Telemedicine in diabetes foot care delivery: health care professionals’ experience

Kolltveit et al. BMC Health Services Research (2016) 16:134 DOI 10.1186/s12913-016-1377-7 RESEARCH ARTICLE Open Access Telemedicine in diabetes foot care delivery: health care professionals’ experience Beate-Christin Hope Kolltveit1*, Eva Gjengedal2,3, Marit Graue1, Marjolein M. Iversen1,4, Sally Thorne5 and Marit Kirkevold1,6 Abstract Background: Introducing new technology in health care is inevitably a challenge. More knowledge is needed to better plan future telemedicine interventions. Our aim was therefore to explore health care professionals’ experience in the initial phase of introducing telemedicine technology in caring for people with diabetic foot ulcers. Methods: Our methodological strategy was Interpretive Description. Data were collected between 2014 and 2015 using focus groups (n = 10). Participants from home-based care, primary care and outpatient hospital clinics were recruited from the intervention arm of an ongoing cluster randomized controlled trial (RCT) (Clinicaltrials.gov: NCT01710774). Most were nurses (n = 29), but the sample also included one nurse assistant, podiatrists (n = 2) and physicians (n = 2). Results: The participants reported experiencing meaningful changes to their practice arising from telemedicine, especially associated with increased wound assessment knowledge and skills and improved documentation quality. They also experienced more streamlined communication between primary health care and specialist health care. Despite obstacles associated with finding the documentation process time consuming, the participants’ attitudes to telemedicine were overwhelmingly positive and their general enthusiasm for the innovation was high. Conclusions: Our findings indicate that using a telemedicine intervention enabled the participating health care professionals to approach their patients with diabetic foot ulcer with more knowledge, better wound assessment skills and heightened confidence. Furthermore, it streamlined the communication between health care levels and helped seeing the patients in a more holistic way. Keywords: Telemedicine, Diabetic foot ulcer, Focus groups, Interpretive Description, Health care professionals Background In recent years, telemedicine (also referred to as telehealth, telemedicine and telecare) has been introduced as a potential method for delivering follow-up care to people with diabetic foot ulcers [1–3]. Although a handful of small quantitative studies [4, 5] have suggested that telemedicine is a feasible method, randomised controlled trials are needed to determine ways to deliver diabetes foot care that are contextually appropriate, feasible and sustainable among people with diabetic foot ulcers [6]. However, where complex interventions are concerned, the evidence from RCTs can be incomplete * Correspondence: 1 Faculty of Health and Social Science, Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway Full list of author information is available at the end of the article without qualitative approaches to capture ongoing processes and provide more indepth insight into the experiences of health care professionals when new technology is introduced. The study we describe in this paper is a part of a larger cluster randomized controlled trial designed to investigate telemedicine follow-up care for people with diabetic foot ulcers in primary health care in collaboration with specialist health care. The intervention consists of an interactive telemedicine platform with a web based ulcer record combined with images sent by mobile phone from primary health care to specialist health care for wound assessment. What has been learned from prior research is that health care professionals’ concerns about their autonomy, the relationship between patient and the health care professionals related to using telehealth © 2016 Kolltveit et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kolltveit et al. BMC Health Services Research (2016) 16:134 technologies [7, 8], and also health care professionals’ scepticism have been reported as possible barriers to implementation [9, 10]. Although one study of telemedicine within a health care district in Finland illuminated the importance of communication between health care professionals for the quality of patient care [11], the available information on broader issues, including inter-professional collaboration at the community level, is as yet quite limited [12]. Where follow up for people with diabetic foot ulcers has been studied, limited communication between their specialist and primary health care services has been reported [13]. More evidence is needed to better plan future telemedicine interventions aimed at improving such communications. Introducing new technology, such as telemedicine, in already existing practices is recognized as a predictable challenge for health care professionals [11, 14]. To obtain knowledge of their experiences early in the process may give us insights into how it is to use this new technology and what kind of structures could be seen as obstacles and facilitators to uptake. The aim of our study was therefore to explore health care professionals’ experience in the initial phase of introducing telemedicine technology in caring for people with diabetic foot ulcers. By focusing on integrated care, this study is intended to contribute to our capacity to more comprehensively describe the processes taking place in complex interventions. This knowledge may help us in understanding factors which might facilitate or impede the introduction of telemedicine service delivery. As telemedicine is considered a potentially viable approach to optimizing health care delivery in many areas of chronic care [8, 15], such insights may have relevance beyond the delivery of diabetes foot care. Methods We used an inductive Interpretive Description (ID) approach for this study [16, 17]. Informed by design technique developed for the purpose of social science methods such as grounded theory, phenomenology and ethnography, ID is a strategy for optimizing qualitatively derived knowledge development for use in the applied clinical fields [18]. A hallmark of ID is its recognition that the applied fields require moving beyond description of phenomena to search for interpretive understandings and meanings expressed in a form that is amenable to being put to use by the intended audience [16]. Participants The participants (...truncated)