Healthcare | Free Full-Text | Adoption Processes of Innovations in Health Systems: The Example of Telemedicine in Germany

Despite a plethora of existing implementation theories and approaches [1], there is still a lack of understanding of how to implement innovations in the context of health systems in a manner that promotes or improves the quality of care in a rapid, holistic and sustainable manner [2]. Several studies show that this can have serious implications for the quality of care and well-being of patients in healthcare systems. For example, it is known that the nonimplementation of medical guidelines can mean that not all patients receive the same quality of care, and this can have a negative impact on their health outcomes [3,4]. In the context of innovative treatment methods, such as telemedicine, it is also known that poor implementation of this treatment method can have a negative impact on patient outcomes [5]. This is also described in an OECD Health Working Paper from 2020: “Telemedicine can be both safe and effective, in some cases with better outcomes than traditional face-to-face care” [6]. Given these far-reaching effects of delayed innovation and implementation of telemedicine, it is of particular interest to study this phenomenon in health systems that are lagging behind.

The Digital Health Index can be used as a possible indicator of innovation implementation in health systems. It is composed of the dimensions of policy activity, technical implementation and readiness for networking and data use and actual data use and exchange, and thus, it allows an international comparison of the implementation of innovations in health systems [7]. As part of a special evaluation, 17 OECD countries were analyzed with regard to telemedicine in standard care. Telemedicine is an umbrella term for various types of medical care that share the fundamental concept of providing medical services to the public in the areas of diagnosis, therapy and rehabilitation and advice on medical decisions via remote (or delayed) locations [8]. The terms telehealth, telecare, eHealth, mHealth, digital health, connected health, digital care and remote care are used synonymously; the terms teleconsultation, telediagnostics, teletherapy and telemonitoring are subcategories. The Digital Health Index combines the different aspects of telemedicine, such as electronic health records, e-prescriptions or video consultations for health purposes, into a country-specific score [7]. While Estonia (score 81.9), Canada (score 74.7) and Denmark (score 72.5) are at the top of the Digital Health Index, Austria (score 59.81), Switzerland (score 40.6) and Germany (score 30) are at the bottom [7]. This means that Germany is a laggard in this ranking in terms of telemedicine implementation.

There are a number of reasons why health systems may lag behind in implementing innovation: different social protection systems (Beveridgean, Bismarkian and private economic systems), different perspectives on implementation (government, finance companies, manufacturers, etc.) and different priorities (public welfare, productivity, technology acceptance) can influence the implementation of innovation. For this reason, when implementing innovations in the healthcare context, it is not sufficient to communicate the positive consequences of an innovation [9,10]; it is necessary to systematically analyze the implementation environment using appropriate methods [10].

Another challenge in the health sector is that the nature of innovation is often not clearly defined. For example, healthcare innovations such as telemedicine often represent a hybrid of product, process and service innovations [11]. A telemedicine consultation does not only involve new software or hardware products but also changes the existing treatment and care processes and enables new forms of services, including new business and billing models [11]. This implies a variety of factors influencing product, process and service innovations.

Given the diverse characteristics of healthcare innovations, various theories and models can be used for the development of implementation strategies. From a scientific perspective, they can be divided into acceptance and adoption theories and models [12]. While acceptance-oriented theories and models (e.g., Theory of Reasoned Action (TRA) [13], Technology Acceptance Model (TAM) [14], Unified Theory of Technology Acceptance and Use (UTAUT) [15]) focus on individual, mental and behavioral determinants in relation to innovative products or technologies [16,17], adoption-oriented theories deal with the individual perceptions and attitudes of individuals.

One of the most frequently used adoption-oriented theories [18] is the adoption theory of Rogers [19]. It iteratively assigns the determinants of individual adoption decisions to a five-stage adoption process [20] consisting of “(1) knowledge, (2) persuasion, (3) decision, (4) implementation, and (5) confirmation” [19]. Based on this process flow, individual adoption processes in healthcare systems can be studied by analyzing existing knowledge, persuasion and developed decisions regarding acceptance or rejection of an innovation and implementation. These individual adoption decisions, in the context of a combined analysis of the adoption decisions of individual members, can provide information about the further diffusion of an innovation at the societal level [19,21]. Previous studies based on adoption theory suggest that the perceived relative advantage, observability and compatibility of an innovation [22], as well as previous behaviors, personal beliefs and values, may be possible predictors of technology adoption [22,23]. Further research on adoption topics such as user perceptions, perspectives and experiences, satisfaction, acceptance and adherence, usability and personal preparedness and awareness are available and underline the relevance of the perception, experience and readiness perspectives in the implementation of technological innovations in healthcare [24,25,26].

Despite evidence that using implementation theories can make a valuable contribution to the theoretical planning and design of implementation strategies in health, they have rarely been used for this purpose [27,28,29]. Their application to date has often been limited to the analysis of barriers to implementation [18] or the retrospective evaluation of implementation processes [27]. Rogers’ adoption theory [19] provides a scientifically accepted theoretical frame of reference from which individual adoption experiences can be explored, thus enabling analysis of the status quo of innovation in complex healthcare systems. This approach can be used to identify organizational and cultural characteristics of individual members of healthcare systems within thematic areas, which can serve as a basis for developing quantifying research methods. The starting point for the analysis of the adoption processes of innovations in healthcare systems is therefore not only the acceptance factors for innovations but also how and in what way the individual members of the healthcare system learn about innovations, what experiences they have had with them and what attitudes they have developed as a result.

The results of the expert interviews fit into the current state of research in implementation and innovation science and expand it to include specific aspects of telemedicine innovation in regulated healthcare markets such as Germany. The deductive–inductive analysis, based on Rogers’ adoption theory, was able to extend the existing knowledge about the special significance of adoption experiences in healthcare systems [22,23,24,36] by revealing context-sensitive issues that may act as hidden influencing factors on the diffusion of innovations.

The interviews show that the phenomenon of inconsistent use and attribution of meaning applies not only to the term innovation but also to the concept of telemedicine. Thus, the underlying basic understanding of the definition of telemedicine is the same among all experts and is based on the understanding of the European Commission, according to which “Telemedicine is the provision of healthcare services, through use of ICT, in situations where the health professional and the patient (or two health professionals) are not in the same location” [37]. Despite this common understanding, the responses reveal uncertainties about the technologies and applications involved, as illustrated by the distinction between telematics and telemedicine. One possible reason for this could be the underlying understanding of the term innovation in telemedicine, which was not further queried. A mixture between a telemedicine understanding of “newly perceived” (understanding according to Rogers [19]) and “completely new” (understanding according to Barnett [38]) forms of telemedicine (e.g., telephone consultation vs. video consultation vs. telemonitoring) cannot be ruled out and is indicated in several interviews. Nevertheless, the basic common understanding of the terminology telemedicine allowed an embedding of the analysis in a general context analysis. With this understanding, the outcome categories of persuasion (n = 171), knowledge (n = 96), implementation (n = 19), decision (n = 10) and confirmation (n = 8) were explored on the basis of E.M. Roger’s adoption theory [19].

Upon further analysis, the most frequently coded segments were the subcodes convictions about the implementation of telemedicine (n = 89) (persuasion), aspects of existing telemedicine innovations (n = 65) (knowledge), international comparison of Germany’s development (n = 50) (persuasion) and aspects of telemedicine in the context of structures in Germany (n = 24) (knowledge). The most frequently coded category, persuasion, indicates that respondents’ opinions and attitudes towards the innovations of telemedicine are already well-established. Possible reasons for this could be the pandemic-related information and education campaigns on teleconsultation [39], its billing integration into standard care with the lifting of the previous ban on telemedicine in Germany [40] and a pandemic-related increased sensitivity towards telemedicine/noncontact treatment methods. The statements indicate that physicians and telemedicine experts have a lot of information, opinions and attitudes regarding telemedicine implementation, despite being latecomers to innovation implementation in the healthcare sector.

The attitudes measured in the subcategory convictions regarding the implementation of telemedicine (n = 89) cover various topics, such as political will as a prerequisite for the implementation of telemedicine, the existing fears of users, unresolved reimbursement issues or different attributions of the importance of telemedicine, e.g., as process optimization rather than as a new treatment method. Some of these aspects, such as political will, reimbursement issues or fears, are also found in several studies [41,42,43]. Other implementation factors, such as user anxiety, are also discussed in the literature as influencing acceptance and attitudes toward eHealth innovations [44]. This subcategory thus overlaps with previous implementation and acceptance research but differs in its focus on individual attitudes toward telemedicine. Whether and to what extent these attitudes have an effect on the perceived responsibility for implementation could not be clarified. However, there were indications that this is seen at the political level.

In terms of knowledge of existing telemedicine innovations, it became apparent that there was broad knowledge of available technologies and possible applications for telemedicine, although the level of detail differed between respondents. The subcode aspects of telemedicine in the context of structures in Germany (n = 24) is closely related to the category persuasion, but it includes the respondents’ knowledge of the specific German structures and framework conditions for the implementation of telemedicine, such as the billing peculiarities of telemedicine-supported functional analyses or the exclusive ban on remote patient treatment that was valid until 2020 [45]. The aspects mentioned here are to be seen in the context of efforts to strengthen “system partnerships between the healthcare industry and the traditional partners (service providers and payers)” [46], which have no tradition in Germany, although they are legally anchored in the Social Code, Book V [46]. They enable cooperation between manufacturers, service providers and payers in the healthcare system and are reflected in pilot projects and integrated care models [47] with the aim of improving the quality of care and treatment, increasing patient satisfaction and reducing treatment costs [48]. If an innovation such as telemedical intervention management for heart failure [49] proves effective, it will be adopted into standard care [50] and will experience the implementation factors described in the literature [41,42,43,51,52,53]. The experts’ statements indicate that the specific healthcare system structures and associated procedures for innovation implementation do not adequately cover the characteristics of telemedicine as a mixture of product, process and service innovation and therefore delay implementation. The extent to which this is a phenomenon specific to the Bismarck system cannot yet be conclusively clarified. However, it appears that the penetration and implementation of innovations such as telemedicine are more difficult in a healthcare system based on self-administration, as is the case in Germany.

The aspects elicited in the subcategory international comparison of Germany’s development (n = 50) provide insight into the development of telemedicine in Germany so far in comparison with international healthcare systems from the perspective of the respondents. Distinctive aspects were Germany’s comparatively lagging role in the international field, the national narrative of data protection and the associated perceived “special path” in the implementation of telemedicine in Germany, which have also emerged in the literature as potential barriers to implementation. It also emerged that knowledge about telemedicine is often based on individual, national and international exchanges of knowledge and experience. Overarching information and communication structures for telemedicine appear to be weak in the German healthcare system. Gagnon et al. [54] even reported that organizational and contextual factors can act as support factors for implementation, although these alone cannot predict actual behavior [55]. Against the background of the influence on the perception of and attitude formation toward innovations [22,23,24,36], it is reasonable to assume that the national narrative of data protection and weak information and communication structures have a reciprocal influence on the implementation of telemedicine.

The results of the implementation, decision and confirmation categories with their elicited aspects on implementation steps and the confirmation or rejection of innovation can be understood against the theoretical background of implementation science. They allow theory-based analyses on barriers and facilitators or on the importance of perceptions and individual attitudes towards innovations [18,22,23,24,36]. The different stages of implementation, or even the acceptance or rejection of an innovation, can be understood in this light. For example, resistance to innovative change and insufficient digital literacy [56], as well as fear and anxiety of losing control, can act as behavioral barriers and hinder the implementation of innovations at the individual level [51,57]. During the interviews, telehealth innovations were not rejected by any of the interviewees, and their benefits and potential were recognized. However, the decision to implement had not yet been made by all interviewees. Factors such as financing, acceptance or lack of information were cited as reasons for this, which are already implementation determinants described in the literature [43]. Against the background of the adoption theory according to Rogers [19], the open attitudes towards innovations in telemedicine but only partial implementation indicate that the respondents were in different phases of the individual adoption process. In relation to the respective adoption phase and the underlying individual communication behavior about innovations, there are also indications of the respective adoption type. The lower number of codes for the categories’ implementation, decision and confirmation can thus be an expression of the different adoption processes, as well as the composition of the adoption types.

The aim of this study was to record the individual perceptions and attitudes of medical and telemedicine experts with regard to the implementation of innovations in healthcare systems using the example of telemedicine in Germany. Based on the adoption theory, the aim was to identify topics that act as hidden influencing factors on telemedicine implementation in Germany. Despite careful study planning, the present study has limitations. The small sample of 13 participants does not allow a statistical evaluation of the statements and is therefore not transferable to all physicians and telemedicine experts in Germany. Furthermore, a bias due to socially desirable statements by the interview participants cannot be completely ruled out, despite the assurance of anonymity. In addition, this research work is subject to the qualitative research paradigm of subjectivity due to its methodology [58]. Accordingly, despite compliance with the quality criteria of intracoder reliability and plausibility checks and the rule-based approach according to Kuckarzt [35], the coding may differ from that of other researchers [59], although it can be categorized within the current state of research. Furthermore, it cannot be ruled out that other topics may have been left out, as the data collection was completed after 13 expert interviews in accordance with the principle of theoretical saturation [33,34].