Needs, Requirements, and Technology Acceptance using Telemedical

Consultations in Acute Medical Situations in Nursing Homes

Julia Offermann

1,* a

, Wiktoria Wilkowska

, Anne Kathrin Schaar

Jörg Christian Brokmann

and Martina Ziefle

(on behalf of the Optimal@NRW-Research Group)

Human-Computer Interaction Center, RWTH Aachen University, Campus-Boulevard 57, 52074 Aachen, Germany

Emergency Department, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany

Keywords: Telemedicine, Telemedical Consultations, Technology Acceptance, Nursing Homes, Geriatric Patients,

Qualitative Research, Interview Study.

Abstract: A lack of (medical) personnel and high proportions of older people in need of care pose enormous challenges

for care institutions, often resulting in hospitalizations of nursing home residents (geriatric patients).

Frequently, these hospitalizations are not medically necessary and cause a deterioration of health. The usage

of telemedical consultations in nursing homes represents one approach that aims at the reduction of

unnecessary hospitalizations of geriatric patients and at supporting care personnel in acute and medically

uncertain situations. For a successful implementation of these telemedical consultations, especially the

patients’ as well as the care personnel’s perspectives and acceptance are essential. This paper presents first

qualitative results from a social communication science perspective within the Optimal@NRW project. Based

on an interview study with residents and care personnel of different nursing homes (N=28) first attitudes,

perceived advantages, and concerns as well as requirements regarding the usage of telemedical consultations

are identified. These results provide the basis for further quantifications and comparisons of acceptance

parameters of using telemedical consultations in nursing homes in general and across the entire duration of

the project in specific.

1 INTRODUCTION

Studies have shown that 20% of nursing home

residents are hospitalised once a year. 40% of these

hospitalisations turn out to be unnecessary or

premature (Jakobs et al., 2018; Sundmacher et al.,

2015). Apart from the stressful emotional component,

hospital admissions can even cause harm to this

vulnerable group of patients. When a resident of a

nursing facility is taken to an emergency room for an

acute medical situation that could have been treated

by the general practitioner (GP), he or she joins the

ranks of other patients whose reasons for visiting the

emergency room are often more urgent and critical.

Corresponding Author

https://orcid.org/0000-0003-1870-2775

https://orcid.org/0000-0002-7163-3492

https://orcid.org/0000-0002-8643-6213

https://orcid.org/0000-0002-1745-6130

https://orcid.org/0000-0002-6105-4729

Long waiting times in an unfamiliar environment are

the consequences, which often trigger delirium,

especially in patients with dementia. It is not

uncommon for nursing home residents to spend

weeks recovering from the strain after a short stay in

an emergency room. In cases with e.g., occurring

delirium it is even likely that a higher level of

dependency persists due to the underlying condition

of frailty (Theou et al., 2018).

The main causes of these so called “ambulatory-

care sensitive conditions” (ACSC) are not finally

elucidated, but in many cases suboptimal outpatient

medical care of nursing home residents seems to be

responsible. This effect can be observed especially

Offermann, J., Wilkowska, W., Schaar, A., Brokmann, J. and Zieﬂe, M.

Needs, Requirements, and Technology Acceptance using Telemedical Consultations in Acute Medical Situations in Nursing Homes.

DOI: 10.5220/0011058100003188

In Proceedings of the 8th Inter national Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2022), pages 105-116

ISBN: 978-989-758-566-1; ISSN: 2184-4984

105

outside the regular consultation hours of the GPs

combined with an increasing workload of the nursing

staff in the facilities (e.g., low number of care

providers during night shifts).

Optimal@NRW project offers a low-threshold

opportunity by implementing telemedical acute care

for nursing home residents around the clock. For this

purpose, 25 participating senior care facilities are

equipped with the technology for telemedical

consultations as well as an early warning system. The

aim is to prevent nursing home residents from

unnecessary hospital admissions. The early warning

system is intended to preventively counteract a

potential deterioration of a health condition by regular

non-invasive measurement of vital parameters.

Likewise, the faster establishment of a doctor's

contact provides support for the nursing staff in acute

medical situations in the care facility.

In addition to the technical implementation of

telemedical infrastructure itself, the aim is to link the

components with the nursing home documentation

system via interfaces. With that approach, every

physician who is not familiar with the patient can also

access relevant preliminary medical information and

in turn document on the acute setting and therapy in a

way that is visible to co-therapists.

Further, the physicians in private practice and the

emergency service of the Association of Statutory

Health Insurance Physicians can optionally

participate in the beneficial telemedical infrastructure

to improve intersectoral medical care for nursing

home residents. It needs to be emphasized that

telemedicine is not intended to be a substitute for

personal doctor-patient interaction, but rather a

supplement to standard medical care - especially in

situations in which hospital admissions are the only

option left. Additionally, positive economic side

effects can be assumed by a reduction in ambulance

transports and hospitalizations.

2 BACKGROUND

In this section, the theoretical and empirical

background is presented, starting with a current state

on telemedical applications as well as insights

regarding empirical technology acceptance research.

Based on that, the underlying research project is

introduced, followed by the specific research aims

and research questions of the present study, focusing

on a social communication science perspective.

2.1 Telemedical Applications

Applying innovative digital applications has the

potential to address the main challenges in the

healthcare sector due to demographic change, i.e.,

high percentages of highly aged people with long-

term care needs at the same time shortages of medical

personnel and lack of financial resources (Wootton,

Craig & Patterson, 2017; Cook, Augusto & Jakkula,

2009). In more detail, the ubiquitous presence of the

Internet in combination with modern sensor-based

and ambient technologies enable the development

and design of innovative monitoring concepts for the

private environments, nursing facilities and hospitals.

With eHealth as a central element within the work

of the World Health Organization (WHO), the value

of information and communication technologies

(ICT) for healthcare applications and their

socioeconomic benefits in healthcare are highly

acknowledged in the last years (Al-Shorbaji, 2013).

In line with this, the design and development of

eHealth and telemedical applications has been

immensely expedited. Regarding telemedicine,

applications addressing doctor-patient

communication and also applications for

communication between medical professionals –

such as tele-intensive care (Amkreutz, et al. 2020) or

tele-emergency care (Felzen et al., 2019; Czaplik et

al., 2014) – are focused. Supporting development and

research, diverse telemedicine and eHealth

approaches are funded as national and international

research projects. One international example is the

EU-project PAAL (Privacy-Aware and Acceptable

Lifelogging services for older and frail people)

aiming for a development of diverse video-, sensor-,

and speech-based systems that support older and frail

people in their everyday lives (Flórez-Revuelta et al.,

2018). Another example is the project AIDA, which

focuses on medical care of residents in nursing

homes, aiming for preparing nursing homes for the

usage of telemedicine to ensure adequate care for

elderly people (Ohligs et al., 2020).

Although the purposes of such research projects

are promising, it is still difficult to transfer the project

phases into the standard care of the national health

insurance funds. Beyond the primarily financial

difficulties, the acceptance of all involved

stakeholders (i.e., caregivers, patients, physicians)

poses an important prerequisite for the successful and

sustainable rollout of usable concepts.

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2.2 Acceptance and Technology

Perception

In line with the increasing development of innovative

digital applications, the efforts in technology

acceptance research have rapidly grown in the last

decades. Initially – focusing on a differentiation

between acceptance subjects, objects, and contexts

(Kollmann, 1998) – technology acceptance research

based on successful and established acceptance

models like TAM (Davis, 1989) and further model

developments such as UTAUT (Venkatesh et al.,

2003). These models focused on the adoption of ICT

in working contexts and identified in particular two

factors, the perceived ease of use and perceived

usefulness, as good predictors for the behavioral

intention to use a specific technology or application.

To date, these models have been applied numerous

times and are frequently adapted to different contexts

(for an overview see Rahimi et al., 2018).

Beyond these models, acceptance research in

early project or technology development phases is

often challenged by the fact that it relates to areas that

have not been researched before, requiring that the

status quo must first be identified. In such phases –

when interaction with technical applications has not

yet started and only theoretical deliberations were

made – adequate explorative methodological

approaches are needed (especially in sensitive

contexts, such as nursing home environments).

Qualitative and scenario-based approaches are one

suitable measure to gain insights into the respective

stakeholders’ associations, mental models, perceived

(dis)advantages, needs, wishes, and the requirements

of using a specific application in a specific context.

2.3 The Context of the Study:

Optimal@NRW

Although telemedicine is a promising approach to

tackle the described challenges in the healthcare

sector, there are no solutions so far that have been

rolled out large-scale.

Continuing the efforts of the AIDA project

(Ohligs et al., 2020), the implementation and

standardization of telemedical processes, the proof of

medical evidence, cost coverage by the health

insurance companies as well as the acceptance of the

involved stakeholders are needed to enable a

sustainable and widespread use of telemedical care in

nursing homes. This is exactly the aim of the project

Optimal@NRW, representing a new intersectoral

approach that focuses on a provision of acute care and

support for geriatric patients based on the integration

of telemedical consultation systems in 25 nursing

homes and outpatient care within the region of

Aachen in Germany. In particular, the project aims

for the avoidance and reduction of inadequate

hospital admissions in ambulatory care-sensitive

hospital cases (Sundmacher et al., 2015) and

improved medical care in nursing homes. For this

purpose, a central emergency number acts as a virtual

hub for the care of geriatric patients and the idea is

that – in case of medical problems or acute situations

– the participating nursing homes firstly contact the

doctor's call center (116 117). The call center then

executes an initial medical assessment and decides

about urgency and following treatment. If the GP is

not available or if the call from the nursing home is

received outside the GP's opening hours, the

physicians of the resident health service are contacted

in order to provide a visit. If timely contact cannot be

guaranteed neither by the GP nor the resident health

service, teleconsultation by the tele-physicians can be

carried out at any time.

Besides medical research and evaluation of the

efficacy of the implemented structure and processes,

the project investigates user-related acceptance,

perceptions, requirements, and wishes of the relevant

stakeholders – in particular, the residents of nursing

homes and care personnel. Since in nursing homes

especially the actions of the care personnel determine

whether new structures and process are used in the

everyday life, it is precisely the perspective of this

group that must be considered, analyzed, and

understood throughout the entire project. Only this

way, central barriers, concerns, and requirements can

be timely identified enabling technical or medical

adaptions of the telemedical infrastructure and

processes.

The current study presents first results from an

initial qualitative interview study, identifying the

wishes, needs, concerns, and requirements of the two

most relevant user groups – geriatric patients and care

personnel – prior to the real usage of the telemedical

consultations.

2.4 Research Aim and Questions

From the perspective of social communication

science, the first aims of the project and, in particular,

of the present study refer to the understanding and

identification of acceptance-relevant parameters of

the telemedical consultations in nursing homes. In

more detail, the specific underlying research

questions were the following:

Needs, Requirements, and Technology Acceptance using Telemedical Consultations in Acute Medical Situations in Nursing Homes

107

 RQ1: How do geriatric patients and care

personnel perceive telemedical consultations in

emergency situations in nursing homes in

general?

 RQ2: Which benefits do geriatric patients and

care personnel perceive related to telemedical

consultations in emergency situations in nursing

homes?

 RQ3: Which barriers and concerns do geriatric

patients and care personnel perceive related to

telemedical consultations in emergency

situations in nursing homes?

 RQ4: Which requirements are relevant for

geriatric patients and care personnel related to

telemedical consultations in emergency

situations in nursing homes?

The qualitative approach as a first step was

necessary to enable subsequent quantifications and

weightings of the identified acceptance parameters.

Beyond that, the investigation in the initial phase of

the project provides a baseline for the comparisons of

acceptance and the identification of impacting

parameters in later project phases.

3 EMPIRICAL APPROACH

This section presents the methodological approach of

the conducted study, starting with a description of the

empirical concept as well as the procedure and

specific contents of the interview study, followed by

an overview of the participants’ characteristics.

3.1 Empirical Concept

The entire project including the individual studies of

the different project partners was reviewed and

approved by the Ethics Committee at the RWTH

Aachen Faculty of Medicine.

Overall, the project can be divided in three

different phases: pre-implementation,

implementation, and post-implementation. During

the implementation phase of the project, an

evaluation of the medical and economic efficacy of

the implemented structure and processes will be

carried out in a cluster-randomized study, which

means that the telemedical infrastructure will be

implemented stepwise in four different clusters

containing each 6-7 nursing homes.

The pre- and post-implementation phases enable

the identification of relevant parameters, processes,

and structures directly at the beginning of the project,

and offer the opportunity to compare perceptions and

acceptance of the telemedical infrastructure regarding

the whole project period.

In each of the three phases, technology acceptance

and perception are investigated, using multi-faceted

empirical approaches consisting of qualitative

interview and quantitative survey studies. In addition,

the implementation phase enables to evaluate

interactions with the telemedical infrastructure in the

participating nursing homes, thus in real and not in

scenario-based or laboratory settings.

This study presents the results of an interview

study with geriatric patients and care personnel from

different nursing homes within the pre-

implementation phase. Hence, the identification of

opinions, attitudes, requirements, and wishes is

focused prior to first interactions with the telemedical

infrastructure. These results represent the basis for

subsequent quantitative investigations.

3.2 Interview Study

At the beginning of the interviews, participants were

shortly informed about the overall project and the

content of the study. Further, they gave their informed

consent to participate in the interview and to agree

with audio recordings of the interview.

In a first step, the participants were asked to share

some personal information, such as their age and

gender. Beyond that, the participating geriatric

patients were questioned about their health situation

as well as for their experiences and feelings

connected to the living in the nursing home. In

parallel, the care personnel answered questions

related to their professional experience in caring for

geriatric patients in general and specifically related to

the current professional everyday life in their nursing

homes.

As a thematic transition, both groups of

participants were then asked for their experiences

with emergency situations in nursing homes, focusing

on real past situations, existing processes, and

potential difficulties.

Afterwards, the concept of telemedical

consultations in nursing homes was introduced to the

participants using a short descriptive scenario

(translated version):

“In the Optimal@NRW project, telemedical

technology is being introduced and tested in

various nursing homes in the region of Aachen.

Once introduced, it will be possible for the on-site

care personnel to request support in emergency

situations via the central emergency number

(116117) of the Association of Statutory Health

Insurance Physicians. The trained staff at the

center will decide whether the specific case is

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Figure 1: Characteristics of the participants.

suitable for teleconsultation or whether another

step must be taken. If the requirements for a

teleconsultation are met, a wheeled stand

equipped with a camera, monitor, microphone

and specific medical technology equipment (for

measuring blood pressure, oxygen saturation,

pulse, and temperature), is pushed into the

patient's room. Then, a specialist is available in a

time period of maximum 10 minutes. The

physician can communicate live with the patient

and the care personnel and view the electronic

patient file. Once the patient's medical history has

been taken, the telemedicine specialist decides on

the next course of action. If necessary, he or she

can, for example, order the deployment of a

specially trained mobile nurse to the nursing

home, who can then carry out interventions on

site, such as changing a catheter. Actions such as

these can prevent a resident from being rushed to

hospital, instead of being able to remain in their

familiar environment. At the same time, long

waiting times for the difficult-to-reach general

practitioners or specialists should be avoided.”

Subsequent to this information, the participants were

asked to describe their first impressions focusing on

the question if they can imagine using (or agree with)

telemedical consultations in emergency situations.

In a next step, the participants were asked to think

about and describe potential advantages they

associate with the usage of telemedical consultations

in nursing homes. In line with this, the participants

should also anticipate potential concerns or barriers

regarding the usage of telemedical consultations in

emergency situations.

In a last step, the participating patients and care

personnel were asked which specific wishes, needs,

and requirements are considered important and

should be addressed when the telemedical

consultations are implemented in their nursing home.

At the end of the interview, the participants had

the opportunity to comment and give feedback on the

topic or the interview itself, or to ask specific

questions about the project.

Following the interviews, the recorded audio files

were transcribed literally, and were analyzed by

means of qualitative content analysis (Mayring,

2014). For data analysis, a deductive system of

categories was derived based on the literature-driven

interview guide, and iteratively supplemented with

inductive categories after analyzing the data material.

The authors coded the quotations independently and

only indisputable quotations were included in the

categories.

3.3 Participants

Overall, N = 28 participants took part in the interview

study (for details, see Figure 1). Among the

participants, 16 persons belonged to the care

personnel and 11 persons were the residents of

nursing homes, whereas one interviewed person was

an accompanying family member. The participants

belonging to the care personnel were on average 40.4

years old, while most of them were female (n=14).

Most of the care personnel reported a long-term

professional experience in care (> 10 years), while

only five participants indicated 4-5 years of

professional care experience. The caregivers

expressed satisfaction with their profession and doing

their job with conviction. However, they also

described high burdens in their everyday professional

activities due to time restrictions and a lack of

personnel. Further, they pronounced the individual

Needs, Requirements, and Technology Acceptance using Telemedical Consultations in Acute Medical Situations in Nursing Homes

109

needs of their patients/residents and that no two days

are alike within their professional everyday life.

Since all residents of the participating nursing

homes suffered of at least one chronic disease (see

Figure 1), we call this group of participants “geriatric

patients” in this study. The geriatric patients were on

average 76.2 years old, whereas the youngest person

was 55 and the oldest 94 years old. Nine participants

were female (75%). On average, the participants

lived comparably long in the nursing homes (M=8.5

years; SD = 6.0), while only one person lived there

only for one year. All participants suffered from

chronic diseases, such as diabetes, paralyses, chronic

obstructive pulmonary disease (COPD), or

cardiovascular diseases (CVD).

All of them described that they were supported in

their everyday life aiming at a support for self-help

and assistance in being as independent and

autonomous as possible. Regarding living in their

nursing home, the participants were on average

satisfied with care and the respective care personnel.

However, they described the high workload of the

caregivers, the lack of personnel, and resulting

missing times for the individual person (in particular,

for social contact, conversations, etc.).

Focusing on experiences with emergency

situations, both groups described that such situations

occur on a regular basis and that waiting times for

physicians on call are mostly too long. Circumstances

like that frequently lead to hospital admissions and

result in burdens and frequent health deteriorations

for the patients. Participants in both groups

emphasized that something must fundamentally

change in terms of healthcare supply and processes.

4 RESULTS

In the following, the key insights of the interview

study are presented guided by the previously

introduced research questions.

4.1 General Insights (RQ1)

The general perception of the concept of telemedical

consultations in emergency situations was well-

reviewed in both groups.

Among the care personnel, all participants

expressed and expected the telemedical consultations

to be a useful and beneficial approach. All of them

indicated a willingness to use telemedical

consultations and confirmed the implementation of

the telemedical care infrastructure within their

nursing home to be highly appreciated. One

participant added a sceptical comment regarding the

accessibility and the interaction with telemedical

physicians (see RQ3).

Considering the perspectives of the geriatric

patients, all of them showed a positive attitude

towards using telemedical consultations in

emergency or medically uncertain situations. Despite

the positive attitude, two of the respondents were also

sceptical about the implementation in everyday life

and possible technical problems (see RQ3).

Nonetheless, all participants could easily imagine

the usage of telemedicine in their nursing home, and

immediately began weighing possible benefits

against potential concerns.

4.2 Perceived Benefits (RQ2)

Overall, the participants mentioned 21 aspects

referring to potential benefits and motives to use

telemedical consultations in nursing homes. From

these, 13 benefits were mentioned and discussed by

at least two of the participants. These perceived

benefits were divided into three categories and are

shown in Table 1: general benefits, patient-related

benefits, and personnel-related benefits.

Table 1: Identified perceived benefits and their categories.

Patient Faster help in an emergency

Shorter waiting times for medical treatment

Avoidance of hospital admission or stay

Avoidance of transport to the hospital

Avoidance of stress and deterioration of health

Personnel Reducing the workload of caregivers

Quick decisions at the nursing homes

Increase of safety for caregivers through

medical decisions

Flexibility in time and place

General Higher sense of security

Improved sense of care

Improved docto

-patient communication

Use of innovative technologies in care

Within the category general benefits, the

participants (in particular, the care personnel)

mentioned that using telemedical consultations would

give them a higher sense of security as fast advice of

medical experts is enabled.

“It simply gives you more safety and a better

feeling.” (Personnel, female, 24)

Further, they expected an improved sense of care

as well as an improved doctor-patient-

communication.

“Maybe it will make residents feel better about

the care they receive – here in the nursing home,

but also in conversations with physicians.”

(Personnel, female, 34)

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Finally, it was also expressed that the use of

innovative technologies in care is beneficial in order

“to move away from old and conventional

conditions more and more” (Personnel, female,

50 years).

The second category included perceived

personnel-related benefits. Here, the geriatric

patients expressed the expectation that the usage of

telemedical consultations would contribute to

reducing the workload of caregivers and enable

flexibility in time and place.

“It would be easier and reduce efforts for the care

personnel because it would be faster and they

would be more flexible.” (Patient, female, 84)

From the perspective of care personnel, the

benefit of quick decisions at the nursing homes was

of major importance and connected with the

expectation that a fast contact to medical experts

would lead to an increase of safety for caregivers

though medical decisions.

“In the future, it may bring relief in care because

responsibility can be handed over; when a doctor

deals with it directly (without waiting time), the

doctor takes responsibility and the decision.”

(Personnel, female, 50)

“And I think it's also a good thing for the

professionals who are at the bedside in this case,

because they are of course often confronted with

uncertainties, they have to make decisions, and

not having to stand there all alone helps, I think,

a lot to overcome these uncertainties.”

(Personnel, female, 25)

The third category referred to patient-related

benefits. Here, both groups of the participants

expected that the use of telemedical consultations

enables faster help in emergencies and shorter

waiting times for medical treatment.

“Decisions are made here on site and, above all,

help can be provided quickly.” (Patient, male, 84)

“If a telemedical consultation would be

guaranteed within 10 minutes, this would be so

great and so much faster than calling a doctor

and he had to come here first. Usually, we have

been waiting many times longer.” (Personnel,

male, 33)

“It would be great to have no, or little, waiting

time here on site.” (Personnel, female, 40)

In addition, more than half of the participants

mentioned the reduction and avoidance of hospital

admissions or stays as well as avoidance of transport

to the hospital as relevant motives to use telemedicine

in nursing homes.

“Sometimes they lie in the emergency room for 6

hours and then come back again – this could be

avoided, and the residents could be spared the

whole procedure (i.e., transport, stay). Especially

for residents with dementia, or other cognitive

impairments, staying in the facility is certainly

always best.” (Personnel, female, 26)

In line with this, also the avoidance of stress and

deterioration of health was mentioned by both care

personnel and geriatric patients, expecting that

reduced or avoided hospitalizations contribute to the

wellbeing of residents in nursing homes.

“Of course, I think that would save a lot of stress

and health deterioration for our residents.”

(Personnel, female, 58)

4.3 Perceived Barriers (RQ3)

Concerning perceived barriers of using telemedical

consultations in nursing homes, the participants

mentioned 15 different aspects, while 14 of them

were discussed by at least two participants. Table 2

presents these 14 potential barriers and concerns,

which were classified into four categories:

communicative concerns, technological concerns,

handling concerns, as well as data management and

privacy concerns.

Table 2: Identified perceived barriers and their categories.

Communicative

concerns

Impersonal/Indirect Contac

Distance to physicians providing

treatmen

Inconvenient communication of

complaints

Lack of understanding of physicians due

to the distance

Technological

concerns

Immature, possibly deterren

technology

Physicians not easy to understan

Physicians not easy to recognize

Technical failures (e.g., WLAN)

Technical errors (e.g., pixelated display)

Handling

concerns

Errors in operation (e.g., physicians, care

personnel)

Lack of availability of trained personnel

Overstraining of care personnel

Data & Privacy

Concerns

Insecure data transmission

Invasion of privacy

Starting with communicative concerns, the

concern of impersonal or indirect contact and thereby

a feared distance to the physicians providing

treatment was mentioned by participants of both

groups.

Needs, Requirements, and Technology Acceptance using Telemedical Consultations in Acute Medical Situations in Nursing Homes

111

“The physician has no or only a difficult personal

insight due to the distance.” (Personnel, male, 33)

“It is just not face-to-face communication. Due to

the distance, there is already the danger that the

personality of the patient is not perceived in its

entirety.” (Personnel, female, 50)

“I am concerned that the doctor may not

understand me as well (as usual), because he is

less close.” (Patient, female, 82)

Further, some of the participating geriatric

patients were afraid that due to the distance health

complaints could be communicated inconveniently by

using telemedical consultations.

“I doubt whether I can describe it exactly how I

feel, what I have and that it doesn't come across

right if I say, for example, 'it's pressing there'.”

(Patient, female, 82)

In line with this, both groups of participants

expressed the concern of a lack of understanding of

the physicians due to the distance to the patients.

The second barrier category referred to

technological concerns. Here, some participants of

the care personnel feared that the technology may

have an immature, deterrent effect on the patients –

especially regarding patients suffering from dementia

or other comparable cognitive impairments.

“For cognitively impaired residents in particular,

the new equipment and also the conversation with

the doctor via a monitor could have an initially

deterrent effect.” (Personnel, female, 20)

Furthermore, some of the geriatric patients (and

the accompanying relative) expressed concerns that

the physicians are not easy to understand and not

easy to recognize within the telemedical

consultations.

In line with this, the greatest concerns related to

specific technical problems were expressed

especially by the participating care personnel, but

also occasionally by the geriatric patients. In more

detail, technical failures (e.g., WLAN interruptions)

based on the infrastructure in the nursing homes and

technical errors (e.g., pixelated display) related to

data transmission and the Internet connection were

discussed.

"But if you have got a data connection that doesn't

work before, which is pixelated, that you don't see

the person properly like on TV, if it's raining,

you've got the pixels. It could happen. And then

you think, you're lying there, you want to tell him

something, you can't see him properly and you

think, does this have to be now? Why is that not

possible and he should help me?“ (Relative of a

patient, female, 57)

A third category contained perceived barriers related

to handling concerns. Both groups thought about

errors in the operation of the telemedical

consultations – both on the side of the physicians and

on the side of the responsible care personnel.

“I'm concerned that it won't work properly or

much more that there won't be a person around to

operate it properly.” (Patient, female, 82)

A majority of the participating care personnel

expressed concerns about a lack of availability of

trained personnel, because they have previously

experienced that new systems can often only be

operated by one or a few trained colleagues, who are

not always available on site.

In line with this, some participants also feared –

especially at the beginning – an overstraining of the

care personnel regarding the processes in interaction

with the new technologies.

“And I think, depending on which caregiver

colleague you have, it could be an overload.

Because they're not used to it, it has to settle in

[...]. They're nervous then thinking ‘am I doing

something wrong’?”(Personnel, female, 58)

“Okay, so where do I start this, where do I stop?

Which button do I press now? But all beginnings

are hard and you just don't know. I think you're in

an excited situation anyway, is now the right

moment for me to use telemedicine? That's

another thing, that's new and then putting

everything on and communicating with the

doctor.” (Personnel, female, 34)

The last barrier category related to data and privacy

concerns. Here, a potential insecure data

transmission and an invasion of privacy was

mentioned. However, it was striking that these well-

known barriers in the context of other health-related

technologies (e.g., Peek et al., 2014) were only

sporadically mentioned by our study participants.

4.4 Needs and Requirements (RQ4)

Considering the results regarding specific needs and

requirements, the participants mentioned overall 25

different aspects: 11 of them were discussed by single

participants, while the remaining 14 aspects were

discussed by several participants and were

subsequently classified in four categories:

introduction and training, trust-related conditions,

technology-related conditions, as well as interaction

with physicians (see Table 3).

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The first category contained requirements related

to the introduction and training regarding the

telemedical infrastructure and processes. Here,

almost all care personnel participants desired a

detailed technical introduction as well as regular

technical trainings on how to use the telemedical

consultations and how to behave in such situations

correctly. Further, some of these participants also

desired a refreshment of specific medical trainings in

this context.

“So in any case, a good introduction to the

equipment must take place and not only once, but

also repeatedly. That you are first of all well

accompanied. That would be important."

(Personnel, female, 34)

A second category referred to trust-related

requirements. Here, participants of both groups

mentioned that the availability of trained staff is a

prerequisite for trust. In line with this, trust in the

technology as well as trust in the respective tele-

physicians were also discussed to be relevant

conditions. Beyond that, the requirement of ensuring

data privacy and system security were also

occasionally mentioned.

“There must be trained personnel and the

technology must be operated 100%, of course

everything must also fit technically.” (Relative of

a patient, female, 57)

Concerning technology-related requirements it

was mentioned that in particular the technical

infrastructure has to be created and ensured. The

majority of these comments referred to the often poor

WLAN connection in the nursing homes. Further,

technical support and maintenance were mentioned

to be essential parameters not only in the beginning

but also continuously during the use of the

telemedical consultations. As a last technology-

related aspect, care personnel but also some of the

geriatric patients mentioned the appearance and

design of the wheeled stand to be an important factor:

As new technologies can have a deterrent effect, in

particular to patients suffering from dementia,

unobtrusive and well-known designs should be

focused.

Finally, the category interaction with physicians

included aspects referring to the indirect contact.

Based on previous experiences with physicians on

call, the geriatric patients mentioned the necessity

that the tele-physicians must have enough time for the

consultations and empathy for the residents’

situations. Some care personnel participants specified

this requirement and added that the tele-physicians

should bring along patience for the residents and

their needs. Beyond that, the care personnel

participants highlighted that an understanding of the

tele-physicians for age-typical clinical pictures is

essential.

“Above all, it needs empathetic physicians who

have time and act in the will and support of the

residents.” (Patient, female, 87)

“The physicians must have time for residents

within the consultations, they must be skilled with

geriatric-psychiatric residents and they have to

take both, residents and their needs as well as the

caregivers, seriously.” (Personnel, female, 55)

Table 3: Identified need/requirements and their categories.

Introduction

and training

Detailed technical introduction for staff

Regular technical training for staff

Refreshment of specific medical trainings

for staff (e.g., medical parameters)

Trust Availability of trained staff

Trust in tele-physicians

Ensure data privacy/system security

Trust in the technology

Technology Creation of technical requirements/

infrastructure (e.g., reliable WLAN).

Appearance/design of technology

Technical support and maintenance

Interaction

with

physicians

Tele-physicians must have enough time for

consultations

Understanding of tele-physicians for age-

typical clinical pictures

Empathy of the tele-physicians for the

situation of the residents

Patience of tele-physicians for residents and

needs

5 DISCUSSION

In this qualitative study, we aimed at the uncovering

of acceptance-relevant aspects for the use of

telemedical consultations in acute medical situations

in nursing homes, thoroughly studying two essential

user groups: the residents of nursing homes and the

care personnel. The results enable us to better

understand the perceived benefits and barriers of such

complex, yet highly useful, technology which has the

potential to significantly relieve the processes and

ease consultations with specialized medical

professionals in the long run. This approach can

therefore positively complement the healthcare

system and significantly support the situation in

Germany’s currently troubled institutional care.

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5.1 Key Insights of the Study

Results reveal that the important stakeholders are

open-minded and have generally positive attitudes

towards using telemedical infrastructure. Confirming

previous research (e.g., Peek et al., 2014; Offermann-

van Heek et al., 2019), these attitudes are associated

with the perception of technology-related perceived

benefits and barriers of using the telemedical

infrastructure. In line with previous research (e.g.,

Jaschinski & Allouch, 2015; Offermann-van Heek &

Ziefle, 2018) the perceptions of benefits and barriers

or concerns possessed different priorities and differed

in their depth of detail depending on the two relevant

user groups under study.

In more detail, this study identified concrete

perceived benefits (divided in general, personnel- and

patient-related aspects) of using telemedical

consultation in acute situations in nursing homes. For

instance, the participating residents of nursing homes

expressed rather generic benefits regarding a

potential reduction of the workload and thus a relief

for the everyday life of the care personnel. In contrast,

the participating care personnel described the

perceived benefits of using telemedical consultations

very precisely in terms of quick decisions at the

nursing homes and an increase of safety for them as

caregivers through medical decisions enabled by the

fast contact to medical experts.

On the other hand, the study also identified that

both investigated user groups were concerned about

possible drawbacks that the technology could bring

along. Concrete barriers and concerns were

determined referring to communicative, technology-,

handling- as well as privacy- and data security-related

issues. Among these issues, a major hurdle is posed

to technical requirements and competence in handling

the technology. Not only is the widest possible

expansion of Internet access perceived as vital, but

also an uninterrupted support from technically

competent and well-trained personnel is highly

required. Other concerns refer to possible

communication issues due to the distance to

physicians providing treatment.

Along with the anticipated benefits and barriers of

using telemedical tools, we also gained insights into

the requirements for, and conditions of, the use from

the involved study groups. These requirements

referred to the main topics introduction and training,

technology, interaction with physicians, and trust.

With regard to the latter and in line with previous

research on trust in medical technologies (Montague

et al., 2009; Wilkowska & Ziefle, 2018), needs and

requirements had different priorities depending on

both investigated user groups. To build trust in the

completely novel ways of communication concerning

the sensible topics of health and assistance of frail

persons in nursing home environments, participants

especially required a proper technical training for,

and an accessible technical support from a technically

competent staff; correspondingly, an appropriate

technological infrastructure is necessary in such

facilities. Empathy, patience, and particular

sensitivity for the situation of the nursing home

residents on the part of treating physicians is all the

more vital here – compared to direct interactions in a

doctor-patient situation – and an important

requirement for a successful usage of telemedical

consultations.

5.2 Future Research Agenda

As far as potential stakeholders solely envision the

use of the technology, instead of the real interaction

with the telemedical tools/infrastructure, we have to

expect that the attitudes greatly differ from the actual

use (Ajzen & Fishbein, 1980). A purposeful and

trouble-free use of the telemedical consultations also

requires the perspective of the attending physicians

and can uncover additional issues, which need to be

appropriately addressed. Based on the insights

identified from the first scenario-based qualitative

study that focused on the essential user groups, i.e.,

residents and care personnel, and their attitudes

towards using telemedicine in acute medical

situations in nursing homes, concrete strategies for

further steps of the user-centered investigations

within the Optimal@NRW project can be derived:

1) Fulfilling a holistic user-centered consideration

and in addition to already applied scenario-based

analyses, a major focus must be put on investigations

of acceptance and evaluations of “real” interactions

with telemedical systems. The analysis and

evaluation of direct interactions within telemedical

consultations enables to identify appearing problems,

the users’ unaltered reactions, and relevant process

flows. Up to now, the initially applied scenario-based

approaches of the present study supported the

understanding and enabled an identification of mental

models, opinions, and perceptions regarding care in

nursing homes, existing process flows, and general

attitudes before telemedicine was integrated in the

nursing homes.

2) As the results of this study revealed differences

between the respective user groups, the opinions and

evaluations of all relevant stakeholders (in particular

residents and care personnel) have to be investigated

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and considered in all phases of the project

(before/during/after implementation).

3) For a successful realization of acceptance

research within the project, qualitative and

quantitative methodological approaches have to be

combined. Thereby, interviews have been conducted

in particular at the beginning of the project to identify

wishes, attitudes, and needs of the involved

stakeholders. Further, qualitative approaches will be

applied to enable the involvement of older and frail

participants who are not able to take part in

quantitative surveys. Only on the basis of, and in

addition to, these qualitative analyses a holistic

quantification of the results using (online) surveys is

usefully realizable. Thereby, a combined usage of

qualitative and quantitative approaches enables the

inclusion of different stakeholders and their specific

characteristics.

4) As a last aspect, combining comparative and

summative acceptance analyses along the project

enables to identify changing acceptance parameters

over time (pre- / during / post-implementation).

Further, the empirical approach enables to identify

influencing characteristics of the stakeholders (e.g.,

age, gender, experience), which may also vary over

the different project phases.

Following this research agenda and considering a

social communication science perspective, the user-

centered investigations will contribute to a better

understanding of needs, requirements, and

technology acceptance patterns of partly vulnerable

stakeholders (in particular residents of nursing homes

and their caregivers). Only this way, an appropriate

medical, technical, or organizational adaption of

telemedical processes and infrastructure to the needs

of the respective user groups can be realized.

ACKNOWLEDGEMENTS

The authors thank all participants – residents and care

personnel of the different nursing homes – for their

patience and openness to share opinions on a novel

technology approach in healthcare. Furthermore, the

authors want to thank Anna Rohowsky for research

assistance. Beyond that, the authors thank the

Optimal@NRW research group. This work was

funded by the German joint federal committee

„Innovationsfond“ (grant number: 01NVF19015).

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