
telemedicine operations. Many of the obstacles are related to professional licensure,
malpractice liability, and “privacy, confidentiality and security issues” (Simonson,
Smaldino, Albright, & Zvacek, 2012, p. 21), as well as payment policies, and “regulation
of medical devices” (Simonson et al., 2012, p. 21). Grigsby and Allen (1997) noted
additional barriers to sustainability including (a) reimbursement, (b) cost, (c) providers’
acceptance, (d) operating revenue, (e) organizational issues, (f) remote site commitment,
and (g) legal/regulatory issue. Also, public policy issues were considered to be the key
barriers to innovation, demand, and investment in telehealth.
Deficiencies in the Evidence
Several studies have examined the perceptions of hospital employees in relation
to telemedicine initiatives (Cusack et al., 2008; Doolittle & Spaulding, 2006; Hopp et al.,
2006; Levy, Jack, Bradley, Morison, & Swanston, 2003). In addition, a number of
professors and telemedicine program directors have explored barriers encountered during
telemedicine implementation (Brown, 2005; Cox, 2001; Davis, 2001; Doolittle, 2001;
Karp, Bogan, Mohanty, & Karp, 1999; Strode, 2001; Tang, 2001; Yellowlees, 2001).
Additional studies have reported on barriers to distance education from various
organizational perspectives (Berge & Muilenburg, 2000; Levine & Sun, 2002; Oblinger,
Barone, & Hawkins, 2001). Similar strategies were utilized to discover the benefits and
potential barriers present in 15–20 hospitals in the GMKCA. However, this study

15. 7
concentrated exclusively on the perceptions of opinion leaders and lead administrative
decision makers.
Audience
Participants in the study consisted of a purposeful sampling of members of
Kansas City hospital’s strategic leadership and planning team including, but not limited
to, the chief executive officer, chief operating officer, director, or president of the
organization.
Data collection methods and forms of triangulation included in-depth interviews,
extensive observations, and surveys of the Strategic Leadership Team and other critical
community stakeholders involved in the telemedicine planning initiative. The site of the
grounded theory study was 18 hospitals located within the GMKCA where leadership
decisions are made. Interviews also provided invaluable information regarding the
leadership styles of the Strategic Planning Team. An extended observation of the
unoccupied, fully-equipped consultation rooms, and tele-video conference laboratories
located within the respective hospitals allowed additional methods of gathering visual
and kinesthetic data on the videoconferencing and distance learning facilities, while
adhering to the HIPAA guidelines.
Definition of Terms
Definitions of major concepts: asynchronous, change agents, CODEC, computer-
based patient records, diffusion, distance education, grounded theory study, HIPAA,
opinion leaders, store and forward, strategic planning, synchronous education, tele-
consulting, telehealth, telemedicine, video conferencing.
Asynchronous is “interaction between people that is separated by time and

16. 8
independence: A type of two-way communication that occurs with a time delay,
allowing participants to respond at their own convenience” (Schlosser & Simonson,
2010, p. 92).
Change agents are “individuals who influence clients’ innovation-decisions in a
direction deemed desirable by a change agency” (Rogers, 2003, p. 473).
CODEC is “a coder-decoder of video and audio signals that converts analog
signals to digital signals, and then compresses digital signals for outgoing information,
then decompresses incoming information and converts digital signals to analog signals”
(Porter, 1997, p. 251).
Computer-based patient records (CPR) are “computerized or electronic patient
records” (Aiken, 2009, p. 94).
Diffusion is “the process in which an innovation is communicated through certain
channels over time among the members of a social system” (Rogers, 2003, p. 474).
Distance education is “the institution-based, formal education where the learning
group is separated, and where interactive telecommunications systems are used to
connect learners, resources, and instructors” (Simonson et al., 2012, p. 7).
Grounded Theory Study is “a methodology, type of design in qualitative research
used when studying a process…systematic, qualitative procedures that researchers use to
generate a theory that explains at a broad conceptual level, a process, action or interaction
about a substantive topic” (Creswell, 2008, p. 432).
HIPAA or the Health Insurance Portability and Accountability Act of 1996
“establishes rights of access to medical information and sets standards for privacy that
impacts how educators and researchers can use medical records” (Reiser & Dempsey,

17. 9
2012, p. 203).
Opinion leadership is “the degree to which an individual is able to influence other
individuals’ attitudes or overt behavior informally in a desired way with relative
frequency” (Rogers, 2003, p. 475).
Store and Forward is “the prerecorded interaction between the client and the
expert or prerecorded information that is transmitted” (Wootten et al., 2011, p. 5).
Strategic plan is “a document that outlines the steps than an organization,
division, or department will take to achieve an overall goal or vision” (Grensing-Pophal,
2011, p. 4).
Synchronous education “involves live, two-way interaction in the educational
process that is occurring simultaneously and in real time. Teachers lecture, ask questions,
and lead discussions. Learners listen, answer, and participate” (Simonson et al., 2012, p.
98).
Tele-consulting “involves seeking medical information or advice from someone at
a distance; may be patient to health care professional or between health care
professionals” (Wootton et al., 2011, p. 119).
Telehealth is “public health services delivered at a distance to people who are not
necessarily unwell, but who wish to remain well and independent” (Wootten et al., 2011,
p. 4).
Telemedicine is “the delivery of health care and the exchange of health care
information across distances; also includes tele-education and distance treatment”
(Wootten et al., 2011, p. 4).
Video conferencing is “a common method of real-time interaction between expert

18. 10
and client” (Wootten et al., 2011, p. 5).
Purpose of the Study
The purpose of this qualitative study was to explore the opinion leaders’
perspective of the benefits and barriers in telemedicine at hospitals and health care
facilities within the GMKCA. Strauss and Corbin (1998) emphasized the importance of
gathering data in “out in the field to discover what is really going on” (p. 9). As a result, a
multiple site, grounded theory study was conducted to analyze each location separately.
Then a cross-case analysis was conducted to identify common themes among all of the
cases (hospitals). Strauss and Corbin (1998) also insisted that “comparing ‘incident to
incident’ will assist in determining the relevance of the developing theory” (p. 202). A
gatekeeper was identified at each of the 18 locations.
Strauss and Corbin (1998) described the significance of adding objectivity and
sensitivity to the data gathering procedure. Consequently, extensive data were collected
using multiple forms of data collection, such as non-participant observations, interviews
(telephone and face-to-face, when available) and documents. The objective was to
develop an in-depth understanding of each case, singularly and collectively, to describe
the barriers and opportunities of implementing telemedicine from the chief executive
officer (CEO) and the chief operating officer (COO) opinion leaders’ perspective.
Charmaz (2006) suggested offering the interviewee a handful of wide-ranging,
open-ended questions will permit the interviewer to inspire and motivate more
spontaneous responses and unexpected testimonials. Therefore, the questions were broad
to allow the participant to construct meaning from the questions and situations. Questions
were open-ended to allow understanding of the historical and cultural settings of the

19. 11
organizations. The interviews were conducted face-to-face when possible, or by
telephone. Research was conducted to obtain open-ended questionnaires from similar
studies when CEOs were interviewed about a new initiative within their organization. If
necessary, existing surveys could have been converted to open-ended questionnaires.
Charmaz (2006) provided detailed guidelines for obtaining rich data by modifying
existing instruments already in existence.
The individual hospitals’ protocols for conducting interviews with their CEOs and
COOs were obtained. Hospital administrators were interviewed to gather their
perceptions of initiatives toward telemedicine within their organizations. Characteristics
of each hospital were described, examined, and compared in order to ascertain their
relationships, if any, to the respective telemedicine initiatives present at the locations. As
CEOs were interviewed, an attempt was made to identify the top five trends, advantages,
barriers, and problems of implementing telemedicine from the opinion leader’s
perspective.
To comply with the HIPAA of 1996, no patient records were viewed, and all
HIPAA regulations were followed (Judson & Harrison, 2010). As recommended by
Charmaz (2006), Institutional Review Board approval was obtained before data were
collected. This study will assist the CEOs at the health care organizations to fine-tune
their organizations.
The population consisted of hospital employees. The target population was CEOs
and COOs of hospitals in the greater Kansas City area. The sample consisted of CEOs
selected from 18 hospitals in the greater Kansas City area.
Telemedicine services in the GMKCA are limited compared to health care

20. 12
services offered face-to-face (Spaulding et al., 2005). While opportunities to participate
in this innovative medical practice are present, Maheu et al. (2001) asserted the presence
of several barriers that preclude the implementation of telemedical, telehealth and health
care education at a distance. An in-depth study of this phenomenon provided insight into
solutions and clarifications to allow more hospitals to develop telemedicine/telehealth
services to the underserved populations in the Kansas City area.
Rural and underserved populations do not have access to equivalent health care
when compared to those in larger, more densely populated cities and higher income areas
(Spaulding et al., 2005). The shortage of physicians in rural areas and underserved
populations in the GMKCA would be assisted by the use of telemedicine. The importance
and prevalence of telemedicine services at hospitals in the GMKCA showed that the
benefits have been valued by its residents (Maheu et al., 2001; Spaulding et al., 2005;
Wootten et al., 2011).
In rural and medically underserved areas, telemedicine is a likely method to
improve the imbalance and respond to the health-care needs of rural citizens (Spaulding
et al., 2005). According to Roger’s (2003) “diffusion of innovation theory,”
Opinion leaders, individuals who are able to influence other individuals’ attitudes
or behavior, are instrumental in persuading adopters toward diffusing innovative
programming such as telemedicine. Opinion leaders were found to have robust
effects within several organizations, including among health-care professionals.
(p. 326)
Spaulding et al. (2005) utilized the diffusion of innovation theory to understand
telemedicine adoption in Kansas’ rural areas. The hospital administrators could likely act
as change agents within their respective organizations. In other words, the CEOs and
hospital presidents are likely to either formally or informally influence their respective

21. 13
organization’s innovation decisions in a direction deemed desirable by the change agency
(Rogers, 2003).
A grounded theory approach (Charmaz, 2006; Creswell, 2008; Strauss & Corbin,
1998) was utilized to chronicle a descriptive view of the strategic planning undertaken by
the chief operating officer and hospital leaders in developing and implementing
innovative telehealth programming within the GMKCA hospitals. Charmaz (2006)
contended grounded theory design affords the chance to obtain abundant, in-depth
information about the routines taking place within the contributors’ day-to-day operations
in their organizations, build hypotheses from the findings, along with observing note-
worthy issues while addressing the basic concerns occurring in the health care
organizations. Observation of the leadership team in relation to perceived opportunities
and barriers to telehealth implementation will provide a deeper understanding of the
processes, events, and actions taken to develop telemedical programming in health care
organizations in Kansas City.
Chapter Summary
The benefits of telemedicine are numerous. In rural and medically underserved
areas, telemedicine is a likely method to improve the imbalance and respond to the
health-care needs of rural citizens (Spaulding et al., 2005). However, barriers are also
present. When opinion leaders within health care organizations implement innovative
telehealth processes, success would be more likely if these change agents approach this
innovative effort armed with solutions in hand. The aim of this study was to identify the
barriers perceived by the organizational leaders in order to circumvent potential
problems.

22. 14
Chapter 2: Literature Review
In support of this proposed study, the following literature review presents an
overview of information relevant to the leadership’s perception of planning, design, and
the benefits and barriers to the development of a telehealth program for patients and
physicians in distant locations. This literature review explored the history, benefits and
barriers of medical services delivered at a distance. It also investigated how opinion
leadership influences organizations to develop, construct, implement, and utilize these
programs.
Purpose Statement
The purpose of this qualitative grounded theory study was to chronicle the
benefits and barriers encountered by the upper level management teams in developing
telemedicine/telehealth and health care distance education programming in hospitals
within the GMKCA within the context of the grounded theory approach as explained by
Creswell (2008). At this stage in the research, the central phenomenon was generally
defined as the influence of opinion leaders on the health care administrator level’s
implementation of tele-video, videoconferencing and medical distance education within
18 hospitals in the GMKCA. The hospitals participating in this case study will be
determined based on responses from CEOs. However, larger hospitals in the GMKCA
that participated in this study included: Children’s Mercy Hospital (Main and South
Campuses), Bates County Memorial Hospital, University of Kansas Medical Center,
Menorah Medical Center, Western Missouri Medical Center, St. Luke’s Hospital of
Kansas City (Main and North Campuses), Truman Medical Center, Shawnee Mission
Medical Center, Lawrence Memorial Hospital, Research Medical Center, Atchison

23. 15
Hospital, Miami County Medical Center, Olathe Medical Center, Samuel U. Rogers
Health Center, and Cass County Hospital.
Distance Education
Simonson et al. (2012) defined distance education as “the institution-based,
formal education where the learning group is separated, and where interactive
telecommunications systems are used to connect learners, resources, and instructors” (p.
7). While distance education has a history spanning over 160 years, Simonson et al.
(2012), Moore (2003), and Rice (2012) traced the innovations in this educational method
from correspondence, radio, television through present day video conferencing and
Internet techniques. The changes that have occurred over the years have largely been
attributed to digital technologies and a new generation of technology savvy students.
Simonson et al. (2012), Moore (2003), and Smith (2009) described the benefits of
distance learning as the instructor and learner can be separated by time and space;
instructor expertise can be utilized by many more students worldwide, regardless of
either participant’s location; collaborative activities can be explored via distance
education; and learning environments are no longer dictated by logistics. Simonson et al.
(2012) also noted that distance education can “supplement existing curricula, promote
course sharing among schools, and reach students who cannot (for physical reasons or
incarceration) or do not (by choice) attend school in person” (p. 138).
Maheu et al. (2001) described the history of telemedicine and its origin in their
book entitled E-Health, Telehealth, and Telemedicine. Allen, founder of the American
Telemedicine Association and co-author to the aforementioned text (Allen, Hayes,
Sadasivan, Williamson, & Wittman (1995), also practiced medicine and the University of

24. 16
Kansas Medical Center in Kansas City, Kansas. The demands of rural patients led to the
necessity of tele-video and videoconferencing when consulting with specialists.
Ten factors were reported by Berge and Muilenburg (2000) that were considered
barriers to distance education. These 10 factors were discovered through a study of
people from diverse backgrounds. The factors include “administrative structure,”
“organizational change,” “technical expertise,” “social interaction and quality,” “faculty
compensation and time”, “threat of technology,” “legal issues,”
“evaluation/effectiveness,” “access,” and “student-support services” (Berge &
Muilenburg, 2000, p. 7).
Telemedicine is a subcategory of distance education because it includes medical
education and, as such Berge and Muilenberg (2000) determined, “underlying
constructs” that make up barriers to distance education. Several of these 10 factors are
similar to barriers identified by other researchers that preclude the successful
implementation of telemedicine. These shared barriers consist of “administrative
structure,” “organizational change,” “technical expertise,” “threat of technology,” “legal
issues and access” (Berge & Muilenburg, 2000, p. 7).
Piamjariyakul and Smith (2008) defined telemedicine as a subcategory of
telehealth, that is using digital data and other technological tools, to aid in providing
health care-related education and services at a distance for the general public and
government communities. Telemedicine, “medicine at a distance, usually contains the
following components: separation or distance between individuals and/or resources; use
of telecommunications technologies; interaction between individuals and/or resources
and medical or health care” (Simonson et al., 2012, p. 19).

25. 17
History of Telemedicine
Simonson et al. (2012) reported the origination of the term telemedicine by Byrd
during his creation of a video microwave network in 1968 from Massachusetts General
Hospital to Boston’s Logan Airport. Its key benefit at that time was to provide access to
medical services where it had previously been unavailable. Norris (2002) found evidence
of earlier uses of telemedicine, when physicians used video television to provide medical
care during the 1950s. Telehealth has also been utilized in other countries, both
developed and less economically developed (World Health Organization [WHO], 2010).
Factors That Contribute to Telemedicine Implementation
The factors that contribute to telemedicine implementation include the need to
provide health care to low income or rural areas, shortages of physicians, improvement
in the quality of health care services, reductions in the cost of delivering health care, and
to provide remote care where there is no alternative (Darkins & Cary, 2000; Long, 1998;
Norris, 2002; WHO, 2010).
Needs for Telemedicine
The needs for telemedicine span several areas: (a) hospitals, (b) military locations,
(c) National Aeronautics and Space Administration (NASA), (d) low income-based
underserved cities, and (e) rural areas where specialists and other health care
professionals are in short supply (Bauer & Ringel, 1999). Karinch (1994) compared
telemedicine to a house call where the doctor was able to come to the patient with the use
of video conferencing technology. These technological advances provide assistance to
medical record keeping, surgery, health maintenance, and health education (Karinch,
1994).

26. 18
Telemedicine utilization reports & evaluation data provided by Piamjariyakul and
Smith (2008) enumerated the advantages of telehealth, namely that it provides access and
continuity of care to those in need of medical services in underserved and rural settings.
Piamjariyakul and Smith (2008) also argued that a heightened access to telehealth brings
about favorable results upon medical results. In addition, the need for telemedicine is
growing due to the aging and chronically ill population, substantial health care provider
shortages in the aforementioned areas. Limited access areas include low income based
rural areas, inner cities, underserved communities, disadvantaged neighborhoods or
Native American reservations, senior citizen centers, roadway clinics for truck drivers
and travelers, prisons, and military locations.
Numerous challenges and concerns have been indicated in recent publications
including privacy and confidentiality of medical information, ensuring quality of care and
regulation, clinician liability, accreditation and certification, public investment in
development and research, payment and reimbursement for services, integration of
interactive health services (Norris, 2002; Peabody, 2013).
Latifi, Ong, Peck, Porter, and Williams (2005) concluded the use of telemedicine
in the management of trauma and emergency care is needed in remote areas and
catastrophic situations. Since trauma requires immediate care and these types of services
are not as prevalent in rural areas, these populations suffer at a higher rate than urban
patients. Latifi et al. (2005) noted
The lack of adequately trained personnel and limited continuous medical
education may lead to disproportionate mortality in these areas. In addition, the
lack of access to trauma specialists in remote locations can contribute to lower
success rates among trauma patients who live in these areas.
In catastrophic disasters, telemedicine and tele-presence can be provided via

27. 19
satellite to provide tele-trauma and tele-resuscitation for victims who might not
otherwise have any alternative for medical care. (pp. 293–294)
Latifi et al. (2005) stressed the importance recognizing that in order for tele-trauma and
tele-resuscitation to be successful, they must have the “collaboration and management of
a large number of authorities and organizations with “high-level command, control and
communications (C3)” (p. 294).
Miller, Reese, and Frieson (2008) described the need for telehealth technology
applications with underserved conduct disorder in child/adolescent populations,
especially when access to specialists is needed in remote areas. Rural areas are plagued
with increased rates of preventable risk factors such as, obesity, smoking, poor diet, and
inactivity. They are also more likely to be uninsured and possess lower levels of
education. Telemedicine in these areas can assist in several ways. Distance education can
provide current information on new medical procedures and medications to health care
personnel who are unlikely to venture into urban areas. It can refresh skills and
knowledge on updated specialties. Time sensitive care can provide assistance with stroke,
cardiology, perinatal and neonatal emergencies. The introduction and implementation of
innovative technological medical procedures requires higher level hospital administration
acceptance as well as key physician acceptance to discourage barriers located within the
organizations (Miller et al., 2008). They also insisted that in order to maintain a
successful telemedicine program, support and enthusiasm from senior management
should be relayed via internal communications, demonstrations, and discussions with
representative from other telemedicine programs. Key physicians, or champions, should
be clearly identified and should serve as physician liaisons to other members of the
telemedicine participants.

28. 20
Barriers to Telemedicine in the United States
Simonson et al. (2012) and Armstrong (1998) identified several barriers to the
practice of telemedicine: (a) professional licensure; (b) malpractice liability; (c) privacy,
confidentiality, and security; (d) payment policies; and (e) regulation of medical devices.
Darkins and Cary (2000) presented additional financial barriers to successful
telemedicine programs related to (a) reimbursement, (b) telecom cost, (c) general cost,
and (d) operating revenue. According to Darkins and Cary (2000), “financial
sustainability has been provided by grant funding from government agencies
(approximately 90%) or capital investment by hospital providers” (p. 14). The reduction
of costs and professional objection along with the increase in quality of service and
access to health care services made up Darkins’ and Cary’s (2002) “formula for
successful telehealth implementation” (p. 15).
The Rehabilitation Act (1973) requires federal agencies to make their electronic
information technology accessible to people with disabilities. Burgstahler (2002)
described the access challenges for people with disabilities; they include mobility, visual,
learning, hearing and speech impairments, and seizure disorders (p. 5). Section 508
(1986) of the Rehabilitation Act requires that electronic and information technologies that
federal agencies procure, develop, maintain, and use are accessible to the disabled as
well. Telemedicine services, medical education, and services delivered from a distance,
are included in the technological services that should be made available to the disabled,
underserved, and unserved populations. To date, only two states, Kansas and Maine,
provide reimbursement for telehealth services within inner cities. On the other hand, the
use of telemedicine can be found nationwide, specifically in: Arizona (DeChant, Tohme,

29. 21
Mun, Hayes, & Schulman, 1996), California (Bashshur, Shannon, Krupinski, & Grigsby,
2011; Krupinski, 2008; Latifi et al., 2005; Sakles et al., 2011), Florida (Naditz, 2009),
Georgia (Young, Chan, & Cram, 2011), Illinois (Vogel, Gracely, Kwon, & Maulitz,
2009), Iowa (Brown, 2005; Hersh et al., 2001), Massachusetts (Zilis, 2012), Michigan
(Garfield & Watson, 2003; Hopp et al., 2006; Miller, 2001; Whitten, Holtz,
Cornacchione, & Wirth, 2011), Ohio (Cusack et al., 2008), Oregon (Harnett, 2008),
Pennsylvania (Bowles et al., 2011; Stalker et al., 2006), Tennessee (Mulvaney, Anders,
Smith, Pittel, & Johnson, 2012), Virginia (Merrell, 2010), Washington, DC, (Hoffman &
Rowthorn, 2011; Shojania, Silver, & Levinson, 2012), and Wisconsin (Young et al.,
2011).
According to Barker et al. (2005), the Arizona Telemedicine Program designed its
service with several goals in mind. One of the major goals was to develop an “open staff”
model for its physicians “to ensure adequate communication with other health care
organizations” (Baker et al., 2005, p. 397). However, many legal issues have impacted
the adoption of telemedicine (Paul, Pearlson, & McDaniel, 1999; Pozgar, 2012;
Stanberry, 2006; WHO, 2010). Pendrak and Ericson (1996) noted licensure and
credentialing as the strongest factors in preventing telemedicine from being fully
accepted. While some states are proposing changes in their legislature, many have not
made telemedicine legally appetizing or cost effective for physicians and health care
organizations. Pendrak and Ericson (1996) noted the uncertainty in the courts’
establishment of legal precedents in their rulings.
Consequently, malpractice questions continue to prevail for decision makers.
Pozgar (2007) defined malpractice as medical negligence where the physician had a duty

30. 22
of care to a patient, and there was a breach of duty that resulted in an injury caused by the
departure from the standard of care. However, when a physician owes a duty to a patient
(whether face-to-face, or from a distance) to exercise ordinary medical care that a
reasonably prudent physician would have exercised under the same or similar
circumstances, there is concern about the relationship between the caregiver and the
patient when this care occurs via videoconference. Does this threat discourage opinion
leaders from recommending the adoption of telemedicine into their organizations?
Pendrak and Ericson (1996) proposed two critical questions for administrators to ponder
when considering the adoption of telemedicine: “Did a doctor-patient relationship exist?”
and “Did the physician breach his or her duty of care?” (p. 48).
Telemedicine in the Midwest
In his essay, Jacobus (2004) presented three reasons that led the adoption rate of
telemedicine to the slow (telehealth) initiatives. In the beginning, telemedicine products
seemed to be too expensive and not directed at a particular audience, which resulted in
uncertainties among payers and cloudy cost-benefit rates. He recommended rectifying
these issues by clarifying the profitability potential for insurance companies and health
care organizations. Jacobus (2004) revealed conclusive facts that substantiated the
usefulness of telemedicine programming. Specifically, it showed how health care-related
education and services can be less expensive. Yet, historically there has not been a clear
and easy-to-follow revenue process or formula to help insurance payers induce the
regular population to rapidly give up conventional methods in favor of telemedicine
adoption.
These factors must be well thought out by opinion leaders when considering the

31. 23
adoption of telemedicine. The cost effectiveness and potential profit margin of any
proposed project is important during this analysis process.
Kansas
The University of Kansas’ Medical Center has been and continues to be a leading
provider of telemedicine in the Midwest. Spaulding, Velasquez, He, and Alloway (2012)
presented cost analysis data on their telemedicine efforts in the field of home telehealth
for the elderly. While Spaulding et al. (2012) suggested additional studies utilizing
randomized controlled trials with larger samples, their study concluded that “hospital
days, emergency department visits, total costs and hospital costs were significantly
lower during a home telehealth intervention” (p. 2).
Rural and urban areas within the Midwest serve individuals from diverse
demographic backgrounds. However, the need for health care remains a constant
concern for most populations, regardless of their location. Members of the underserved
population of the Midwest have received assistance from telemedicine efforts from
multiple locations such as Kansas and Missouri (Maheu, Whitten, & Allen, 2001;
Spaulding et al., 2005). Video conferencing, health care education via distance methods,
telemedicine robots, child psychiatry, teleoncology, tele-dermatology, and tele-radiology
have been offered in the Midwest for several years.
Doolittle (2001) insisted that “all participants are should be brought together
when designing telemedicine care: physicians, nurses, patients and other vital partners’
expertise are needed to define the needs, outline specific goals, analyze and test the
technology, and develop plans for implementation” (p. 43). In 1991, telemedicine
programming in urban and rural Kansas, teleoncology (cancer care at a distance), tele-

32. 24
hospice (the use of telemedicine to provide end-of-life care), and school-based pediatrics
(ambulatory medical and psychiatric) services were successfully delivered. However,
additional attempts within the same geographic area were unsuccessful. Doolittle (2001)
maintained that tele-cardiology (heart care at a distance) and home telecare for cystic
fibrosis patients have been unsuccessful as a result of strained interactions involving
caregivers, product complications, and not enough recognized desire for the products
and services.
Nelson (2004) found that many patients lived hours from the Kansas University
Medical Center and did not have child psychiatrists or psychologists in their counties.
Telemedicine provided specialty mental health care at a distance. Krupinski (2002)
noted that clinical telemedicine is especially helpful and used most often in specialty
settings. However, the mental health providers in Kansas found mixed reactions.
Families receiving psychotherapy over interactive video were satisfied with the services
(Ermer, 1999). In fact, these systems have been praised for providing help without travel
or waiting months to see a professional. Telehealth could be used to link therapists who
were miles away with children in rural settings or could be used to link therapists with
settings common to the child, such as the school or the pediatricians office. Factors to
consider include the urban or rural setting, the telemedicine room set-up, the presenter,
the format, session characteristics, outcome measures, patient population and treatment
package. Nelson (2004) provided research that supports her notion that “tele-mental
health intervention works” (p. 136).
Whitten and Cook (1999) provided school-based telemedicine to low-income
urban children who would otherwise not receive basic medical care. The Wyandotte

33. 25
County Kansas area was designated as a “Federal Health Profession Shortage Area” due
to its high population-physician ratio and high population of residents who lived in
poverty. Its main objective was to provide medical services for children while they were
at school to circumvent the need for transportation. This program was a successful
attempt at providing much-needed medical services to an underserved population.
Whitten and Spaulding (2004) argued the benefits of telehealth within the
underserved and poverty-stricken populations. A general demographic description of
this population includes 75% receiving free/reduced lunches, 50% black, 25% Hispanic
with languages other than English being spoken in their homes; inadequate
transportation, lack of economic resources; lack of familiarity with the medical
community, and questionable citizenship status. “These high risk groups, such as
children living in poverty, children from racial and ethnic minority groups and children
in remote areas, will particularly benefit from access to health services from their
schools” (Whitten & Spaulding, 2004, p. 249).
Doolittle and Spaulding (2006) emphasized the importance of determining the
needs for telemedicine before beginning the implementation process. A needs-assessment
should be required before designing and planning the telemedicine program. Doolittle
and Spaulding (2006) observed that a “bottom-up” (p. 277) strategy has been crucial to
an effective plan. Simply stated, a poor health care area needs to be identified and
planned for, rather than creating a program then locating a place to put it. In addition,
locating a stable funding source and reliable equipment were found to be equally
important in the success of a telemedicine initiative. In short, Doolittle and Spaulding
(2006) presented six steps to defining the needs of a telemedicine service:

34. 26
1. Defining the need for a telemedicine service
2. Planning a service
3. Conducting a needs assessment (clinical, economic, technology)
4. Developing a health-care team
5. Marketing
6. Evaluating the program. (p. 277)
Doolittle, Spaulding, and Spaulding (2004) showed the cost savings involved in
providing teleoncology services in rural Kansas. There were a number of factors involved
in calculating the cost per visit amount for teleoncology services in comparison to face-
to-face visits such as equipment use and personnel salaries. However, Doolittle et al.
(2004) provided ample support for the continuation of this type of medical assistance for
rural, underserved communities in need of oncology services.
Opinion leaders should heed the views of the consumers and operators of
telemedicine services. Patients’ perceptions of many of these services have been
gathered by researchers in order to gain a better understanding of how the service could
be improved. Researchers at a study conducted in Kansas attempted to determine the
Patients’ perceptions of a telemedicine specialty clinic. As a result of the study, it was
determined that “the technology did not impair the service, nor did it present itself as a
major concern” (Mair, Whitten, May, & Doolittle, 2000, p. 38). However, it was noted
that the patients’ level of satisfaction was more closely related to the fact that only
partial services were being obtained at a distance. There remained an impersonal feeling
following the telemedicine visit which the patients attributed to the absence of a
traditional or conventional, “face-to-face interaction” (Mair et al., 2000, p. 38).
The sparsely populated areas that make up the Midwest have benefitted from
several telemedicine initiatives. Warren, Fletcher, Connors, Ground, and Weaver (2004)
described their medical education initiative developed at the University of Kansas

35. 27
Medical Center as a combined effort with Cerner, a worldwide, innovative, health care
technology organization that provides a wide range of services supporting the clinical,
financial, and operational needs of organizations (Cerner, 2014). “The SEEDS Project,
Simulated Electronic Health Delivery System, is a live-application clinical information
system with virtual patients within a virtual health care delivery system” (Warren et al.,
2001, p. 225). Additional telemedicine-related efforts located within the Midwest that
have proven to be successful include teletherapy (Nelson, 2006), Kendallwood palliative
or end-of-life care (Doolittle, 2001), home telehealth (Spaulding et al., 2012), robots
(Cass Regional Medical Center, 2012), clinics (Mair et al., 2000), teleoncology,
telehospice, and school-based pediatrics, (Doolittle et al., 2004).
Diffusion of Innovations
Rogers (2003) “diffusion of innovations theory suggests that organizational
structures and cultures will affect health professionals’ perceptions of telehealth” (p. 73).
In her essay, Whetton (2003) did not pinpoint one specific or consistent factor present
that affected the adoption of telemedicine. Considering the fact that health-related
businesses tend to be rather conventional, in addition to slower to change, telehealth may
possibly provide a progressive course of action that will produce unrest within
hierarchical framework of the organization. Instead, Whetton (2003) insisted that the
successful diffusion of an innovation such as telehealth within the health care industry is
a result of the interaction between the “innovation, organization and participating
adopters” (Whetton, 2003, p. S: 90). Recruiting champions in strategic management
positions within the organization was cited as necessary for adoption of telemedicine
within the health care organization (Whetton, 2003).

36. 28
Berwick (2003) recognized the challenge diffusion of innovations presents within
the health care industry. The innovators exhibit riskier behavior; thus, they tend to be a
little disconnected from the rest of the pack. Early adopters tend to follow the innovators;
thus, they are more similar to the remaining members of their peer group. As such, they
act as opinion leaders for their peers. “It should be noted that no style is best in all
circumstances” (Berwick, 2003, p. 1973). Berwick (2003) argued that finding and
supporting early adopters is crucial to effective diffusion within the health care
community. In addition, Berwick (2003) encouraged early adopters to garner their ideas
from innovators in a formal fashion to ensure that the process continues on a consistent
basis. Next, Berwick (2003) insisted that early adopters’ activities be made visible
through open communication in order to encourage members of the early majority to
accept these new ideas. “There should also be time allowed for early adopters to find
innovators, test the innovations and create confidence in the reinvention so the remaining
peers will trust and follow” (Berwick, 2003, p. 1974). Finally, leaders must invest the
time and energy in the key players that encourages change toward a new process or
method. Most importantly, leaders must follow up by leading by example and change
their methods as well.
Considering the limited amount of time physicians have for socializing and
networking, many influential conversations take place within their network of hospital
peers (Wenrich, Mann, Morris, & Reilly, 1971). Consequently, informal dialogue results
in peers obtaining knowledge from informal educators (Wenrich et al., 1971). These
informal educators act as persuasive peers who indirectly affect medical decisions,
whether in private practice or in hospital settings.

37. 29
Menachemi, Burke, and Ayers (2004) described the key benefit of telemedicine,
namely the ability to deliver medical services or health-related education from a distance.
Most of these types of products and services are essential to individuals who reside in
underserved locations such as urban and rural areas, and correctional facilities where
medical professionals tend to be scarce (Menachemi et al., 2004). Menachemi et al.
(2004) noted the importance of considering the viewpoint of opinion leaders and
administrators when considering adopting new medical technologies within a health care
organization.
The focus of this research consisted of interviewing administrators such as chief
operating officers and chief executive officers about their viewpoints of the influence of
opinion leaders on adopting telemedicine within their health care organizations.
Menachemi et al. (2004) discussed Rogers’ (2003) diffusion of innovation theory as it
applied to telemedicine adopters. When new technologies are under consideration,
administrators must study Rogers’ adoption factors: (a) relative advantage, (b)
compatibility, (c) trialability, (d) observability, and (e) complexity (Menachemi et al.,
2004). Advantages such as cost savings, profitability and increased market share will be
crucial in this decision-making process. Next, the compatibility of the innovation with the
organization’s current mission and vision will influence the possibility of adoption.
Compatibility with current HIPAA compliance guidelines and accreditation Joint
Commission for Accreditation of Healthcare Organizations (JCAHO) should also be kept
in mind. When making an allowance for trialability, administrators should ponder
telemedicine funding, leasing equipment, training participants, and alternate uses for the
new infrastructure. Observability, the ability to observe the benefits of telemedicine, may

38. 30
not be apparent when it is first implemented. A higher quality of care that results could
take considerable time and public relations efforts to be visible to those out of direct
contact with the department. Administrators might experience a high level of complexity
due to hazy guidelines and regulation regarding telemedicine. As a result, “flexibility and
creativity” (Menachemi et al., 2004, p. 623) are required to ensure a successful
telemedicine implementation result (Menachemi et al., 2004). According to Menachemi
et al. (2004) administrators should create cost-effective programs that are easy to use with
infrastructures that reduce implementation and maintenance costs.
Bonneville and Paré (2006) noted that “more information is needed about the
factors that influence the diffusion; implementation; outcomes and behaviors associated
with the spread of information and communication technologies (ICT)” (p. 217). Factors
such as lack of economies of scale, budget competition within health care departments,
reorganization of medical practices, and questionable patient care were discussed as
reasons for hindering ICT efforts such as telemedicine.
Gagnon et al. (2005) conducted a study that explored the influence of hospitals’
organization characteristics on telehealth adoption by health care organizations in
Quebec. The data captured with the use of questionnaires and telephone interviews were
triangulated and analyzed for correlations with adopter versus non-adopter status.
Gagnon et al. (2005) found the size as well as the location of the hospital influenced the
adoption of telehealth services within its organization. Lack of resources in a hospital,
such as specialists within a certain department resulted in referrals rather than telehealth
utilization. However, when telehealth was considered a major concern by key members
of hospital administration, the impact of their decisions concerning financial viability and

39. 31
physician acceptance took priority. To ensure success, physicians and daily operators of
the equipment should be consulted and remain active in the design of the telemedicine
infrastructure. Administrators also discovered the importance of gathering logistical
desires from clinicians and other participants (Gagnon et al., 2005). The findings of the
study supported the following hypotheses:
The influence of functional differentiation on telehealth adoption depends on
groups’ values towards the system; few planning and control systems have a
negative influence on telehealth adoption; decentralization of power has a variable
influence on telehealth adoption, depending on physicians’ values towards the
technology; smaller hospitals are more likely to adopt telehealth; and hospitals
located in remote and isolated regions are more likely to adopt telehealth.
(Gagnon et al., 2005, pp. 38–39)
Campbell, Harris, and Hodge (2001) discovered six themes that related to the
adoption of telemedicine in Missouri: “turf, efficacy, practice, context, apprehension,
time to learn and ownership” (p. 419). Each of these themes could also have been
considered either a barrier or expediter of change. Turf pertained to the physician’s
perception of telemedicine as a threat or advantage to their practice. Efficacy referred to
the participant’s belief that telemedicine would provide assistance in their medical
practice. Practice and context implied the notion of acceptance of telemedicine within the
local area in Missouri. Apprehension meant the comfort level or (technophobia)
experienced by the individual providers toward the introduction of telemedicine within
their respective practices. “Time to learn” indicated “hesitancy” among clinicians to take
the time to learn a new technological method and convince the clients to accept it as a
viable method of treatment. Finally, ownership denoted the level of “professional and
emotional investment” in the new technological method. In other words, it described how
vested they would be in telemedicine and whether it had been adapted to their specific

40. 32
needs (Campbell et al., 2001, 422).
Campbell et al. (2001) found that rural participants would be more likely to accept
telemedicine if certain perceptions of organizational dynamics are present:
Rural providers acceptance of telemedicine is more likely “when the organization
has accepted technology as an integral component of its procedures, better time
efficiency, closer affiliation with a tertiary care center, perceived increase in
ownership, enhanced ability to accommodate the changes, a reduction in
apprehension, and the realization of the slower pace of change in a rural
community. (p. 422)
Spaulding et al. (2005) randomly surveyed physicians and physician assistants
within 20 counties in Kansas in order to gather a better understanding of their
telemedicine use. Spaulding et al. (2005) applied Rogers’ (2003) diffusion of innovations
theory was used to gather a better understanding of the slow adoption of telemedicine
within the state of Kansas. Spaulding et al. (2005) discussed Rogers’ five core
characteristics of innovation diffusion analyzed in this study: (a) relative advantage, (b)
compatibility, (c) complexity, (d) trialability, and (e) observability. The presence and
impact of an opinion leader at the rural site was also examined. The presence of an
opinion leader was reported more frequently by adopters than non-adopters. In addition,
the presence of the opinion leader resulted in a higher rate of referrals made to
telemedicine clinics. It was implied that adopter of telemedicine might possess “different
perception of telehealth than non-adopters and that strategies based on diffusion of
innovation theory should be devised to introduce this innovative process more effectively
to non-adopters” (Spaulding et al., 2005, p. S:109).
Paying for telemedicine in the United States has been a concern for several
participants within the health care arena. Jonathan Linkous, Chief Executive Officer of
the American Telemedicine Association, itemized five primary sources that support

41. 33
telemedicine. These sources provide financial sustenance for telehealth in the United
States. Hospitals and health care systems; private, public and employer insurers; federal
Medicare; state Medicaid; and health services provided to beneficiaries make funding
available for telemedicine services. Hospital and health care systems offer two ways of
supporting telemedicine: managed care, health home and accountable are plans allowing
providers the flexibility to pay for and use telemedicine wherever it is needed. Another
approach hospitals and health care systems provide financial backing for telemedicine is
between facilities in an effort to lower costs by sharing specialty services and increasing
revenue from expanded referrals (Linkous, 2013).
Next, several large health insurers have expended their coverage to include
telemedicine. At the article’s printing, 16 states mandated private insurance coverage and
13 more states had pending legislation. In addition, federal Medicare reimbursement was
made available for remote imaging services. Furthermore, synchronous consultations are
eligible for reimbursements for patients in rural areas, plus some State Medicaid coverage
is available in 44 states. Finally, according to the American Telemedicine Association,
health services provided to beneficiaries directly from state and federal agencies such as
the Veterans Administration, Department of Defense, Indian Health Service, federal and
state and local corrections departments are active and prevalent in the field of remote
health care (Linkous, 2013).
International Telemedicine
Applications of telemedicine have been shown to provide medical services and
education to underserved populations within cities including: London, United Kingdom
(Barlow, Bayer, Castleton, & Curry, 2005; Brebner, Brebner, Ruddick & Bracken, 2005;

42. 34
Finch, Mort, May & Mair, 2005; Hjelm, 2005; Levy et al., 2003; Mort & Finch, 2005;
Mort, May, & Williams, 2003; Newton, 2003; Padgham, Scott, Krichell, McEachen, &
Hislop, 2005; Stanberry, 2006; Varga-Atkins, & Cooper, 2005), and Tehran (Akhlaghi,
Asadi, & Akhlaghi, 2005).
Entire nations have had medical services and education for underserved
populations improved by providing telemedicine: Alberta, Canada (Jennett et al., 2003;
Klein, Davis, & Hickey, 2005); Africa and the Middle East (Hailey, Roine, & Ohinmaa,
2002; Khoja, Durrani, Nanyani, & Fahim, 2012); Australia (Paul, Carey, Hall, Lynagh,
Sanson-Fisher, & Henskens, 2011; Darkins & Cary, 2000; Hailey & Crowe, 2003; Loane
& Wootton, 2002; Omar, Wahlqvist, Kouris-Blazos, & Vicziany, 2005; Ryan, Stathis,
Smith, Best, & Wootton, 2005; Smith, Bensink, Armfield, Stillman, & Caffery, 2005;
Wootton, 2001; Wootton & Batch, 2005; Wootton, Youngberry, Swifen, & Swifen, 2004;
Yellowlees, 1997); the Balkan countries (Doarn et al., 2009); Brazil (Gundim & Chao,
2011; Kavamoto, Wen, Battistella, & Bohm, 2005); Bulgaria and Greece (Anogianakis et
al., 2003); Calgary, Canada (Hailey, 2005); Canada (Roine, Ohinmaa, & Hailey, 2001);
Estonia (Port, Palm, & Viigimaa, 2005); Europe (Marsh, 2003; Routsalainen & Pohjonen,
2003); Greece (Bray, 2003; Kokolakis & Spyros, 2003); Japan (Hasegawa & Murase,
2007); the Netherlands (Berg, 1999; Broens et al., 2007; Esser & Goossens, 2009;
Vollenbroek-Hutten & Hermens, 2010); Norway (Burkow & Nilsen, 2005); Nova Scotia,
Canada (Allen, Sargeant, Mann, Fleming, & Premi, 2003); Pakistan (Bajwa, 2010);
Singapore, China, and Canada (Goldberg, Sharman, Bell, Ho, & Patil, 2005); Sweden
(Carlfjord, Lindberg, Bendtsen, Nilsen, & Andersson, 2010); Taiwan (Liu, 2011; Wang,
2009); Toronto, Canada (Boydell, Volpe, Kertes, & Greenberg, 2007).

43. 35
Hjelm (2005) proclaimed several benefits and drawbacks of telemedicine in his
article of the same name: “The benefits included improved access to information,
provision of care not previously deliverable, improved access to services and increasing
care delivery, improved professional education, quality control of screening programs
and reduced health-care costs” (Hjelm, 2005, p. 60). However, Hjelm (2005) also
expressed concern over the drawbacks of telemedicine, namely (a) breakdown in the
relationship between health professional and patient, (b) breakdown in the relationship
between health professionals, (c) issues concerning the quality of health information,
and (d) organizational and bureaucratic difficulties.
The Western Governors Association’s Telemedicine Action Report of 1994 also
listed six noteworthy telemedicine barriers:
1. problems with infrastructure planning and development,
2. problems with telecommunications regulations,
3. problems with reimbursement for telemedicine services because of absent or
inconsistent policies,
4. problems with licensure and credentialing because of conflicting interests with
regard to ensuring quality of care regulating professional activities and
implementing health policies,
5. problems with medical mal-practice liability because of uncertainties with
regard to the legal status of telemedicine within and between states and
finally,
6. problems with confidentiality, because of increased risk of unauthorized
access to patient information compared with information on paper. (Hjelm,
2005, p. 69)
Brebner et al. (2005) maintained a list of reasons for failure of telemedicine
programming: (a) service was not needs-driven, (b) no commitment to provide the
service, (c) no suitable exit strategy after research funding expired, (d) poor
communication, (e) lack of training, (f) technical problems, (g) outdated work practices,
and (h) poor or non-existent protocols. Conversely, Brebner et al. (2005) insisted that

44. 36
An established steering group provides guidance during the design and
implementation process. In addition, champions need to be identified at the main
a peripheral sites to maintain open lines of communication between the steering
group and the practitioners. On-going evaluative measures are required to ensure
sustainability, success and effectiveness. (pp. S1–5)
Bower (2005) identified several indicators to explain the diffusion of health care
information technology and pinpoint key drivers of diffusion. Within his research,
interviews with chief information officers (CIOs) proposed policy direction and various
other reasons for incomplete diffusion, ranging from “cost to technical need to
technological progress of competing innovations” (Bower, 2005, p. 13). Bower (2005)
described “social pressure via activated peer group networks” (p. 27), whereby
“physicians and hospital administrators gather their facts concerning health care
information technology through casual or informal associations with their peers” (p. 27).
The “epidemic effects” described by Bower (2005) resulted from informal discussions
with peer groups in a similar fashion to Rogers’ (2003) influence by “opinion leaders.”
Rogers (2003) mentioned the importance of opinion leaders during the diffusion
of innovations process. He observed that opinion leaders were more influential with
implementing change than with workshops or mandates from superiors. In the health care
field, opinion leaders have also been referred to as “champions, lay health advisors,
health advocates, or community leaders” (Rogers, 2003, p. 882).
According to Valente and Pumpuang (2007), “opinion leaders can act as
gatekeepers for interventions, helping change social norms, and accelerating behavioral
change” (p. 881). These researchers analyzed approximately 200 studies involving
opinion leaders and the methods used to influence their peers. These approaches were
categorized into 10 methods. The importance of opinion leaders in the introduction of

45. 37
innovative medical procedures was noted, especially when communicating with their
peers and other members within their communities. The 10 techniques used for
identifying opinion leaders categorized by Valente and Pumpuang (2007) are shown in
Table 1.
Locock, Dopson, Chambers, and Gabbay (2001) expressed difficulty in
discovering a universal definition of opinion leaders. Opinion leaders were often referred
to as product champions who were needed to prompt their peers toward adopting a new
idea, product, or process. The influence of opinion leaders could also be negative by
discouraging the acceptance of innovative methods into the mainstream of their peer
group or organization. Opinion leaders were seldom innovators; on the contrary, they
were more connected to innovative ideas. Locock et al. (2001) reported of medical
champions who were crucial to the adoption of new procedures involving stroke patients.
Interpersonal skills and charisma were noted as prerequisites to the acceptance of fresh
ways of solving medical obstacles (Locock et al., 2001). Furthermore, Locock et al.
(2001) discovered that “the closer the project was to reaching completion and
implementation, the more importance the opinion leaders’ view became” (p. 753).
Finally, the opinion leaders effect on his peers was noted to be dependent upon his
“intrinsic characteristics and the extrinsic circumstances of his environment” (Locock et
al., p 756).
The British Medical Journal (Coiera, 2002) reported that many opinion leaders
were being paid by pharmaceutical companies for their participation in introducing new
drugs to their colleagues. Also known as thought leaders among their peers, opinion
leaders were key players for getting their peers to try new procedures and medications.

46. 38
Furthermore, drug companies worked to make opinion leaders into “product champions”
(Coiera, 2002, p. 1043). Most pharmaceutical companies maintained databases of their
potential product champions or “key opinion leaders” (Coiera, 2002, p. 1043). These key
opinion leaders possessed immeasurable influence toward potential prescription success
or failure. The right nod toward a particular product could “influence thousands of
research, lectures, publications and their participation on advisory boards, committees,
editorial boards, professional societies and guideline/consensus document development”
(Coiera, 2002, p. 1043). However, payments to key opinion leaders have been viewed as
“corrupt and not in the best public interest” (Coiera, 2002, p. 1043).
Rogers and Cartano (1962) were key players in the introduction of opinion
leadership. These influential individuals were consulted before decisions were made or
processes adopted. This influence was more powerful than workshops, journals,
mandates from superiors, or any otherwise credible sources. Furthermore, Rogers and
Cartano (1962) listed three generalizations about opinion leaders: (a) they deviate less
from group norms than the average group members, (b) little overlap exists among the
different types of opinion leaders, and (c) Rogers and Cartano (1962) differ from their
“followers in information sources, cosmopolitanism, social participation, social status,
and innovativeness” (Rogers & Cartano, 1962, p. 437).
Herzlinger (2006) identified six forces that can help or hinder innovations in
health care:

47. 39
Table 1
Methods, Techniques, Advantages, Disadvantages, and Instruments Used for Identifying
Opinion Leaders
Methods Techniques Advantages Disadvantages Instruments
Celebrities Recruit well-known
people who are national,
regional, or local
celebrities.
Easy to implement,
Preexisting opinion
leaders, High
visibility
Contradictory
personal behavior,
Difficult to recruit
Media or individuals
identify
Self-
selection
Volunteers are recruited
through solicitation
Easy to implement,
Low cost
Selection bias,
Uncertain ability
Individuals volunteer for
leadership roles
Self-
identification
Surveys use a
leadership scale and
those scoring above
some threshold are
considered leaders
Easy to implement,
Preexisting opinion
leaders
Selection bias,
Validity of self-
reporting
When you interact with
colleagues, do you give
or receive advice?
Staff
selected
Leaders selected based
on community
observation
Easy to implement Staff misperceptions,
Leaders may lack
motivation
Staff determines which
persons appear to be
opinion leaders
Positional
Approach
Persons who occupy
leadership positions
such as clergy, elected
officials, media, and
business elites
Easy to implement,
Preexisting opinion
leaders
May not be leaders
for the community,
Lack of motivation,
Lack of relevance
1. Do you hold and
elected office or position
of leadership?
2. Are you a member of
any community
organizations?
Which ones?
Judge's
ratings
Knowledgeable
community members
identify leaders
Easy to implement;
Trusted by
community
Dependent on the
selection of raters
and their ability to
rate
Persons who are
knowledgeable
identify leaders to be
selected and rate all
community members
on leadership ability
Expert
identification
Trained ethnographers
study communities to
identify leaders
Implementation can
be done in many
settings
Dependent on
experts' ability
Participant observers
watch interaction within
the community and
determine who
people go to for advice
Snowball
method
Index cases provide
nominations of leaders
who are in turn
interviewed until no new
leaders are identified
Implementation can
be done in many
settings; Provides
some measure of
the social network
Validity may depend
on index case
selection; It can take
considerable time to
trace individuals who
are nominated
Randomly or
conveniently selected
index cases are asked
who they go to for
advice
Sample
socio-metric
Randomly selected
respondents nominate
leaders and those
receiving frequent
nominations are
selected
Implementation can
be done in many
settings; Provides
some measure of
the network
Results are
dependent on the
representatives of
the sample; May be
restricted to
communities with
less than 5,000
members
Randomly selected
sample or cases are
asked who they go to for
advice
Socio-metric All (or most)
respondents are
interviewed and those
receiving frequent
nominations are
selected
Entire community
network can be
mapped; May have
high validity and
reliability
Time-consuming and
expensive to
interview everyone;
May be limited to
small communities
(i.e., less than 1,000
members)
All respondents are
asked who they go to for
advice.

48. 40
1. Players can destroy or help an innovation’s chance of success
2. Funding (generating revenue and acquiring capital) can affect the possibility
of future accomplishment of innovative medical processes.
3. Policy or government regulations have the ability to help adopt new practices
within the health care arena.
4. Technology evolves at a fast rate and these changes impact competition within
the health care field.
5. Customers are more knowledgeable about health care options and can impact
the success or failure of innovative products.
6. Accountability on the part of health care innovators is necessary to satisfy
consumers and insurance payers. (p. 61)
Paul et al. (1999) acknowledged technological obstacles to telemedicine within
various clinical environments which might impact telemedicine usage activity. These
kinds of hindrances involved (a) the caliber of audio broadcasts as well as video graphics
transmitted; (b) the capability of medical care specialists to make use of the tools; (c)
end-user instruction; (d) difficulty associated with operating telemedicine gear; and (e)
the perceived weaknesses connected with digital health documents, along with tele-
consultation transmission to unauthorized staff members. Additional noted limitations
involved fiscal, specialist, and legal concerns (Paul et al., 1999).
Bower (2005) identified additional technological barriers to the implementation of
telemedicine. “The lack of interoperability among health care systems has prevented a
synchronous flow of information among and between clinics, hospitals and various other
health care organizations” (Bower, 2005, p. 51). Multiple products that were
manufactured by countless vendors were not systematically consistent with each other to
allow a plug and play type of compatibility. Often individual doctor offices would
purchase a system that works for their clientele and specific physician’s needs without
confirming the compatibility with its cooperating hospital. This major purchase of
software and hardware represented a significant investment in time, effort, and money.

49. 41
However, the local hospitals within the neighboring areas might have recently installed
an incompatible telemedicine or electronic health records system within its regional or
national group of hospitals that would not talk to the smaller offices. This scenario
created a huge barrier to the successful flow of information between the parties involved;
thus, precluding the advancement of telemedicine within the health care group (Bower,
2005).
Communication between large health care organizations and the individual
physicians is critical to the advancement of telemedicine within the field. Opinion leaders
should be consulted as to the compatibility and integration of technological advances
within the health care organizations in order to maximize the potential gains of this
innovation. Bower (2005) argued,
Three things must be present in order to ensure interoperability and result in
significant gains for patient care. Separate pieces of hardware must be technically
compatible, software from different vendors must share a common medical
vocabulary, and the different systems must be electronically interfaced so that
they can communicate with each other. (p. 58)
Bower (2005) continued with additional data related to the 8% annual
improvement in productivity in the field when health care information technology was
implemented correctly. The factors required to ensure this growth were listed as:
1. Intense competition
2. Tremendous technical improvement
3. Aggressive deregulation followed by minimal government intrusion
4. Firms that are integrated to the right level to make optimal IT investment
decisions
5. Physical ability to lay down a fixed IT investment combined with support
from the IT infrastructure. (p. 52)
Bower (2005) confirmed the importance of the epidemic effects of key opinion
leaders within the medical community. The impact of such influencers within the

50. 42
adoption process ought to be acknowledged and appreciated when contemplating
providing innovative products and services into the mainstream. Similarly, Liu (2011)
argued the significance of the character of leaders in the adoption of innovations within
health care institutions. Furthermore, additional key factors were identified that impacted
the adoption of technology in general, and telecare in particular, within the health care
environment. Liu (2011) found that “government support, technological knowledge,
compatibility, supplier support, and team skills were key factors influencing the intention
of the study’s location to adopt telecare” (p. 6).
Benefits and Barriers Identified by Literature (International)
The WHO (2010) listed a multitude of potential benefits and barriers to
telemedicine diffusion: “Telemedicine can help underserved communities and those in
rural areas with shortages of medical personnel. Socioeconomic benefits to patients,
families, health practitioners and the heal system, including enhanced patient-provider
communication and educational opportunities have been demonstrated” (p. 11). However,
several barriers were noted as well. Cultural, linguistic, or traditional practices may
preclude patients from participating in telemedicine activities. Legal restraints, cost, local
skills, resources and technological complications may impede the adoption of
telemedicine in developing countries. Specifically, (a) product malfunctions; (b)
deficiencies in repair service throughout smaller, outlying health care facilities; (c) lack
of technology experts, along with fewer health-related technicians; (d) sluggish
bandwidth speeds; and (e) an unwillingness among medical personnel, can produce
difficulties towards the endorsement of telemedicine (WHO, 2010).
Removing licensure and professional liability impediments would allow clearer

51. 43
understanding for physicians and health care organizations regarding acceptability of
patients from other states in need of a physician’s care. Siegal (2012) expressed the need
and importance of state medical boards in developing an “expedited licensure-by-
endorsement process to facilitate multistate practice” (p. 266). As noted and discussed by
Siegal (2012), The Joint Committee and Centers for Medicare & Medicaid Services
produced a ruling allowing for “practitioners who render care using live/interactive
systems be allowed to obtain credentials and privileges at the consultant site when they
are providing direct care to the patient” ( p. 269). Nevertheless, additional safeguards
were proposed to alleviate the fear of excessive malpractice claims (Siegal, 2012).
Increased insurance coverage and consistent standards of care should provide improved
protection for the patient and caregiver. In addition, in-depth training programs should
educate all concerned parties. Finally, attention should be given to the informed consent
documents and HIPAA regulations regarding IT tools.
Opinion leaders and health care administrators cannot ignore the perceptions of
patients and physicians when designing telemedicine operations within hospitals or other
settings (Sheng, Hu, Wei, Higa, & Au, 1998). Allen and Hayes (1995) examined patient
satisfaction with teleoncology within a rural setting to determine levels of satisfaction
among rural cancer patients being seen using interactive videoconferencing (IAVC).
Although the sample size was considered too small to draw conclusions regarding all
rural cancer patients, these particular rural cancer patients rated their treatment utilizing
the interactive videoconferencing system in a favorable way (Allen & Hayes, 1995).
Allen et al. (1995) also assessed the level of satisfaction among physicians
involved in a teleoncology initiative within the state of Kansas. Similarly, the sample

52. 44
size was too small to make generalizations. However, the study revealed that there was a
“reasonable level of physician satisfaction with, and confidence in, the use of video to
replace some on-site oncology consultations” (Allen et al., 1995, p. 36).
Opinion leaders and decision-makers on the administrative level should be
familiar with the inner-workings of a successful telemedicine consultation. Ferguson
(2006) noted the required communication media needed during a synchronous exchange
of medical information. The environment, session initiation, dialogue, and the session
closure will impact the diagnosis of the patients and delivery of the service. Further,
Ferguson (2006) recommended the standardization of Internet quality and reliability.
The environment should be well planned, adequately equipped, and its staff should be
efficiently trained.
Whited (2010) relayed the importance of economic considerations when planning
and executing a telemedicine program within health care organizations. Opinion leaders
and decision makers should study these factors before designing innovative systems.
Whited (2010) enumerated several perspectives for administrators to consider: (a) fiscal,
(b) social, (c) medical system, (d) patient, (e) predetermined as opposed to changing
expenses, (f) labor prices, and (g) cost-effectiveness as they relate to telemedicine. It
was noted that telemedicine in general, and tele-dermatology in particular, are cost-
saving methods of medical treatment because they save patients and health care
providers money by avoiding travel costs and lost wages. However, Whited (2010)
discussed additional cost-related factors that will affect telemedicine programming. As a
result, administrators should be familiar with these factors and investigate their impact
on the bottom line before implementing innovative health care endeavors.