Blind Spots in Telemedicine: A Qualitative Study of Staff Workarounds to Resolving Gaps in Chronic Disease Care

Background: Novel telemedicine platforms have allowed critical retinal screening to expand into primary care settings, making retinal screening no longer confined to specialty eye care clinics. This enhanced access has contributed to improved retinal screening for diabetic patients, particularly those treated in Federally Qualified Health Centers (‘safety net clinics’). While the implementation of telemedical screening for diabetic retinopathy within primary care settings is improving the delivery of critical preventative services, it is also introducing changes to clinic workflows, which in many cases are adding additional tasks and responsibilities to resource-constrained clinics. Methods: A qualitative approach was employed to study the workflows and perspectives from a range of medical staff involved in the telemedicine platform for diabetic retinopathy screening and subsequent follow-up and treatment. Data were collected through in-depth, semi-structured interviews and extensive participant observation at three geographically-dispersed Federally Qualified Health Centers in California. Qualitative content analysis was performed using standard thematic analytic approaches within a qualitative data analysis software program. Results: The insertion of telemedicine screening platforms, such as diabetic retinopathy screening, into primary care settings is creating additional strain on medical personnel across the diabetes eye care management spectrum. Although the reasons are diverse, central issues are related to scheduling patients, issuing referrals for follow-up care and treatment, and initiatives to improve adherence to treatment and diabetes management. These issues are overcome in many cases through medical staff performing workarounds, or working outside of their job descriptions, purview, and permission to move patients through the care continuum. Conclusions: This study demonstrates that the implementation of novel telemedical platforms induces the phenomenon of workarounds to account for additional tasks and patient volume within workflows introduced by a telemedicine screening program for diabetic retinopathy. Often benevolent and not self-serving, these workarounds should not be considered a sustainable model of healthcare delivery, but rather as an initial step to understanding how clinics can adapt to the inclusion of telemedicine. The presence of workarounds suggests that as novel telemedicine platforms are expanded, adequate staffing and resources, as well as the collaborative, cross-sectoral co-design of new work flows must be simultaneously provided. Systematically bolstering resources and staff would contribute to a more consistent success of telemedicine screening platforms, as well as more optimal treatment and prevention of disease.

• Human-Computer Interaction and Visualization