Telehealth Barriers and Digital Ageism Experienced by Older Veterans: Formative Ethnographic Study to Inform a Telepharmacy Randomized Trial.

Background: As telehealth has become an increasingly common mode of care delivery, older adults may face structural, technological, and interactional barriers that limit their ability to engage with video-based care. Although digital ageism, defined as the presence of age-related stereotypes, lowered expectations, or assumptions about older adults' technology-related competence, has been described in prior literature, less is known about how such dynamics surface during real-time telehealth encounters and how they may shape participation in technology-focused clinical trials. Objective: This formative ethnographic study aimed to (1) document real-world barriers encountered by older adults immediately before and during video telehealth visits and (2) inform recruitment and implementation procedures for a subsequent telepharmacy randomized controlled trial. Methods: We conducted in-home, real-time ethnographic observation of 20 community-dwelling veterans aged ≥65 years participating in pharmacist-led video visits for medication management. Recruitment occurred over approximately 6 to 10 months using mailed invitation letters (>300 sent), supplemented with outbound telephone calls. Data sources included structured field notes completed independently by an in-house anthropologist and the remote clinical pharmacist, as well as observational documentation of previsit preparation, visit navigation, and postvisit reflections. Data were analyzed using qualitative rapid analysis, with iterative team review and triangulation across data sources. Results: Participants had a mean age of 74 (SD 3.18) years; 19 of 20 (95%) were male, and 18 of 20 (90%) identified as White. All participants completed a video visit with technical support as needed. Structural barriers (eg, broadband access and device availability) and usability challenges (eg, audio-video setup and navigation) were common. Although digital ageism was not a predefined analytical category, age-related assumptions about technology emerged during observation, including participants attributing anticipated or experienced difficulties to age and expressing surprise or pride following successful completion of the visit. These age-related interpretations were analytically distinct from access and usability barriers and were interpreted as manifestations of digital ageism, particularly as internalized age-based expectations. Conclusions: Formative ethnographic observation provided critical insights into how older adults experience telehealth encounters in real-world contexts and informed adaptations to recruitment and implementation procedures for a subsequent randomized controlled trial. Although digital ageism was not an original study aim, age-related assumptions about technology emerged as an important interpretive factor shaping engagement with video-based care. Incorporating ethnographic methods prior to trial implementation may help identify otherwise overlooked barriers and improve the inclusivity and feasibility of technology-focused clinical research involving older adults.