Between October 2, 2020, and January 31, 2021, we conducted in-depth interviews with primary care providers, nurses, telehealth clinical technicians, medical and program support assistants, and administrators from 2 community-based outpatient clinics and distant reading sites. Semistructured interviews (interview guide detailed in Textbox 1) aimed to explore perspectives, identify telespecialty care facilitators and barriers, and derive solutions from community-based outpatient clinics [4]. A trained interviewer (TS) conducted 30 individual telephone interviews lasting 30-60 minutes, with digital audio recording and participant consent. Interviews were transcribed professionally and deidentified. Qualitative content analysis followed a summative approach [5] with latent content analysis for underlying meanings and patterns. Coders (CP and JD) independently reviewed transcripts, resolving discrepancies by consensus. Diagramming mapped conceptual relationships across stakeholder perceptions to identify facilitators, barriers, and solutions.

This study received approval from the Emory University Institutional Review Board (STUDY00000383) on June 3, 2020, and from the Atlanta Veterans Affairs (VA) Medical Center Research and Development Committee. The results are reported in accordance with COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines [6]. All participants provided verbal informed consent prior to the study conduct, and participant data were deidentified. No compensation was provided to the participants.

Of the 30 participants, a total of 27 (90%) had experienced the hybrid format of telespecialty encounters, where patients visited the community-based outpatient clinic site for image acquisition during the study period, and 3 (10%) had in-person visits only. Interviews identified two primary facilitators to telespecialty care: (1) positive perception of telespecialty care and (2) optimized implementation processes (task lists, deadlines, and bringing together multiple capable diverse stakeholders in regular meetings).

This study identified facilitators and potential challenges to telespecialty care implementation through summative content analysis, highlighting the complexity of telespecialty care as an intervention to bridge the access issue for veterans. In line with these findings, recommendations provided in Textbox 2 further complement this study, offering actionable steps for improving the implementation of telespecialty care.

Our findings are consistent with previous research, providing further support for the numerous advantages of telespecialty care for patients. In line with existing literature [7-11], this study highlights that telespecialty care offers several facilitators, including improved efficiency, convenience, and reduced travel and wait times. Telespecialty care enhances access to health care, especially for underserved areas, enabling access to specialized services [12-16] and addressing emergent conditions that patients may not have initially recognized [17]. Specifically, using store-and-forward teledermatology offers comparable effectiveness to in-person assessment, significantly reduces travel time, and expedites management [18].

Organizational barriers stemming from staffing shortages and lack of designated personnel hindered telespecialty care implementation. This barrier was exacerbated by the clinic's unmodified workflow, forcing nurses with in-person duties to take on extra work for telespecialty appointments. Consistent with our findings, a study examining the perspectives of primary care physicians on telespecialty care referral reported that teledermatology can disrupt the existing in-person workflow [13]. In situations where staffing shortages occurred, informal temporary workaround strategies were frequently used to handle exceptions to normal workflow [19]. However, reliance on workaround strategies added to the already heavy workload of staff members, as they attempted to manage the demands of telespecialty care within their existing schedules. While workarounds are commonly used in medical settings, it is important to recognize that they have the potential to increase the occurrence of medical errors [20] and place additional strain on clinics with limited resources [21].

This study highlights the criticality of establishing standardized protocols and providing ongoing training for the successful telespecialty care implementation. Stakeholders emphasized the need for protocols to guide troubleshooting and equipment failure and ensure consistent practices. These findings align with existing research, which consistently identifies limited technological knowledge, skills, and a lack of education and training as significant barriers to the implementation and acceptance of telemedicine interventions [22,23]. Furthermore, effective planning for equipment maintenance is paramount to ensure the efficient and effective provision of telespecialty care [24]. Previous research investigating the challenges of maintaining eye care equipment revealed that equipment breakdowns led to frustrating delays in conducting proper examinations and increased the risk of disease progression, resulting in poorer treatment outcomes [25]. Therefore, implementing regular maintenance protocols and establishing contingency plans are critical for minimizing disruptions and optimizing the delivery of telespecialty care.

This study reveals an increase in administrative workload for primary care providers and their support staff due to the surge in specialty care referrals. This underscores the complexities and unintended consequences of telespecialty care implementation, particularly the challenge of managing this heightened workload within limited time constraints [26]. The amplified workload pressures from specialty care referrals have compelled health care professionals to dedicate more time to collecting comprehensive patient histories for teleconsultation referrals. This additional time investment is crucial for maintaining the quality of telehealth consultations and preventing potential errors [27]. Our findings align with broader literature concerns about the workload burden imposed by administrative tasks in telehealth, emphasizing potential consequences, such as system failures, resulting from increased workload [27].

This study has several limitations. First, the use of convenience sampling and unequal sample sizes across stakeholder groups may have introduced selection bias into this study. Additionally, participant perspectives were obtained solely from Teledermatology and Technology-Based Eye Care Services providers at the 2 referring sites within the VA Southeastern Network, which may not be representative of other health care settings, potentially limiting the generalizability of the findings. Future patient interviews may provide additional perspectives on telespecialty care to supplement our providers’ perspectives.

Implementation of telespecialty care should apply implementation science framework to align technology, people, organizations, and context and to add value to patient care and health care systems [28]. Adapting a learning system approach that continually improves telespecialty care implementation is needed to account for health care system complexity and different user needs and to avoid unintended consequences and challenging workflow issues [28-32]. This study provided insights into the intricacies of telespecialty care implementation, shedding light on both facilitators and barriers encountered in the delivery of these services. Addressing these challenges and opportunities has the potential to increase access to care, enhance the quality of care provided, and promote the sustainability of telespecialty care innovations.