Adoption of telemedicine from the healthcare management perspective

Defined as the application of information and communication technologies (ICT) for healthcare purposes (Velsen, Tabak, & Hermens, 2017), telemedicine is making healthcare feasible for the population, especially in very challenging circumstances like the global COVID-19 pandemic (Anthony, 2024). Understanding how people adopt and use telemedicine can be a way to increase access to healthcare, mainly for those living in remote areas with poor transportation systems (Nitiema, 2022).

The challenges of implementing telemedicine can be considered multifaceted. A technological infrastructure must be set up to address not only the teleconsultations themselves, but also the integration of all data and information produced from telemedicine into the healthcare institution's systems. Problems of different complexities arise, such as physicians' limited knowledge about telemedicine (Bashir, Lalithabai, AlOtaiby, & Abu-Shaheen, 2023); physicians' difficulties in making clinical evaluation, diagnosis and investigations; medical staff and patients with low e-literacy; and a traditional mindset for physical appointments (Gupta et al., 2023). In general, physicians have positive attitudes towards telemedicine (Fouad, Osman, Abdelmonaem, & Karim, 2023) as much as the patients (Holzman, Davis-Dao, Khoury, Fortier, & Kain, 2023), although the latter still prefer in-person appointments (Ahmad, Wysocki, Fernandez, Cohen, & Simcock, 2023).

Considering the context above, the question raised here is: how do healthcare managers perceive and deal with the main drivers and barriers to the adoption of telemedicine in their institutions? Thus, this article aims to evaluate the challenges of adopting and using telemedicine from a healthcare management perspective. The main idea is to appraise how much and to what extent enhancers and inhibitors are influencing the adoption of telemedicine by healthcare personnel in Brazilian healthcare institutions, especially since the COVID-19 pandemic, a crisis that forced social distancing and stimulated remote healthcare assistance (Farr, Duvic, & Joshi, 2021; Escobar et al., 2021; Abdel-Wahab, Rosenblatt, Prajogi, Zubizarretta, & Mikhail, 2020).

The theoretical model used to support this research sought to unite fundamental aspects of innovation adoption, based on the Innovation Diffusion Theory - IDT, with basic elements to be considered in the organizational adoption process, available in the Technology, Organization, Environment - TOE framework.

Due to this study's special interest in the organizational adoption of innovation, the most appropriate theories to be addressed were IDT (Rogers, 2003) and TOE (Tornatzky & Fleischer, 1990).

The choice of the IDT and TOE frameworks was attributable to their importance for the understanding of the processes of innovation adoption and diffusion, as evidenced in the following literature reviews: Taherdoost (2022), Yadegari, Mohammadi, and Masoumi (2024), Anthony (2024), Bell et al. (2023), FakhrHosseini et al. (2024), and Prakash (2025). The criteria used to highlight the theoretical relevance in management were importance and applicability (Machado, 2021; Carton, 2025). Importance refers to theories surviving the test of time because enduring patterns that transcend contexts were identified (Carton, 2025), whereas applicability refers to a theory's potential to solve real-world problems (Machado, 2021; Carton, 2025). Although the IDT and TOE theories were initially proposed in the 1960s and 1990s, respectively, they have stood the test of time and are still in widespread use (i.e. importance), serving as a basis for new models that can explain the adoption and diffusion of innovations in diverse contexts (i.e. applicability). The following research papers present model proposals combining IDT and TOE in various organizational environments: Amini and Javid (2023) in cloud computing; Hasani, O'Reilly, Dehghantanha, Rezania, and Levallet (2023) in cybersecurity; Horani et al. (2025) in artificial intelligence-based technologies; Sun, Hall, and Ceglelski (2020) in big data; Shahadat, Nekmahmud, Ebrahimi, and Fekete-Farkas (2023) in small and medium enterprise; Pateli, Mylonas, and Spyrou (2020) in hospitality; Lu et al. (2021) in healthcare, Durao and Palma dos Reis (2025) and Ioakeimidou, Chatzoudes, Symeonidis, and Chatzoglou (2024) in various sectors.

Specifically, Amini and Javid (2023) presented this combination of IDT and TOE as an approach to the organizational diffusion process, highlighting a series of factors that might influence the adoption of technology. From the IDT theory, the factors include (1) relative advantage, (2) compatibility, (3) security concerns and (4) cost saving; and from the TOE framework, the factors are (5) technology readiness (technology context), (6) top manager support (organizational context), (7) competitive pressure and (8) regulatory support (environmental context). This group of factors, originating from IDT and TOE that affect the organizational adoption, was identified by Amini and Javid (2023) in their study with information technology professionals and users of cloud computing services. In their study of telemedicine, Chauhan, Jakhar, and Jabbour (2022) also identified a set of success factors strongly connected to IDT and TOE, all relevant to this digital healthcare service.

According to Chauhan et al. (2022), the categories are understood as follows: economic category is associated with patient affordability and telemedicine payment model; ethical category is linked to patient data security and privacy; legal category is about legislation guidelines, data responsibility and secrecy of patient data; organizational category concerns resistance to change, location of facilities, incentives to clinicians, cost reduction and quality of care; social category concerns the educational level of patients and digital literacy, demographics of the patient, trust in telemedicine and convenience of transportation; and technological category deals with the availability of ICT devices, physician's and patient's familiarity with ICT devices, connectivity, technological infrastructure and IT support.

Table 1 portrays a proposed model composed of categories and factors affecting telemedicine practice in healthcare units by drawing on IDT and TOE. The nature of these intervening factors is diverse due to the complexity regarding remote healthcare, as economic, ethical, legal, organizational, social and technological issues are involved (Chauhan et al., 2022). Moreover, they may exert their influence individually or systemically. This group of influential factors forms a framework that supports the research methodological design.

The methodology was subdivided into two steps: a systematic literature review and a qualitative research. A systematic literature review guided by the PRISMA protocol and Mendeley software identified articles published between 2019 and 2023 on Web of Sciences and PubMed databases by using the keywords “Telemedicine and (ICT or Technology) and (Adoption or Diffusion or Acceptance) and (User or “User Intention”) and (Pandemic or COVID or Crisis)”. They were submitted to a screening process of four phases: (1) identification, (2) selection, (3) eligibility and (4) inclusion.

In the identification phase, 2,422 articles were found based on the above-mentioned keywords and established period. In the selection phase, 281 duplicate articles and 1,122 articles out of the first quadrant (Q1) of the SJR Scimago database (quality criterion) were excluded. In the eligibility phase, articles dealing with telemedicine or remote healthcare variants were included, as well as those related to the use of ICT in telemedicine, totaling 356 articles. Finally, in the inclusion phase, articles addressing the use, acceptance and dissemination of technologies in telemedicine; considering the use of telemedicine during the COVID-19 pandemic; and that were not literature reviews were selected, resulting in 125 articles chosen to support the present review, which was unfolded in six categories as referenced by Chauhan et al. (2022), namely: economic, ethical, legal, organizational, social and technological.

In the second step, i.e. the qualitative research, data collection was performed following an open-ended in-depth interview script (Table 2) based on the categories and intervening factors (Table 1), with IDT and TOE being used as references. A content analysis was conducted on the basis of the categories of intervening factors affecting telemedicine. The answers in each category were discussed, with highlights of similarities and differences in the approach of the ten hospitals under analysis.

The content analysis observed the following steps, according to Guimaraes and Paula (2022): (1) preparation of information, in which the material is organized and in-depth interviews transcribed; (2) use of the corpus, in which the text is adjusted and prepared for subsequent analysis; (3) categorization, in which definition and classification consider the common part between them, with the categories being structured a priori based on the literature review; (4) description, in which each of the categories is explained for literature review (see Table 1); and (5) interpretation, in which categories, theoretical framework and researcher's position are compared. In terms of limitations of content analysis, some points deserve to be highlighted (Cavalcante, Calixto, & Kerr Pinheiro, 2014): (1) risk of observer bias influencing the analysis; (2) extrapolation of the text content, requiring skill and experience of the observer, (3) frequent themes in the text with little relevance and, conversely, infrequent themes with great relevance; and (4) limitation regarding the non-probabilistic sample.

The sample selected for the study was based on a non-probabilistic judgmental sampling, which, according to Malhotra (2019), is a method by which the researcher identifies participants relevant to the intended analysis. Although it is a limited sample, the interviewed institutions (especially nonprofit/charitable and public ones) are leaders in the healthcare field both nationally and internationally. Of the ten hospitals initially chosen, five are nonprofit/charitable institutions, two are public hospitals (state and federal) and three are private entities. The analyses showed that the selected sample allowed for reaching the saturation point, as the items addressed in the six categories of analysis began to repeat themselves throughout the interviews (Fontanella, Ricas, & Turato, 2008).

Top managers of ten Brazilian hospitals (seven of them being large, with 150 beds or more, according to National Private Hospitals Association/ANAHP criteria) participated in the interviews, which lasted 50 minutes on average and were carried out via videoconference based on an unstructured interview script (see Table 2). The interviews were transcribed into text, in which each transcription from videos (MP4) to MS Word took an average of 3 minutes. The time spent on analysis was around three weeks and the entire process lasted from June to November 2023. For confidentiality reasons, the names of the hospitals were not mentioned and they were consequently referred to as “Hospital 1”, “Hospital 2”, until “Hospital 10”, as follows:

1. Hospital 1 - Private institution (Goiania, GO): 70 ophthalmologists; 100,000 consultations annually; 150 direct employees; executive profile: male, 35/40 years old; master's degree in health administration, postgraduate degree in medical law, MBA in health management.

2. Hospital 2 - Nonprofit association/charitable organization (Sao Paulo, SP): 668 hospital beds, 4,181 accredited physicians; 7,808 employees. Accreditation: JCI, CARF, QOPI, GEDA; executive profile: male, 40/45 years old, degree in biological sciences, postgraduate degree in business; member of the hospital's executive committee.

3. Hospital 3 - Private institution (Curitiba, PR): 263 hospital beds; 3,225 registered physicians, 992 employees. Accreditation: JCI and Qmentum International; executive profile: male, 65/70 years old, physician, executive vice-president and corporate medical director.

4. Hospital 4 - State-owned entity (Sao Paulo, SP): 2,829 hospital beds; 105 operating rooms, 23,000 employees, ten specialized institutes and two auxiliary hospitals. Accreditation: CARF, JCI, ONA; executive profile: male, 65/70 years old, professor of radiology and president of institutional and hospital councils.

5. Hospital 5 - Nonprofit association/charitable organization (Sao Paulo, SP): 100 hospital beds, 16,000 visits per month, 700 employees. Accreditation: ONA; executive profile: male, 35/40 years old, medical executive of supplementary health; medical management; medical director; coordination of health services.

6. Hospital 6 - Nonprofit association/charitable organization (Sao Paulo, SP): 1,080 hospital beds, 3,966 physicians, 233 ICUs, 52 operating rooms, 5,214 employees. Accreditation: ONA; executive profile: male, 45/50 years old, medical, technical, teaching and research executive director.

7. Hospital 7 - Nonprofit association/charitable organization (Sao Paulo, SP): 340 hospital beds, 1,738 registered physicians; 3,485 employees. Accreditation: JCI; executive profile: male, 60/65 years old, economist, specialized in human resources, hospital and health business, corporate superintendent, hospital's CEO.

8. Hospital 8 - Nonprofit association/charitable organization (Sao Paulo, SP): 1,835 hospital beds, 12,296 registered physicians, 22,272 employees, 30 public health units, including three hospitals. Accreditation: JCI, Planetree, Top Performer; executive profile: male, 50/55 years old, master's and doctorate in medicine, hospital's director and superintendent; associate professor and senior lecturer.

9. Hospital 9 - Private institution (Goiania, GO): 35 ophthalmologists; medical specialties: ophthalmology, otolaryngology, speech therapy; executive profile: male 40/45 years old, ophthalmologist, doctorate in science, technical director, professor of telemedicine.

10. Hospital 10 - Federal public institution (Brasilia, DF): 240 hospital beds; 2,800 collaborators; various specialties; executive profile: male, 40/45 years-old, graduated in computer science, specialization in project management; head of IT and digital health sector.

The results are presented according to the six categories that influence the adoption and use of telemedicine by healthcare providers in the study. Each category, with its respective drivers and barriers, was analyzed based on the responses from healthcare executives for each specific issue, highlighting similarities and differences in opinions in the context of the institutions they serve.

Starting with the economic category, most of the ten managers (Hospitals 2, 3, 4, 6, 7, 8) did not consider investing in a basic telemedicine infrastructure a financial burden, which contradicts Bairapareddy et al. (2021) and Escobar et al. (2021). However, on the one hand, some concerns were raised about physicians' payment (Hospital 7), especially that established by healthcare insurance companies, being well below the usual figure for private medical care in Brazil: “But telemedicine, in some cases, is perceived as a much cheaper medical consultation than a normal appointment” (Hospital 7 executive). This corroborates Nitiema (2022), who argues that these institutions (i.e. healthcare insurance) do not value remote services as much as in-person healthcare. On the other hand, telemedicine made low-cost appointments (Hospital 8) feasible for patients in poorer regions of the country, where this hospital assists in social programs in partnership with the Unified Healthcare System (SUS).

Considering the ethical category, the managers confirm previous research findings (Abdel-Wahab et al., 2020; Macoir, Desmarais, Martel-Sauvageau, & Monetta, 2021) regarding the necessity of keeping the patients' data privacy, which is regulated in Brazil by the General Data Protection Law (LGPD). The comments made by the interviewees suggested that telemedicine reinforced the concerns about protecting the information produced by healthcare systems, as reported by Hospital 6 executive: “I honestly see much less risk of data exposure on a telemedicine platform.”

With regard to the legal category, there is unanimity among the interviewees that the COVID-19 pandemic was a milestone in terms of legislation, updated in Brazil by Law 14,510 of 2022, which has been supporting the extensive use of telemedicine since then. This is corroborated by the Hospital 4 executive, who reported that “Technology, in particular digital health, was very accelerated with the pandemic”. Due to the emergency situation caused by the pandemic, telemedicine overcame the legal boundaries, which obliged policymakers to provide room for flexibility in the new regulations, thus confirming previous studies (Chauhan et al., 2022; Reynolds et al., 2021).

As for the organizational category, most managers agreed that telemedicine has been strongly integrated into ordinary healthcare systems. However, one point was highlighted by the manager of Hospital 8 in that some partners (e.g. healthcare insurance companies) still operate their own idiosyncratic systems, which cannot interact with others. For such integration, there is a real hope that soon there will be a unique medical record for each patient to be accessed by any healthcare professional. This is emphasized by the Hospital 8 executive about interoperability in telemedicine: “I think it's the goal of everyone working in this area of ​​medical records, electronic medical records, and digitization of medicine.” But the interoperability challenge has yet to be overcome (Mohammed et al., 2021).

An important initiative from the public sector is currently underway to promote interoperability and is already in use at Hospital 10 (a public hospital). As highlighted by its executive, this initiative comes from the National Health Data Network (RNDS) of the Digital Health Secretariat/Brazilian Ministry of Health. Created in 2020, this network provides secure connectivity between different health systems across the country in accordance with the LGPD, thus integrating public and private institutions, allowing the exchange of information and being accessible not only to medical professionals and managers, but also to citizens who want access their own data.

As for the compatibility between virtual healthcare structure and its actual level of use, one can see that most institutions possess adequate telemedicine capacity (Shiferaw et al., 2021; Rahi, Khan, & Alghizzawi, 2021; Minghao & Wei, 2021). Nevertheless, according to the interviewees, the business model should be modified to focus on better payment for the physicians, as stated by the Hospital 7 executive: “The problem is to understand that telemedicine is a way to pay less”. Also, protocols are needed to organize procedures for the clinical personnel to deal with the growing demands for telemedicine (Hospitals 3 and 6). Concerning the human resources, the interviewees agreed that they have enough personnel to face the challenges (van Zelst et al., 2021; Neher, Nygårdh, Broström, Lundgren, & Johansson, 2022; Sasangohar et al., 2021; Taboada et al., 2021). Some specific issues drew attention: managers from Hospitals 1, 3, 4 and 8 highlighted the need to have room for human resources improvements, as telemedicine does not mean teleconsultation only. In fact, it involves all digital interactions among patients and their data, medical professionals and healthcare institutions.

Analysis of the social category comprises the following factors: attitudes of medical professionals, acceptance of telemedicine, convenience, demographics and manager's perception. Executives of hospitals 2, 5 and 8 reported positive attitudes towards telemedicine practice, with hospital 2 executive stating that “I see an enthusiasm among healthcare professionals to use telemedicine”. Yet, some issues remain to be considered as executives of hospitals 1 and 6 agreed that there is no unanimity in this sense, with the former reporting that “we have everyone, from skeptics to enthusiasts, who are the minority”. Although some advocate the use of telemedicine, others are afraid of it (Gupta et al., 2023; Bashir et al., 2023; Fouad et al., 2023). This is corroborated by the Hospital 6 executive, who stated that “I still see a very technophobic society”. Managers from Hospitals 3 and 7 argue that negative predispositions may grow due to the unfavorable payment system for physicians.

Convenience is an important factor in the use of telemedicine for patients and physicians (Reynolds et al., 2021; Smith, Gregorio, & Hung, 2021). There was a consensus among the interviewees about the differential that telemedicine provides, as confirmed by Bhatia (2021). Managers from Hospitals 2 and 7 highlighted the comfort provided by telemedicine, especially among patients living in remote rural areas, where transportation may be difficult (Farr et al., 2021), or among those who are on the hard side of the “digital divide”, which is characterized by a chasm that separates higher from lower socioeconomic strata (Malfatti et al., 2021; Röhricht et al., 2021). In the words of the Hospital 2 executive: “It's convenient. The physician feels he's fulfilling his purpose by bringing more access to those who need it”.

One type of organizational and technological design in telemedicine that has generated significant social benefits is the so-called “teleinterconsultation”. This modality enables the connection between specialist physicians working in large health centers and remote health units, such as emergency care units (UPAs) and basic health units (UBSs) of the Unified Health System (SUS). Large health networks (charitable societies such as hospitals 2, 5, 6, 7 and 8), operating through the Program to Support the Institutional Development of the Unified Health System (PROADI-SUS) of the Ministry of Health, installed high-technology equipment in remote units. These units, assisted by local medical professionals connected with specialists at the institutions' headquarters, can make more complex decisions involving secondary health care levels. This architecture has enabled care for low-income populations living in remote locations.

Analysis of the technological category comprises four intervening factors as follows: staff training, technology features/design, in-person versus telemedicine appointments and telemedicine infrastructure. All hospitals have a training structure with own peculiarities. The COVID-19 pandemic was a real driver for the development of instructions about telemedicine, which was corroborated by the Hospital 8 executive, who stated that “The pandemic changed that rapidly because many had to learn to continue seeing their patients”. Because of this, hospitals had to quickly develop a training structure to face urgent needs. However, managers from Hospitals 1, 3, 6 and 8 reported that improvement is needed in their teaching areas. An interesting point is that the experience acquired by the healthcare staff in the training process can be shared with telemedicine providers. This partnership allows the technology industry to appropriately customize the telemedicine devices to the users (Taboada et al., 2021; Neher et al., 2022; Nitiema, 2022).

Quality was considered good, although it is important to appraise the limits of telemedicine. According to the Hospital 9 executive, “If we think that telemedicine is coming to replace traditional medicine, that's a big mistake.” Not all medical situations are appropriate for a remote healthcare service, especially when the physician/patient proximity is an essential condition. For the Hospital 8 executive, “Those who thought telemedicine would steal the jobs of the physicians, it's not the case, it's just a technological evolution.”. Besides that, problems of connection can be a substantial barrier to the practice of telemedicine, mainly in distant localities, as mentioned by managers of Hospitals 3, 4, 5 and 6. Answers from the interviewees are in line with findings from recent studies, showing that telemedicine can be as good as or even better than face-to-face care (Holzman et al., 2023; Ahmad et al., 2023).

The present findings pointed to challenges in economic, ethical, legal, organizational, social and technological areas (Chauhan et al., 2022). The most recurrent issues raised by the hospital managers regarding the use of telemedicine were related to physician payment, access to low-income patients, legal compliance, integration with partners' systems (i.e. interoperability), patients' poor internet connection and limited scope of telemedicine.

The most intense criticisms regarding IDT and TOE frameworks that served as basis for the present analysis come from Prakash (2025) and FakhrHosseini et al. (2024). The former considers the TOE framework as generic and theoretically limited, whereas the latter raises doubts about the potential of both to explain the adoption of more sophisticated innovations with learning and autonomy capabilities, such as artificial intelligence technologies.

The limitations of the present study are especially related to the fact that the results were based on a small sample of Brazilian hospitals. This makes the inference of the findings to the general population nonviable. Although the sample is indeed restricted, discussions held with hospital executives showed how telemedicine can overcome geographical restrictions through specific technological designs. This happens with the PROADI-SUS program, which enables partnerships with large, high-performance hospitals so that high-quality healthcare can be delivered to low-income populations.

As for the findings, another relevant limitation is the fact that the analytical framework supported by IDT and TOE models encompasses economic, ethical, legal, organizational, social and technological factors, which makes the study somewhat ambitious for a single research project, given the complexity of the issues addressed.

Nevertheless, there is an expectation that the insights brought up in this investigation can be useful in assisting decision makers, such as hospital executives, policymakers and healthcare leaders in general, with a topic that has been challenging for healthcare providers, especially since the advent of COVID-19 pandemic.

The connection of IDT and TOE frameworks allowed a complementarity between the two approaches in what each one does best: IDT contributed with its emphasis on individual aspects of innovation adoption, whereas TOE provided an organizational focus, including external perspectives regarding regulatory issues for the practice of telemedicine and sectoral trends in the technology under study (Prakash, 2025; Horani et al., 2025; Amini & Javid, 2023).

As for the TOE framework, Prakash (2025) highlights a group of critical points that deserve attention, such as limited theoretical development, neglect of individual and task-related factors, limited focus on performance outcomes and excessive reliance on customization, among others. In Prakash's words (2025, p. 80), “The TOE theory framework is viewed as a ‘generic theory’”. Another relevant criticism of innovation adoption models, including IDT, is presented by FakhrHosseini et al. (2024). By focusing on intelligent environments (e.g. homes, cars, offices, streets and other environments frequented by humans) embedded within artificial intelligence with learning capabilities, these authors indicate some shortcomings and gaps related to the fact that the existing models were built to deal with simpler technologies, thus lacking the complexity of intelligent and intuitive learning environments within sophisticated innovation ecosystems.

In short, FakhrHosseini et al. (2024) draw attention to a new dynamics that disruptive technologies in intelligent environments are bringing, which is already defying the current knowledge of already-established innovation adoption theories. This criticism is assumed in the present study as the technological context of the investigation (i.e. telemedicine) has been evolving towards technologies based on artificial intelligence with learning and autonomy capabilities (Mishra & Sharma, 2022; Roppelt, Kanbach, & Kraus, 2024), which may challenge the analytical potential of the existing innovation adoption models.

The reports from the healthcare executives participating in the study showed that the most relevant uses of telemedicine occur in an integrated manner for the categories considered in the analysis: economic, ethical, legal, organizational, social and technological. With regard to “teleinterconsultation”, for instance, the connection between organizational and technological categories aimed to generate social benefits was clear. Through a federal government initiative (PROADI-SUS program), an organizational design uniting large hospital networks (i.e. charitable/nonprofit institutions operating at the state-of-the-art in medicine and telemedicine) with remote care units (i.e. UPAs and UBSs) enabled care for low-income patients living in regions with limited access to high-quality healthcare.

The issue of interoperability is a condition that, if fully achieved, would be quite beneficial to all players in the healthcare field as medical professionals could have access to patient information across various public and private health platforms. In this sense, one initiative that stood out was the National Health Data Network (RNDS) of the Brazilian Ministry of Health. The RNDS centralizes information on exams, vaccines and care, thus allowing the patient's history to be unified and accessible through the “My Digital SUS” application, for example. However, interoperability can only be made feasible within acceptable ethical and legal parameters that protect the data privacy of the people involved. In short, the public sector has revealed great potential for the development of telemedicine through initiatives that have been underway for some time already, such as PROADI-SUS (since 2009), RNDS (since 2020) and “My Digital SUS” (since 2019, formerly called “Conecte SUS”).