“You can only help them save the patient once they trust you”: Clinician perspectives and theories of use of a pediatric emergency teleconsultation program

While telemedicine applications in low- and middle-income countries are growing rapidly, few studies address the social and organizational factors of implementation essential to sustaining clinician engagement. This study aims to explore clinician experiences and perspectives of a pediatric emergency teleconsultation support program in Sindh, Pakistan, and theories of use behind its implementation in government hospitals. We conducted in-depth interviews with 20 stakeholders of the teleconsultation program, including program administrators (n ​= ​3), teleconsultants (n ​= ​7) and on-site physicians and nurses (n ​= ​10) purposively sampled for maximum variation across perceived fidelity and acceptability on a preliminary questionnaire. Interview questions and probes were designed to elicit rich perspectives on communication structures, enabling and constraining factors, and overall effects of teleconsultation on clinical routines and quality of care. Transcripts were analyzed thematically using combined inductive and deductive coding. We found that, behind the technical adaptation to using telemedicine in the resuscitation room, providers perceived a dynamic reconfiguration of professional roles and routines of consultation according to opportunities and constraints associated with mutual confidence or trust, constructions of distance, subjectivity of information, and the interface of technological artifacts with medical practice. Descriptions of communication patterns revealed an unstable tension between two competing theories of use premised on either inherent contextual differences or presumed asymmetries in expertise. Long-term sustainability of telemedicine applications to pediatric emergency care requires serious consideration of how such conflicting theories of use and their associated assumptions about end-user needs crystallize in practice and affect clinician engagement and perceived benefits to patient care in the future.