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Family Practice Advance Access originally published online on January 10, 2005
Family Practice 2005 22(1):2-7; doi:10.1093/fampra/cmh716
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© The Author (2005). Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions{at}oupjournals.org

Remote working: survey of attitudes to eHealth of doctors and nurses in rural general practices in the United Kingdom

Helen Richardsa, Gerry Kinga, Margaret Reidb, Sivasubramaniam Selvaraja, Iain McNicolc, Eileen Brebnerd and David Goddena

a Highlands and Islands Health Research Institute, Aberdeen University, b Section of Public Health and Health Policy, Community Based Sciences, Glasgow University, c Port Appin Medical Practice, Port Appin and d Department of General Practice and Primary Care, Aberdeen University, UK

Corresponding author Dr Helen Richards, Highlands and Islands Health Research Institute, University of Aberdeen, The Green House, Beechwood Business Park North, Inverness IV2 3ED, Scotland, UK; Email: h.richards{at}abdn.ac.uk

Received 4 June 2004; Accepted 28 June 2004.

Richards H, King G, Reid M, Selvaraj S, McNicol I, Brebner E and Godden D. Remote working: survey of attitudes to eHealth of doctors and nurses in rural general practices in the United Kingdom. Family Practice 2004; 22: 2–7.


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Declaration
 Appendix 1
 References
 
Background. Health professionals in rural primary care could gain more from eHealth initiatives than their urban counterparts, yet little is known about eHealth in geographically isolated areas of the UK.

Objective. To elicit current use of, and attitudes towards eHealth of professionals in primary care in remote areas of Scotland.

Methods. In 2002, a questionnaire was sent to all general practitioners (n = 154) in Scotland's 82 inducement practices, and to 67 nurses. Outcome measures included reported experience of computer use; access to, and experience of eHealth and quality of that experience; views of the potential usefulness of eHealth and perceived barriers to the uptake of eHealth.

Results. Response rate was 87%. Ninety-five percent of respondents had used either the Internet or email. The proportions of respondents who reported access to ISDN line, scanner, digital camera, and videoconferencing unit were 71%, 48%, 40% and 36%, respectively. Use of eHealth was lower among nurses than GPs. Aspects of experience that were rated positively were ‘clinical usefulness’, ‘functioning of equipment’ and ‘ease of use of equipment’ (76%, 74%, and 74%, respectively). The most important barriers were ‘lack of suitable training’ (55%), ‘high cost of buying telemedicine equipment’ (54%), and ‘increase in GP/nurse workload’ (43%). Professionals were concerned about the impact of tele-consulting on patient privacy and on the consultation itself.

Conclusions. Although primary healthcare professionals recognize the general benefits of eHealth, uptake is low. By acknowledging barriers to the uptake of eHealth in geographically isolated settings, broader policies on its implementation in primary care may be informed.

Keywords. Information technology, telemedicine.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Declaration
 Appendix 1
 References
 
Ensuring equal access to good quality health care remains a core aim of the National Health Service.1 Overcoming geographical barriers to access is one of the principal challenges for providing health services in remote and rural areas.2 eHealth has the potential to improve access to care and access to educational opportunities for professionals, and in remote areas it could reduce professional isolation and thus help in the recruitment and retention of health professionals.3 Immediate National Health Service Information Technology targets include the connection of all NHS staff to the NHS Network for the use of email and the Internet, the electronic transfer of laboratory results, and to support the Information Technology requirements of National Service Frameworks.4

Most Scottish GPs use computers routinely for clinical and administrative activities5 and all general practices in Scotland are connected to NHS Net. Some routine communication functions within primary care such as booking outpatient appointments, obtaining laboratory results, and referrals are being carried out electronically, albeit by a minority of practices.6 In addition, there are some good examples of ongoing telemedicine projects in specific clinical areas.7,8 However, most of those initiatives have been driven by champions of the technology itself and are based in secondary care.

Despite the presence of NHS Network links in Scotland's general practices, the routine adoption of eHealth in Scottish primary care has been slow. International literature suggests possible barriers to the uptake of telemedicine in primary care include concerns that the technology may not offer tangible benefits to patients9 and that there may be negative effects on the clinical encounter.10 Concerns have also been raised about the ethical issues surrounding telemedicine11 and the potential difficulties integrating telemedicine into existing work patterns.12

Practitioners in remote and rural primary care stand to gain more from eHealth initiatives than their urban counterparts in terms of clinical usefulness13 and cost benefits,14 yet little is known about eHealth in geographically isolated areas of the UK. We therefore carried out a survey of current use of, and attitudes towards eHealth of doctors and nurses working in some of the remotest general practices in the UK.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Declaration
 Appendix 1
 References
 
In the summer of 2002, a postal questionnaire was sent to all GPs (n = 154) working in the Inducement Practices15 and to one nurse from each practice with a nurse (n = 67). All of the practices were eligible for inducement payments because of the sparseness of their practice populations or their geographical remoteness. Non-responders were sent two reminders.

In the absence of validated instruments for assessing attitudes to information technology amongst GPs,16 most questions were generated de novo from themes in the literature, from a pilot study of GPs and nurses in a local rural area served by one Local Health Care Co-operative, and by referring to previous surveys (Sarah Snowden, personal communication). The questionnaire asked about 5 aspects of eHealth: (i) respondents' experiences of using computers; (ii) their access to and experience of eHealth; (iii) the quality of that experience; (iv) their views of the potential usefulness of eHealth; and (v) their perceived requirements for and barriers to the implementation of eHealth. Most questions required a ‘yes/no’ response or used a 5-point rating scale.

Questions about computer use were included because computer literacy is a prerequisite for using many eHealth applications. Views about the potential usefulness of eHealth were ascertained using 3 hypothetical scenarios: (i) a GP and patient videoconsulting with a specialist; (ii) a nurse and a patient videoconsulting with a GP; and (iii) a health professional videoconferencing for education. For each scenario, respondents rated 5 aspects of the scenario on a 5-point rating scale. The eHealth needs of the practice were ascertained by respondents selecting from series of 9 eHealth applications and 11 clinical speciality links, the 3 applications/links that they considered most potential beneficial to their practice. Similarly, perceived barriers to the implementation of eHealth were ascertained by respondents indicating the 3 out of 8 aspects that they believed would be most problematic in their practices. The lists of options (Appendix 1), were derived from the literature and our pilot study.

Respondent data included: professional group (nurse or GP); age-group (20–39; 40–49; 50+); gender; and special interests (in at least one of teaching, research, management or politics). Practice and location data included: number of registered patients (<1000/>1000); and average patient travel time to the nearest District General Hospital. Data were entered onto SPSS for Windows (version 10) and analysed using Stata 7.0. Results are presented as percentages. Chi-square tests were used to assess the statistical significance of differences between groups in the frequency distribution of categorical variables, unless the expected cell size was less than five, when Fisher's exact test was used.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Declaration
 Appendix 1
 References
 
Of the 221 questionnaires sent, 193 (87%) were returned complete. The response rate was similar amongst GPs (87%) and nurses (88%). Of the 193 respondents, 134 (69%) were GPs and 59 (31%) were nurses. Characteristics of the professionals and practices are shown in Table 1.


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  		TABLE 1 Characteristics of the professionals and practices

 
Use of computers
Thirty-seven per cent of respondents rated themselves as ‘experienced’ or ‘very experienced’ in the use of computers. That proportion was higher for GPs (44%) than nurses (20%) (P = 0.001). Ninety-five percent of respondents said they had used either the Internet or email, and 71% said they had used both, with no differences by profession. Twenty per cent of respondents stated that they had used all 6 computer applications (word-processing, spreadsheet, Powerpoint, email, Internet and databases). Again the proportion was higher for GPs (24%) than nurses (10%) (P = 0.027).

Access to and use of eHealth equipment
The proportions of respondents stating that they had access to each of ISDN line, scanner, digital camera, and videoconferencing unit were 71%, 48%, 40% and 36%, respectively. Seventeen percent of respondents reported access to all four types of equipment.

One hundred and thirty four respondents (69%) said that they had used at least one of the following 8 eHealth functions: Internet for obtaining laboratory results; Internet for making outpatient appointments; transmission of ECGs; transmission of X-Rays; transmission of still images; teleconferencing by phone; videoconferencing for education and videoconferencing for consulting (Table 2). The most common application was using the Internet for obtaining laboratory results (47%) and the least common was transmission of X-Rays (7%). For 5 of the 8 the functions, GPs were more likely to have used the function than nurses.


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  		TABLE 2 Percentage of respondents who have carried out each of eight eHealth functions

 
Of the 134 respondents who had used at least one eHealth application, 60% had used it for communication (teleconferencing by phone, or videoconferencing). The remainder had used transmitting functions only. GPs were more likely than nurses to have used eHealth for transmitting and communicating (Table 3).


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  		TABLE 3 Percentage of respondents who have used eHealth for communication and transmission, by profession

 
Quality of experience of using eHealth (Table 4)
When asked to state the eHealth application that they were most familiar with, 112 respondents replied, of whom 54% said obtaining laboratory results using the Internet, 20% said videoconferencing for education or clinical purposes, and 27% said a variety of other applications. Sixty-eight percent of respondents rated that overall experience as ‘good’ or ‘very good’. Aspects of the experience that were most likely to be rated positively were ‘ease of use of equipment’, ‘functioning of equipment’, and ‘clinical usefulness’ (74%, 75% and 76%, respectively). ‘Technical support’ and ‘training’ were rated positively by just 44% and 39% of respondents, respectively.


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  		TABLE 4 Percentage of respondents rating 6 aspects of eHealth positively

 
Views about the potential usefulness of eHealth (Table 5)
Respondents were presented with 3 scenarios in which eHealth could be used as an alternative to standard practice and asked to rate 5 aspects of each scenario as beneficial, neutral or detrimental.


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  		TABLE 5 Views about the potential usefulness of eHealth applications

 
Scenario 1: Patient and GP videoconsult with a specialist, as an alternative to a standard outpatient appointment (GPs only). Three of the 5 aspects (knowledge and skills, sense of professional isolation and access to secondary care) were considered beneficial by the majority of GPs. Effect on quality of consultation was rated as beneficial by 44% and effect on patient privacy by just 13%. A quarter of GPs considered there to be a detrimental effect on patient privacy.

Scenario 2: Patient and nurse video-consulting with a GP, as an alternative to a standard GP appointment. Only 2 out of 5 aspects of this scenario (nurse's knowledge/skills and nurse's professional isolation) were considered beneficial by the majority of respondents. Forty-five percent of respondents rated access to the GP positively and just one third considered the effect on the quality of the consultation to be beneficial. The effect on patient privacy was rated positively by just 16% of respondents, and 32% considered the effect on patient privacy to be detrimental.

Scenario 3: Videoconferencing, as an alternative to attending an educational meeting. Four out of 5 aspects of this scenario (ease of access to educational events, equity of access, cost of attending events, and professional's knowledge and skills) were rated as beneficial by the majority of respondents: 90%, 86%, 82%, and 80%, respectively. Twenty one percent of respondents considered that eHealth would enhance the enjoyment of educational meetings but half of respondents said it would have a detrimental effect.

Needs of the practices (Appendix 1)
Respondents selected 3 eHealth applications from a list of 9, and 3 clinical speciality-links from a list of 11, that they considered would be most useful to their practice (Appendix 1). The top three applications were: ‘obtaining laboratory results via the Internet’ (69%), ‘transmission of ECGs’ (44%), and ‘videoconferencing for education’ (39%). The top three clinical specialities were: dermatology (62%), accident and emergency (53%), and general medicine (46%).

Respondents rated 4 potential effects of eHealth on primary care (improvement in patient care, improved access to care, reduction of costs, successful integration with existing work patterns). Sixty-four percent rated ‘improvement in patient care’ as the most important factor for deciding whether to implement an eHealth initiative. Lastly, respondents chose 3 potential barriers to successful implementation of eHealth from a list of 8. The top three barriers were ‘lack of suitable training’ (55%), ‘high cost of eHealth equipment’ (54%), and ‘increase in GP/nurse workload’ (43%).


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Declaration
 Appendix 1
 References
 
Despite respondents reporting their actual experiences of eHealth as good, and viewing the hypothetical scenarios as beneficial, reported levels of access to eHealth equipment and use of eHealth was low, especially among nurses. Concern was expressed that video-consulting could be detrimental to patient privacy and confidentiality, and that video-conferencing could reduce the enjoyment of educational meetings. Compared with GPs, nurses were less likely to report being experienced computer users, less likely to have used a range of computer and eHealth functions, and less likely to have used eHealth for transmitting data and communicating.

eHealth applications reported as potentially most useful were ‘obtaining laboratory results’, ‘transmission of ECGs’ and ‘videoconferencing for education’, all of which are highlighted in recent National Health Service IT strategy.4 The perceived usefulness of obtaining laboratory results electronically concurs with the findings of a recent evaluation of a Scottish electronic communication initiative,17 which found that 90% of respondents with access to electronic results use the facility at least once a week. The specialities with which it was considered that videoconferencing links would be most useful were dermatology, accident and emergency and general medicine. That Scottish telemedicine systems already exist for those specialities7,8 may have influenced those choices. The most important barriers to implementing eHealth were ‘lack of suitable training’, ‘cost of equipment’ and ‘increased workload’.

The study population comprised practitioners working in some of the remotest practices in the UK, where innovations such as eHealth aimed at improving access should have most relevance and impact. In the absence of standard measures of ‘rurality’ or ‘remoteness’, we judged that eligibility for Inducement payments (because of geographical remoteness or sparseness of population) would be the best criterion for inclusion in the survey sample. Very little research into the organization of primary care has been conducted in rural settings18 and important lessons about practitioners' attitudes to eHealth can be learned from our ‘test-bed’ of remote practices and applied to the wider debate on the implementation of eHealth. The choice of a small, reasonably homogeneous population meant that there was limited scope for comparing sub-groups, yet we have demonstrated that GPs report a greater use of eHealth than nurses. Our response rate of 88% was higher than the average primary care survey19 and may be attributable to our use of strategies known to improve survey response rates,20 such as: contacting respondents by phone before the survey; using personalized letters; using follow-up phone calls; and providing a second copy of the questionnaire.

The low rates of access to and use of telemedicine are similar to those found in recent survey of Australian physicians,21 although that survey was limited by its low response rate of under 25%. Low usage in Scotland cannot be explained by lack of policy drive or low levels of financial investment,22 and we found no evidence of a generalized resistance among practitioners to the technologies. Our results do however suggest important organizational barriers to the uptake of eHealth such as perceived increased cost and workload and, like previous research,23 we highlight the perceived lack of suitable training and technical support. In addition, doctors and nurses were concerned about the impact of tele-consulting on patient privacy and on the consultation itself.

eHealth was rated more positively for education than for clinical purposes, lending support to the statement that "Using videoconferencing and other techniques of e-learning provides a non-threatening way of introducing the culture of remote working easing the transition to using similar technology for clinical care".1 However, remote practitioners' perceptions that eHealth will diminish the enjoyment of education should be taken into account when planning educational programmes. The relative under-use of eHealth by nurses has been observed elsewhere.24 It may reflect: a lack of a need to interface with specialist services; a belief that nursing relies essentially on face-face contact and practical tasks; or the relatively low access of to desktop computers.17 The lack of involvement of nurses in eHealth has important implications for the proposed expansion of the role of nurses2 which may involve greater use of eHealth.

Information technology and telemedicine are seen as integral to transforming the way in which health care is delivered in the UK. For example, Scotland's recent Health White Paper "Partnership for Care"1 recognizes the central role of electronic communications to the development of health services and states: "We urgently require an eHealth culture to be established, driven by clinical leaders". Our survey shows that primary care professionals in remote and rural areas of the UK recognize the potential benefits of eHealth, but it also highlights important perceived barriers to its widespread uptake especially amongst nurses, such as lack of training and technical support. When planning further implementation of eHealth initiatives in primary care, it is important that these perceptions are taken into account.


   Declaration
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Declaration
Appendix 1
 References
 
Funding: the study was funded by the Scottish Executive Remote and Rural Areas Resource Initiative.

Ethical approval: Ethical approval was obtained from Highland Research Ethics Committee.

Conflicts of interest: none.


   Appendix 1
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Declaration
 Appendix 1
References
 
Telemedicine applications

  1. Obtaining laboratory results via the Internet
  2. Making outpatient appointments using the Internet
  3. Transmission of Electrocardiograms
  4. Transmission of X-rays
  5. Transmission of still images
  6. Teleconferencing by phone
  7. Videoconferencing of a consultation between health professionals
  8. Videoconferencing a meeting for education
  9. Monitoring patients at home

Clinical specialities

  1. 1 Accident and emergency
  2. Obstetrics
  3. Psychiatry
  4. Psychology
  5. Nursing
  6. General medicine
  7. Rheumatology
  8. Dermatology
  9. Communication between members of the primary care team
  10. Dentistry
  11. Ophthalmology

Barriers to the use of eHealth

  1. High cost of equipment
  2. Lack of suitable training in the use of equipment
  3. Concerns about patient privacy/confidentiality
  4. Negative attitudes of staff involved
  5. Lack of user-friendly software
  6. Lack of perceived clinical usefulness
  7. Lack of consultation between Information Technology experts and clinicians
  8. Perceived increase in workload


   Acknowledgments
 
We would like to thank the Scottish Executive Remote and Rural Areas Resource Initiative (RARARI) for funding this study and the health professionals who completed the questionnaire.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Declaration
 Appendix 1
 References
 
1 NHS Scotland. Partnership For Care: Scotland's Health White Paper. Edinburgh: Scottish Executive; 2003.

2 Deaville, JA. The Nature of Rural General Practice in the UK—Preliminary Research. Newtown: Institute of Rural Health; 2001.

3 Scottish Remote and Rural Areas Resource Initiative. Solutions For the Provision of Health Care in the Remote and Rural Areas of Scotland. RARARI; 2002.

4 Department of Health. Delivering 21st Century IT Support For the NHS: National Strategic Programme. London: Department of Health; 2002.

5 Morris L, Dumville J, Campbell LM, Sullivan F. A survey of computer use in Scottish primary care: general practitioners are no longer technophobic but other primary care staff need better computer access. Informatics in Primary Care 2003; 11: 5–11.[Medline]

6 NHS Scotland. Electronic Clinical Communications Implementation; 2003. http://www.show.scot.nhs.uk/ecci/ Accessed December 2003.

7 Jones DH, Crichton C, Macdonald A, Potts S, Sime D, Toms J et al. Teledermatology in the Highlands of Scotland. Journal of Telemedicine & Telecare 1996; 2 (suppl 1): 7–9.

8 Brebner EM, Brebner JA, Ruddick-Bracken H, Wootton R, Ferguson J. Evaluation of a pilot telemedicine network for accident and emergency work. Journal of Telemedicine & Telecare 2002; 8 (suppl 2): 5–6.

9 Campbell JD, Harris KD, Hodge R. Introducing telemedicine technology to rural physicians and settings. J Fam Pract 2001; 50: 419–424.[Medline]

10 May C, Gask l, Atkinson TEN, Mair F, Esmail A. Resisting and promoting new technologies in clinical practice: the case of telepsychiatry. Soc Sci Med 2001; 52: 1889–1901.[Medline]

11 Stanberry B. Telemedicine: barriers and opportunities in the 21st century. J Internal Med 2000; 247: 615–628.

12 Lehoux P, Sicotte C, Denis JL, Berg M, Lacroix A. The theory of use behind telemedicine: how compatible with physicians' clinical routines? Soc Sci Med 2002; 54: 889–904.[CrossRef][ISI][Medline]

13 Wootton R. Telemedicine and isolated communities: a UK perspective. Journal of Telemedicine & Telecare 1999; 5: 27–34.

14 Wootton R. Telemedicine. Br Med J 2001; 323: 557–560.[Free Full Text]

15 Scottish Executive Health Department. Statement of Fees and Allowances Payable to General Medical Practitioners in Scotland from 1 April 1990. http://www.show.scot.nhs.uk/redbook/45.htm Accessed December 2003.

16 Cork RD, Detmer WM, Friedman CP. Development and initial validation of an instrument to measure physicians' use of, knowledge about, and attitudes toward computers. J Am Med Inform Assoc 1998; 5: 164–176.[Abstract/Free Full Text]

17 Pagliari C, Gilmour M, Sullivan F. Electronic Clinical Communications Implementation (ECCI) in Scotland: a mixed methods programme evaluation. J Eval Clin Pract 2003; 10: 11–20.[CrossRef]

18 Godden DJ, Richards HM. Health research in remote and rural Scotland: what is out there? Scot Med J 2003; 48: 10–12.

19 Sibbald B, Addington-Hall JM, Brenneman D, Freeling P. Telephone versus postal surveys of general practitioners: methodological considerations. Br J Gen Pract 1994; 44: 297–300.[ISI][Medline]

20 Edwards P, Roberts I, Clarke M, DiGuiseppi C, Pratap S, Wentz R et al. Increasing response rates to postal questionnaires: systematic review. Br Med J 324: 1183–1193.

21 White C, Sheedy V, Lawrence N. Patterns of computer use among medical practitioners in rural and remote Queensland. Aust J Rural Health 2002; 10: 137–146.[Medline]

22 Scottish Telemedicine Initiative. http://www.show.scot.nhs.uk/telemedicine/ Accessed December 2003.

23 Barry N, Reid M, Ibbotson T, Bower J. Telemedicine diffusion in Scotland: training and technical support issues. Brit J Healthcare Comp Information Management 2000; 17: 20–22.

24 Wallace P, Haines A, Harrison R, Barber J, Thompson S, Jacklin P et al. Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomized trial. Lancet 2002; 359: 1961.[CrossRef][ISI][Medline]


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