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Why do telemedicine systems fail to normalize as stable models of service delivery?
Abstract
Two groups independently carried out qualitative studies of the development, implementation and evaluation of telehealth systems and services in the UK. The data collected (in more than 600 discrete data collection episodes) included semistructured interviews, observations and documents. We conducted a conjoint reanalysis of the data. The objective was to identify the conditions which dispose a telehealth service to be successful or to fail. There appear to be four conditions necessary for a telemedicine system to stabilize and then normalize as a means of service delivery. When one or more is absent, failure can be expected. These conditions are often overlooked by local proponents of telemedicine, who seem to rely on demonstrations that the equipment works as the primary criterion of success.
... Finally, we gathered additional information through the direct observation of daily activities, by spending time in the hospital units and shadowing professionals in their daily activities, before and after performing the interviews. [12,33,34,29,35,36,32,21,23,30,24] Financing Availability of funds for purchasing devices, for their maintenance and for sustaining the operational costs of the organizations who implements the service; ...
... ○ Clear reimbursement for the professionals involved; ○ Adequate incentives to promote implementation and sustain implementation over time; ○ Patients' safety and privacy. [31,36,28,21,23,30,24] F. Segato, C. Masella ...
... The contributions in the literature agree upon the fact that acceptance from both patients and professionals tends to increase when telemedicine services prove to meet their needs [7,22,23]. This statement might seem trivial, but it is not in practice: too often, it is not clear to what extent telemedicine services are intended to meet a specific care need, rather than being "solutions in search of a problem" [8,12,21]. ...
Objectives
Telemedicine is extensively used in healthcare settings, although we still lack knowledge on how to make telemedicine services last over time. This study aims to: investigate how the factors supporting the implementation of telemedicine services affect their duration over time; explore if further factors need to be considered, to foster the services duration.
Methods
We conducted a six-year in-depth study on three Italian cases of telemedicine services lasting more than 10 years. Dimensions explaining the duration of services over time are explored and discussed against existing literature.
Results
The three cases show that, to support the duration over time, financial and organizational stability should be set before the “champion” leaves the service. Financial stability was reached through different strategies. About organizational stability, we found that providing opportunities to enrich the competences and getting more responsibilities over the patients enhanced the professionals’ acceptance, which, in turn, supports the organizational stability of the service over time. About patients, to meet their crucial needs for their health and to receive the nurses’ support on the use of technologies contains the abandon and increases the chances for the service to last over time. Last, the three services observed pursued a strategy of focalization on a specific need.
Conclusions
The findings provide insights for policy makers and hospital managers on how to set effective services and avoid service abandon, thus reducing waste of resources, and on how to motivate the professionals and patients, by increasing the chances of duration of the services over time.
... Despite government backed initiatives and research finding indicating improved healthcare outcomes, telehealth has not been widely integrated alongside standard care in the United Kingdom (U.K.) [4][5][6][7][8][9][10]. It is clear from the growing literature that the use of technology such as telehealth is a function of a complex interplay of technological as well as social and organisational issues, where it is suggested that the success of technology in healthcare is dependent on the "match" of these factors [4][5][6][7][8][9][11][12][13][14][15][16]. ...
... Despite government backed initiatives and research finding indicating improved healthcare outcomes, telehealth has not been widely integrated alongside standard care in the United Kingdom (U.K.) [4][5][6][7][8][9][10]. It is clear from the growing literature that the use of technology such as telehealth is a function of a complex interplay of technological as well as social and organisational issues, where it is suggested that the success of technology in healthcare is dependent on the "match" of these factors [4][5][6][7][8][9][11][12][13][14][15][16]. For example, problems and even the failure of the telehealth initiative may result from discrepancies between the perspectives of healthcare stakeholders, the aspirations of the administrators and the capabilities and limitations of the healthcare technology [4][5][6][7][8][9][13][14][15][16][17]. ...
... It is clear from the growing literature that the use of technology such as telehealth is a function of a complex interplay of technological as well as social and organisational issues, where it is suggested that the success of technology in healthcare is dependent on the "match" of these factors [4][5][6][7][8][9][11][12][13][14][15][16]. For example, problems and even the failure of the telehealth initiative may result from discrepancies between the perspectives of healthcare stakeholders, the aspirations of the administrators and the capabilities and limitations of the healthcare technology [4][5][6][7][8][9][13][14][15][16][17]. The extant literature also acknowledges that the change in an organisation occasioned by the introduction of new technology causes its users to feel threatened [18,19]. ...
Introduction of telehealth into the healthcare setting has been recognised as a service that might be experienced as disruptive. This paper explores how this disruption is experienced.
In a longitudinal qualitative study, we conducted focus group discussions prior to and semi structured interviews post introduction of a telehealth service in Nottingham, U.K. with the community matrons, congestive heart failure nurses, chronic obstructive pulmonary disease nurses and community support workers that would be involved in order to elicit their preconceptions and reactions to the implementation.
Users experienced disruption due to the implementation of telehealth as threatening. Three main factors add to the experience of threat and affect the decision to use the technology: change in clinical routines and increased workload; change in interactions with patients and fundamentals of face-to-face nursing work; and change in skills required with marginalisation of clinical expertise.
Since the introduction of telehealth can be experienced as threatening, managers and service providers should aim at minimising the disruption caused by taking the above factors on board. This can be achieved by employing simple yet effective measures such as: providing timely, appropriate and context specific training; provision of adequate technical support; and procedures that allow a balance between the use of telehealth and personal visit by nurses delivering care to their patients.
... This literature has increasingly broadened its focus from the technical to the socio-technical dimensions of information systems suggesting that the success of IT implementations not only depend on the quality of hard-and software used [7][8][9]39]. The literature also argues that organizational factors are also the key to success [10][11][12]. Several organizational prerequisites for 'successful' IT implementations are identified by a number of authors and these include financial and structural support, mobilizing 'champions' during implementation, involving, educating and motivating users, and dealing with confidentiality, standardization and legal-related issues [7,10,11,[13][14][15][16][17][18][19]. ...
... The literature also argues that organizational factors are also the key to success [10][11][12]. Several organizational prerequisites for 'successful' IT implementations are identified by a number of authors and these include financial and structural support, mobilizing 'champions' during implementation, involving, educating and motivating users, and dealing with confidentiality, standardization and legal-related issues [7,10,11,[13][14][15][16][17][18][19]. In general, the importance of embedding the technology in practice is underlined and this involves a mutual adjustment of both technology and care practices [7,13,16,17,20,21]. ...
... These are crucial insights that inform the current research. However, while claims about the importance of introducing the technology with consideration to the organizational context abound, there are still uncertainties as regards how this can be achieved in actual work settings [10]. This is particularly the case as regards the use of telehealth in the care of frail elderly living in their ordinary homes. ...
Purpose:
This paper explores the constituents of and challenges related to the innovation of technology-based services in the long-term homecare sector.
Methods:
This research used purposeful extreme case sampling, a mixed methods approach to research that included focus groups and interviews, to learn from the experiences of an innovative telehomecare project. The paper uses a framework that integrates service management; information systems innovation and medical informatics theory.
Results:
The findings indicate that the claimed and the rather abstract benefits of the technology espoused by information technology vendors were difficult to transform into a service concept. The organization studied is still struggling with conflicts between technological possibilities on the one hand, and the prevailing service delivery systems and user preferences on the other. Decisions about the extent to which the service needs to be reengineered, what non-technology resources are required, what should be the role of the consumer in the new care process and identifying who is actually the primary beneficiary and user of the new service remain.
Conclusions:
A comprehensive development model and 'mindfulness' is necessary for radical service innovation in the long-term homecare sector. Creating new services that exploit the capability of radical technical innovations requires organizational development and the use of many non-technology innovations and resources. To understand what combinations of technological and non-technological resources can provide sustainable benefit, all key internal and external stakeholders must be involved from the beginning of the project.
... Elle apporte aussi une contribution importante au domaine des technologies de l'information (TI) en développant un cadre conceptuel basé sur des notions issues des sciences sociales qui sert à analyser l'implantation des TI. De plus, le recours à l'approche qualitative basée sur la triangulation de plusieurs sources de données répond à la demande de plusieurs auteurs d'élargir les devis des études dans le domaine de la télésanté afin de développer des connaissances qui servent à comprendre ce qui se passe lorsqu'un programme de télésanté est mis en place (Harrison et al. 2002;May et al. 2003b;May et al. 2003c;May et al. 2003a). ...
... Furthermore, once the initial funding for a pilot project runs out, many telehealth programs do not survive (May et al. 2003b;Noorani & Picot 2001b;Picot & Cradduck 2000b). The literature evaluating the success of telehealth activities, including telerehabilitation, focuses mainly on feasibility of technologies, efficacy and user satisfaction, and very little on implementation and actual use (Cardno 2000;Kairy et al. 2009a;Lehoux et al. 2002;May et al. 2003c). Several authors have suggested using methods other than clinical trials in order to develop a better understanding of processes and changes that occur with telehealth use (Harrison et al. 2002;Lehoux et al. 2002;May et al. 2003b;May et al. 2003c;May et al. 2003a). ...
... The literature evaluating the success of telehealth activities, including telerehabilitation, focuses mainly on feasibility of technologies, efficacy and user satisfaction, and very little on implementation and actual use (Cardno 2000;Kairy et al. 2009a;Lehoux et al. 2002;May et al. 2003c). Several authors have suggested using methods other than clinical trials in order to develop a better understanding of processes and changes that occur with telehealth use (Harrison et al. 2002;Lehoux et al. 2002;May et al. 2003b;May et al. 2003c;May et al. 2003a). ...
La téléréadaptation, tout comme d’autres champs en télésanté, est de plus en plus interpelée pour la prestation de services. Le but de ce projet de thèse est d’enrichir l’évaluation de la téléréadaptation afin que les connaissances qui en découlent puissent venir soutenir la prise de décision d’acteurs impliqués à différents niveaux en téléréadaptation. Le premier article présente une revue systématique dont l’objectif était de faire synthèse critique des études en téléréadaptation. La revue rassemble 28 études en téléréadaptation, qui confirment l’efficacité de la téléréadaptation pour diverses clientèles dans différents milieux. Certaines des études suggèrent également des bénéfices en termes de coûts, mais ces résultats demeurent préliminaires. Cette synthèse critique est utile pour soutenir la décision d’introduire la téléréadaptation pour combler un besoin. Par contre, les décideurs bénéficieraient aussi de connaissances par rapport aux changements cliniques et organisationnels qui sont associés à la téléréadaptation lorsqu’elle est introduite en milieu clinique. Les deux autres articles traitent d’une étude de cas unique qui a examiné un projet clinique de téléréadaptation dans l’est de la province de Québec, au Canada. Le cadre conceptuel qui sous-tend l’étude de cas découle de la théorie de structuration de Giddens et des modèles de structuration de la technologie, en particulier de l’interaction entre la structure, l’agent et la technologie. Les données ont été recueillies à partir de plusieurs sources (groupes de discussion, entrevues individuelles, documents officiels et observation d’enregistrements) suivi d’une analyse qualitative. Le deuxième article de la thèse porte sur le lien entre la structure, l’agent et la culture organisationnelle dans l’utilisation de la téléréadaptation. Les résultats indiquent que les différences de culture organisationnelle entre les milieux sont plus évidentes avec l’utilisation de la téléréadaptation, entraînant des situations de conflits ainsi que des occasions de changement. De plus, la culture organisationnelle joue un rôle au niveau des croyances liées à la technologie. Les résultats indiquent aussi que la téléréadaptation pourrait contribuer à changer les cultures organisationnelles. Le troisième article examine l’intégration de la téléréadaptation dans les pratiques cliniques existantes, ainsi que les nouvelles routines cliniques qu’elle permet de soutenir et la pérennisation de la téléréadaptation. Les résultats indiquent qu’il y a effectivement certaines activités de téléréadaptation qui se sont intégrées aux routines des intervenants, principalement pour les plans d’intervention interdisciplinaire, tandis que pour les consultations et le suivi des patients, l’utilisation de la téléréadaptation n’a pas été intégrée aux routines. Plusieurs facteurs en lien avec la structure et l’agent ont contraint et facilité l’intégration aux routines cliniques, dont les croyances partagées, la visibilité de la téléréadaptation, le leadership clinique et organisationnel, la disponibilité des ressources, et l’existence de liens de collaboration. La pérennité de la téléréadaptation a aussi pu être observée à partir de la généralisation des activités et le développement de nouvelles applications et collaborations en téléréadaptation, et ce, uniquement pour les activités qui s’étaient intégrées aux routines des intervenants. Les résultats démontrent donc que lorsque la téléréadaptation n’est pas intégrée aux routines cliniques, elle n’est pas utilisée. Par contre, la téléréadaptation peut démontrée certains signes de pérennité lorsque les activités, qui sont reproduites, deviennent intégrées aux routines quotidiennes des utilisateurs. Ensemble, ces études font ressortir des résultats utiles pour la mise en place de la téléréadaptation et permettent de dégager des pistes pour enrichir le champ de l’évaluation de la téléréadaptation, afin que celui-ci devienne plus pertinent et complet, et puisse mieux soutenir les prises de décision d’acteurs impliqués à différents niveaux en téléréadaptation. Telerehabilitation, like other telehealth applications, has been increasingly used to provide health services. The goal of this thesis is to enrich the field of telerehabilitation evaluation such that it can better contribute to informed decision making of those involved in telerehabilitation at different levels. The first article is a systematic review of telerehabilitation studies and it was conducted in order to provide a critical synthesis of the current telerehabilitation literature. The revue included 28 studies of telerehabilitation, which, overall, confirmed the efficacy of telerehabilitation when used with a variety of clienteles in different settings. Some of the studies also suggest that there may be some cost benefits associated with telerehabilitation although the findings remain preliminary. Such a synthesis of the literature can contribute to some decisions regarding the pertinence of introducing telerehabilitation. However, decision makers also need information regarding the clinical and organizational changes that are associated with telerehabilitation when implemented in a clinical setting. The next two articles contain the results of a single case study that was centered on a telerehabilitation clinical project implemented in the eastern part of the province of Quebec, in Canada. A conceptual model was developed to guide this study, and it was based on Giddens’ Theory of Structuration and on models of technology structuration, in particular drawing upon the notion of the interaction between structure, agent and technology. Data was collected from several sources (focus groups, interviews, official documents and observation of recordings) and was analyzed using a qualitative analysis approach. The second article in this thesis examined the relationship between structure, agent and organizational culture with respect to telerehabilitation use. The results indicate that differences in organizational culture between the centres are more visible when telerehabilitation is used, which can in some cases lead to conflicts, while in other cases create opportunities for change. In addition, organizational culture also played a role in shared beliefs linked to the technology. Lastly, the results suggest that telerehabilitation could be used to bring about changes in organizational culture. The third article examined how telerehabilitation became integrated into existing clinical practices, how it contributed to the development of new routines and explored the sustainability of telerehabilitation. The results indicate that some activities, namely interdisciplinary care plans were integrated into clinical routines, while consultations and patient follow-up were not. Several factors related to the structure and agent were found to facilitate or hinder the integration of telerehabilitation into routine practices, including shared beliefs, the visibility of telerehabilitation activities, the clinical and organizational leadership, the availability of resources and the existence of collaborations. Sustainability was also observed when telerehabilitation use became more generalized and novel applications were developed, although this was only found to occur for activities which had integrated into routine practice. The results therefore suggest that when telerehabilitation is not integrated into routine practices, it will not be used, but that, on the other hand, telerehabilitation may be sustainable for activities which are repeated and then integrated into routine day-to-day clinical activities. Together, these studies put forth findings which can be useful when implementing new telerehabilitation programs. They also help elucidate directions for future research in order to enrich the field of telerehabilitation evaluation so that it may become more pertinent and comprehensive to support decision-makers involved at all levels of telerehabilitation.
... Telerehabilitation is a growing branch of telemedicine that is becoming increasingly relevant given the aging population and growing prevalence of chronic diseases. Studies in telemedicine and telerehabilitation have focused mainly on feasibility of technologies, efficacy, and user satisfaction, and very little on implementation and actual use (10)(11)(12)(13). Several authors suggest using methods other than clinical trials for developing a better understanding of processes and changes that occur with telemedicine use (6,11,12,(14)(15)(16). ...
... Studies in telemedicine and telerehabilitation have focused mainly on feasibility of technologies, efficacy, and user satisfaction, and very little on implementation and actual use (10)(11)(12)(13). Several authors suggest using methods other than clinical trials for developing a better understanding of processes and changes that occur with telemedicine use (6,11,12,(14)(15)(16). More specifically, it remains unclear what facilitates or hinders the integration of telemedicine, including telerehabilitation programs, into routine clinical practice. ...
Objective:
This study examines how telerehabilitation becomes part of existing and new clinical routines and identifies factors that enable or constrain its routine use.
Methods:
An in-depth case study of a telemedicine program in rehabilitation implemented between an urban specialized rehabilitation center and a rural regional rehabilitation center was conducted. Using a conceptual framework based on Giddens' theory of structuration, a qualitative analysis was carried out using four data sources: focus groups and phone interviews (with health professionals, managers, and patients and their family members); telerehabilitation video recordings; and project documents (e.g., proposals, requests for funding, summaries, agendas of meetings, operating procedures, patient handouts, and tools for clinicians).
Results:
In two rehabilitation programs for 1) patients who sustained a traumatic brain injury and 2) those who sustained a spinal cord injury, telerehabilitation was successfully incorporated into routine clinical practices for activities such as interdisciplinary care plans. However, for specialized clinical consultations or long-term patient follow-up, telerehabilitation was not successfully incorporated. Factors that facilitated or prevented the integration of telerehabilitation in routine practices stemmed from both the structure (norms, rules, resources, and values) and the agent (e.g., users of telerehabilitation, including clinicians, managers, and patients and their families) and include 1) shared beliefs and assumptions held by patient care team members regarding the nature of the clinical activities, and the perceptions of patients and their family members; 2) clinical and organizational leadership; 3) extent and type of telerehabilitation use; 4) available resources; and 5) collaborations already in place or needing to be developed.
Conclusions:
This study provides empirical evidence of how telerehabilitation activities may become integrated into routine day-to-day clinical activities.
... However, to date we know very little about how telerehabilitation actually impacts on the users. For example, we do not know the extent to which clinical practice needs to change in order to incorporate telerehabilitation [5][6][7]. Previous studies have not taken into account the fact that telerehabilitation will, by its very nature, change the interaction between health professionals in different institutions, and between these professionals and their patients [5,8]. Furthermore, we do not have a clear understanding of how the various telerehabilitation technologies are in fact used in the clinical setting, in particular for activities involving several organizations. ...
... The types of data obtained through rigorous qualitative methodologies, such as focus groups, interviews and observations, are complementary to those obtained through quantitative methodologies, and contribute to the understanding of the underlying causes and processes that occur in real settings [6,7]. As well, such methodologies lend themselves well to obtaining an in-depth understanding from different perspectives, such as from therapists and managers in different settings, as well as from patients and their families. ...
There has been a steady increase in the number of telerehabilitation programmes, as well as studies of telerehabilitation technology development, efficacy and effectiveness. However, few studies have examined the impact of telerehabilitation when it is actually implemented in a clinical setting. The objective of this study was therefore to explore how the properties of the technologies used for telerehabilitation affect clinical practice and interprofessional communication in a rehabilitation setting. A qualitative case study of an interorganisational telerehabilitation programme for traumatic brain injured and spinal cord injured patients was conducted, using data obtained from focus groups and interviews, along with observations of recordings of videoconference sessions. A conceptual framework based on technology adoption and organisational change theories was used to structure the data collection and thematic analysis. Several key characteristics of the telerehabilitation technologies were identified that impacted on interprofessional and interorganisational collaborations and patient participation, including the audio and video quality, the real-time communication capability, user-friendliness and time restrictions. The technology was used primarily for interdisciplinary care plan meetings, and occasionally for direct patient interventions in speech therapy and sexology, although additional uses had been identified in the planning stages. Implications for the development of future telerehabilitation programmes are discussed, in particular relating to sensitizing team members to each other's roles and organisational cultures.
... 6 In health care research, most evaluations are summative, describing quantitative outcomes such as clinical effectiveness, safety, and costs. 7 However, a formative evaluation postulates a wider view on how the quantitative outcomes were achieved, mostly by applying qualitative techniques. 8 A formative evaluation may yield useful information about organizational aspects, social interactions, and contribute to more adaptable and scalable interventions. ...
BACKGROUND
Sustainable implementation of telemonitoring in healthcare is challenging. Especially so, if one aims to scale-up telemonitoring initiatives nationwide.
OBJECTIVE
The purpose of this study protocol is to describe the methodology and evaluation of a collaborative eHealth program, attempting to do precisely so. The National collaborative eHealth program of the Netherlands is supporting implementation of telemonitoring in three clinical domains in all Dutch University Medical Centers (umc’s). The chosen themes are: 1) telemonitoring solutions in the domain of cardiology, 2) telemonitoring solutions providing care-at-a distance in obstetrics and 3) telemonitoring solutions monitoring vital functions in hospital wards.
METHODS
A before-and-after study will be conducted to assess the degree of successful implementation. Primary outcome of study is the degree of normalization in which health care providers in umc’s consider telemonitoring to be a part of their routine practice. The secondary outcome is the uptake of telemonitoring in the Dutch umc’s. The framework for Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) will be used to safeguard for structured analysis. Normalization of telemonitoring will be measured using the Normalization MeAsurement Development tool (NoMAD).
RESULTS
Data will be collected between May 2020 and December 2022. Results will be retrieved in June 2023.
CONCLUSIONS
This study expects to yield unique evidence and insights about the use of telemonitoring in Dutch umc’s and hence provide better understanding on how to scale-up telemonitoring across the healthcare sector. The study protocol could serve as inspiration for those planning to execute a programmatic intervention supporting a large-scale scale-up of eHealth.
... mHealth interventions such as TelePraCMan are often not used in the "real" world [22]. Therefore, it is crucial to check the development and implementation for understanding and learning for future digital projects. ...
Background:
Mobile health (mHealth) interventions for self-management are a promising way to meet the needs of patients with chronic diseases in primary care practices. Therefore, an mHealth intervention, TelePraCMan, was developed and evaluated for patients with type 2 diabetes mellitus, chronic obstructive pulmonary disease, high blood pressure, or heart failure in a German primary care setting. TelePraCMan entails a symptom diary, an appointment manager, a manager to document goals, and a warning system. The app should foster the self-management of participating patients.
Objective:
We aimed to examine the effects of TelePraCMan on patient activation and quality of life and explored the underlying contextual factors, impacts, and degree of implementation.
Methods:
In a prospective observational study design, we collected data by using interviews and written questionnaires from participating patients (intervention and control groups) and primary care workers (physicians and practice assistants). The primary outcomes of interest were patient-reported quality of life (12-Item Short Form Survey) and patient activation (patient activation measure). The quantitative analysis focused on differences between patients in the intervention and control groups, as well as before (T0) and after (T1) the intervention. Interviews were analyzed by using qualitative content analysis via MAXQDA (VERBI GmbH).
Results:
At baseline, 25 patients and 24 primary care workers completed the questionnaire, and 18 patients and 21 primary care workers completed the follow-up survey. The patients were predominantly male and, on average, aged 64 (SD 11) years (T0). The primary care workers were mostly female (62%) and, on average, aged 47 (SD 10) years (T0). No differences were observed in the outcomes before and after the intervention or between the intervention and control groups. In the additional interviews, 4 patients and 11 primary care workers were included. The interviewees perceived that the intervention was useful for some patients. However, contextual factors and problems with implementation activities negatively affected the use of the app with patients. The main reasons for the low participation were the COVID-19 pandemic and the target group, which seemed to have less interest in mHealth; the interviewees attributed this to the older age of patients. However, the respondents felt that the app would be better accepted in 5 or 10 years.
Conclusions:
Although the TelePraCMan app was rated as very good and important by the participants, few patients used it. The digital intervention was hardly implemented and had limited impact in the current setting of German primary care.
Trial registration:
German Clinical Trials Register DRKS00017320; https://tinyurl.com/4uwrzu85.
... Some ethical issues have also arisen, including autonomy, beneficence, non-maleficence, justice, and professional-patient relationships [26]. Nevertheless, studies have shown to agree that telemedicine projects should not be driven by technology but rather by the users' needs and objectives [27][28][29]. ...
Evaluating the use and impact of telemedicine in nursing homes is necessary to promote improvements in the quality of this practice. Even though challenges and opportunities of telemedicine are increasingly becoming well documented for geriatrics (such as improving access to healthcare, patient management, and education while reducing costs), there is still limited knowledge on how to better implement it in an inter-organizational context, especially when considering nursing homes. In this regard, this study aimed first to describe the telemedicine activity of nursing homes when cooperating with a general hospital; and then understand the behavioral differences amongst nursing homes while identifying critical factors when implementing a telemedicine project. We conducted a sequential, explanatory mixed-method study using quantitative then qualitative methods to better understand the results. Three years of teleconsultation data of twenty-six nursing homes (15 rural and 11 urban) conducting teleconsultations with a general hospital (Troyes Hospital, France) were included for the quantitative analysis, and eleven telemedicine project managers for the qualitative analysis. Between April 2018 and April 2021, 590 teleconsultations were conducted: 45% (n = 265) were conducted for general practice, 29% (n = 172) for wound care, 11% (n = 62) for diabetes management, 8% (n = 47) with gerontologist and 6% (n = 38) for dermatology. Rural nursing homes conducted more teleconsultations overall than urban ones (RR: 2.484; 95% CI: 1.083 to 5.518; p = 0.03) and included more teleconsultations for general practice (RR: 16.305; 95% CI: 3.505 to 73.523; p = 0.001). Our qualitative study showed that three critical factors are required for the implementation of a telemedicine project in nursing homes: (1) the motivation to perform teleconsultations (in other words, improving access to care and cooperation between professionals); (2) building a relevant telemedicine medical offer based on patients’ and treating physicians’ needs; and (3) it’s specific organization in terms of time and space. Our study showed different uses of teleconsultations according to the rural or urban localization of nursing homes and that telemedicine projects should be designed to consider this aspect. Triggered by the COVID-19 pandemic, telemedicine projects in nursing homes are increasing, and observing the three critical factors presented above could be necessary to limit the failure of such projects.
... 6 In health care research, most evaluations are summative, describing quantitative outcomes such as clinical effectiveness, safety, and costs. 7 However, a formative evaluation postulates a wider view on how the quantitative outcomes were achieved, mostly by applying qualitative techniques. 8 A formative evaluation may yield useful information about organizational aspects, social interactions, and contribute to more adaptable and scalable interventions. ...
Background
A total of 8 Dutch university hospitals are at the forefront of contributing meaningfully to a future-proof health care system. To stimulate nationwide collaboration and knowledge-sharing on the topic of evidence-based eHealth, the Dutch university hospitals joined forces from 2016 to 2019 with the first Citrien Fund (CF) program eHealth; 29 eHealth projects with various subjects and themes were selected, supported, and evaluated. To determine the accomplishment of the 10 deliverables for the CF program eHealth and to contribute to the theory and practice of formative evaluation of eHealth in general, a comprehensive evaluation was deemed essential.
Objective
The first aim of this study is to evaluate whether the 10 deliverables of the CF program eHealth were accomplished. The second aim is to evaluate the progress of the 29 eHealth projects to determine the barriers to and facilitators of the development of the CF program eHealth projects.
Methods
To achieve the first aim of this study, an evaluation study was carried out using an adapted version of the Commonwealth Scientific and Industrial Research Organization framework. A mixed methods study, consisting of a 2-part questionnaire and semistructured interviews, was conducted to analyze the second aim of the study.
Results
The 10 deliverables of the CF program eHealth were successfully achieved. The program yielded 22 tangible eHealth solutions, and significant knowledge on the development and use of eHealth solutions. We have learned that the patient is enthusiastic about accessing and downloading their own medical data but the physicians are more cautious. It was not always possible to implement the Dutch set of standards for interoperability, owing to a lack of information technology (IT) capacities. In addition, more attention needed to be paid to patients with low eHealth skills, and education in such cases is important. The eHealth projects’ progress aspects such as planning, IT services, and legal played an important role in the success of the 29 projects. The in-depth interviews illustrated that a novel eHealth solution should fulfill a need, that partners already having the knowledge and means to accelerate development should be involved, that clear communication with IT developers and other stakeholders is crucial, and that having a dedicated project leader with sufficient time is of utmost importance for the success of a project.
Conclusions
The 8 Dutch university hospitals were able to collaborate successfully and stimulate through a bottom-up approach, nationwide eHealth development and knowledge-sharing. In total, 22 tangible eHealth solutions were developed, and significant eHealth knowledge about their development and use was shared. The eHealth projects’ progress aspects such as planning, IT services, and legal played an important role in the successful progress of the projects and should therefore be closely monitored when developing novel eHealth solutions.
International Registered Report Identifier (IRRID)
RR2-10.1016/j.ceh.2020.12.002
... 6 In health care research, most evaluations are summative, describing quantitative outcomes such as clinical effectiveness, safety, and costs. 7 However, a formative evaluation postulates a wider view on how the quantitative outcomes were achieved, mostly by applying qualitative techniques. 8 A formative evaluation may yield useful information about organizational aspects, social interactions, and contribute to more adaptable and scalable interventions. ...
Background
University Hospitals (UHs) are key players in contributing to a sustainable health care system. In the Netherlands the eight UHs joined forces from 2016 till 2018 within the Citrien fund (CF) - program eHealth to develop sustainable eHealth solutions by carrying out 32 research projects.
Objective
The objective of this study was to develop an evaluation study protocol that would be capable of evaluating the first Dutch University Hospitals eHealth program in depth.
Methods
To develop the protocol three consecutive steps were carried out: 1) a rapid review to find suitable eHealth evaluation frameworks and eHealth project progress indicators, 2) assessment of the selected eHealth evaluation frameworks to determine the most suitable framework to evaluate CF - program eHealth, and 3) development of a mixed-methods study to evaluate eHealth project progress indicators in relation to the 32 eHealth research projects.
Results
The ‘Commonwealth Scientific and Industrial Research Organization (CSIRO) framework for evaluating telehealth trials or programs’ was deemed most suitable for evaluating CF - program eHealth. The aspects planning, needs assessment, policy/organization, technology, ethics, legal, and finance, were considered useful indicators for monitoring the progress of an eHealth project, and therefore incorporated into the survey.
Conclusion
The developed evaluation study protocol will be used to evaluate the first Dutch University Hospitals’ eHealth program, the CF – program eHealth, and therewith contribute to maximizing successful uptake of eHealth solutions. Also, the selected set of eHealth project performance indicators could be used by researchers or policymakers to securely monitor the progress of eHealth projects.
... Governments and care providers around the world are seeking to introduce telemedicine to address the rising demand for health-care and system capacity constraints (1). Despite the growing political support, telemedicine systems have failed to normalize (ie, become part of everyday practice) due to doubts about their efficacy, cost-effectiveness, and user acceptance (2,3). Technological competence, costeffectiveness, and acceptability are central to the successful implementation of telemedicine services. ...
This article provides an analysis of the skills that health professionals and patients employ in reaching diagnosis and decision-making in telemedicine consultations. As governmental priorities continue to emphasize patient involvement in the management of their disease, there is an increasing need to accurately capture the provider–patient interactions in clinical encounters. Drawing on conversation analysis of 10 video-mediated consultations in 3 National Health Service settings in England, this study examines the interaction between patients, General Practitioner (GPs), nurses, and consultants during diagnosis and decision-making, with the aim to identify the range of skills that participants use in the process and capture the interprofessional communication and patient involvement in the diagnosis and decision-making phases of telemedicine consultations. The analysis shows that teleconsultations enhance collaborative working among professionals and enable GPs and nurses to develop their skills and actively participate in diagnosis and decision-making by contributing primary care–specific knowledge to the consultation. However, interprofessional interaction may result in limited patient involvement in decision-making. The findings of this study can be used to inform training programs in telemedicine that focus on the development of effective skills for professionals and the provision of information to patients.
... The authority and social legitimacy of institutional biomedicine and clinic-centred healthcare systems remain powerful while being challenged by the cases discussed above. Comparing these cases to other informatics-enabled healthcare innovations, we can note that the introduction into healthcare systems of telemedicine technologies was far less extensive than many early commentators predicted (May et al. 2003), and the same may be the case for the potentially even more individualised mHealth medical technologies. Likewise, medical regulators, although chasing fast-moving technology developments, are making efforts to defend the safety of people using technologies and software as medical devices. ...
This chapter approaches PMDs firstly by outlining the uncertain environment of existing and emerging regulatory regimes, and secondly by examining actual and discursive local processes of adoption of exemplar devices both within and outside organised healthcare systems, given the regulatory context of the UK and the European Union. Two case studies are presented of portable devices that measure and/or monitor blood flow or blood pressure, one within medical jurisdiction, the other more or less ‘recreational’. The European Union regulatory frameworks are shown to be struggling with the challenge of ‘mHealth’ innovations. The concept of ‘technology identity’ is used to highlight key features of the devices in their regulatory context that shape the way in which potential users understand, evaluate, and might actually use these devices.
... This has tended to cause technology-based approaches to sit outside of normal practice and to form islands of activity. This then fails to integrate with practice [3] and [4]. Often the costs are increased by such interventions sitting outside of day-to-day practice [5]. ...
Optimization of care provision, in the future, requires a shift from the current paternal model of dispensing care, to a collaborative model of coaching, supporting and enabling self-care and promoting independence. This will not be appropriate for all people and for all care providers but if resource utility is to be maximized, an approach must be developed that facilitates as much independence and selfdetermination as each person can safely and capably engage in. This requires that care provision be personalized and include broader engagement, such as social and family connections, as part of a person's care network. In order to facilitate a transformation of care providers into care collaborators, communications technology can play a significant enabling role as it has in other eSystems. Ubiquity of such technology across care providers, care receivers and their support networks can underpin new models of care provision. Developing a platform approach for communication and having a menu of interfaces and devices, care services can be personalized such that the technology reflects a person's specific needs. This novel approach to person-centered communication moves away from a "one-size-fits-all" model and can facilitate combinatorial interventions. However, the move to eSystemmediated autonomy in remote care provision is confounded by many factors. This paper will discuss the development of just such a communication platform and more than ten year's experience will be explored in developing combinatorial innovations reflecting personal needs in two care scenarios. Through working with care practitioners and patients the platform has addressed needs in primary, secondary and social care in the UK. The current challenges in scaling the approach will be examined from the point of view of the difficulties in mapping the use of eSystems on to the fragmented nature of current care delivery.
... Some within the literature question the cost effectiveness (Henderson et al., 2013) and the rigour of the benefits analysis applied to existing telehealth programs (Bergmo, 2009;Dávalos et al., 2009;Jennett et al., 2003). Others assert that there still remain a number of technical and legal challenges (Kienzle, 2001;May et al., 2003) that must be overcome particularly the areas of legislation and licensure, informed patient consent, and reimbursement (Baker and Bufka, 2011;Mars and Jack, 2010). In addition some have highlighted (Stanberry, 2001) that such a change in the care delivery model and dependency on technology may have negative consequences on the traditional patient clinician relationship and quality of care. ...
Purpose
Diabetes is regarded as a global epidemic with 382 million people globally suffering from diabetes. It also has major implications on patients’ quality of life. There are also high cost of treatment associated with diabetes for both patient and healthcare provider. Telemonitoring represents an excellent technology opportunity to redefine health care delivery. Using technology for home-based care promises the ability to deliver more cost effective care whilst also enhancing quality of care and patient satisfaction. The paper aims to discuss these issues.
Design/methodology/approach
The current research aims to contribute to the methodological design of action research projects in their use to implementation health technologies such as telemonitoring. In particular, it seeks create a model which can be used to demonstrate the efficacy of the use of the action research method as a viable alternative to the traditional randomised control trials methodology currently employed in healthcare.
Findings
The paper contributes towards the methodological design to investigate the area of practice making use of the telemonitoring programme within a Victorian Health Services Network using action research.
Originality/value
It intends to address the research problem of the low utilisation of telemonitoring within Monash Health as a whole, and more specifically within the diabetes unit. In this context the research intends to utilise the benefits of telemonitoring to improve clinical outcomes of patients by increasing insulin stabilisation. It is also intended the research organisation benefits by increased efficiency by decreasing clinical workforce time spent on managing patient insulin data.
... It is argued that these results are due to organizational conflicts and other context-specific reasons, rather than the technology itself (e.g. Berg, 1999;Forsythe, 2001;Kaplan & Shaw, 2002;May et al., 2003;Mohd et al., 2007;Nicolini, 2006). ...
... Senior management support is essential for the introduction of clinical information technology and the effect on the subsequent adoption of the systems across care settings. 3,29 Similarly, Smart Homecare Technology and TeleHealth 2013:1 submit your manuscript | www.dovepress.com ...
The use of wound telemedicine systems in the home care environment has been expanding for the last decade. These systems can generally be grouped into two main types: store and forward systems and video conference type systems; additionally, there are also hybrid systems available that include elements of both. Evidence to date suggests that these systems provide significant benefits to patients, clinicians, and to the health care system generally. Reductions in resource use, visit substitution, costs, and high patient and clinician satisfaction have been reported; however, there is a lack of integration with existing health care technology and no clearly defined technical or clinical standards as yet. Similarly, the legalities associated with wound telemedicine and remote consultation remain unclear. As wound telemedicine systems continue to evolve and be deployed in different locations, there remains significant potential to harness their power to benefit patients being treated at home.
... In the implementation of telehealth, the applicability in daily work proved to be very important. 20,21 With that in mind, it is likely that the telenephrology system fi t in well during the daily work routine; most clinicians and physicians used the system during offi ce hours, spending less than 10 minutes on a consultation and nephrologists responded quickly. ...
PURPOSE: A Web-based consultation system (telenephrology) enables family physicians to consult a nephrologist about a patient with chronic kidney disease. Relevant data are exported from the patient's electronic file to a protected digital environment from which advice can be formulated by the nephrologist. The primary purpose of this study was to assess the potential of telenephrology to reduce in-person referrals.
METHODS: In an observational, prospective study, we analyzed telenephrology consultations by 28 family practices and 5 nephrology departments in the Netherlands between May 2009 and August 2011. The primary outcome was the potential reduction of in-person referrals, measured as the difference between the number of intended referrals as stated by the family physician and the number of referrals requested by the nephrologist. The secondary outcome was the usability of the system, expressed as time invested, the implementation in daily work hours, and the response time. Furthermore, we evaluated the questions asked.
RESULTS: One hundred twenty-two new consultations were included in the study. In the absence of telenephrology, 43 patients (35.3%) would have been referred by their family physicians, whereas the nephrologist considered referral necessary in only 17 patients (13.9%) (P <.001). The family physician would have treated 79 patients in primary care. The nephrologist deemed referral necessary for 10 of these patients. Time investment per consultation amounted to less than 10 minutes. Consultations were mainly performed during office hours. Response time was 1.6 days (95% CI, 1.2-1.9 days). Most questions concerned estimated glomerular filtration rate, proteinuria, and blood pressure.
CONCLUSION: A Web-based consultation system might reduce the number of referrals and is usable. Telenephrology may contribute to an effective use of health facilities by allowing patients to be treated in primary care with remote support by a nephrologist.
... This focus has helped to identify a variety of barriers and facilitators to successful implementation but less attention has been paid to wider strategic, political or workforce issues. In terms of research design, with a few notable exceptions [25,26] this work has relied on case studies focussing on specific occupational groups (e.g. doctors or nurses) and their response to particular technological interventions. ...
Background
Information and communication technologies (ICTs) are often proposed as ‘technological fixes’ for problems facing healthcare. They promise to deliver services more quickly and cheaply. Yet research on the implementation of ICTs reveals a litany of delays, compromises and failures. Case studies have established that these technologies are difficult to embed in everyday healthcare.
Methods
We undertook an ethnographic comparative analysis of a single computer decision support system in three different settings to understand the implementation and everyday use of this technology which is designed to deal with calls to emergency and urgent care services. We examined the deployment of this technology in an established 999 ambulance call-handling service, a new single point of access for urgent care and an established general practice out-of-hours service. We used Normalization Process Theory as a framework to enable systematic cross-case analysis.
Results
Our data comprise nearly 500 hours of observation, interviews with 64 call-handlers, and stakeholders and documents about the technology and settings. The technology has been implemented and is used distinctively in each setting reflecting important differences between work and contexts. Using Normalisation Process Theory we show how the work (collective action) of implementing the system and maintaining its routine use was enabled by a range of actors who established coherence for the technology, secured buy-in (cognitive participation) and engaged in on-going appraisal and adjustment (reflexive monitoring).
Conclusions
Huge effort was expended and continues to be required to implement and keep this technology in use. This innovation must be understood both as a computer technology and as a set of practices related to that technology, kept in place by a network of actors in particular contexts. While technologies can be ‘made to work’ in different settings, successful implementation has been achieved, and will only be maintained, through the efforts of those involved in the specific settings and if the wider context continues to support the coherence, cognitive participation, and reflective monitoring processes that surround this collective action. Implementation is more than simply putting technologies in place – it requires new resources and considerable effort, perhaps on an on-going basis.
... In the implementation of telehealth, the applicability in daily work proved to be very important. 20,21 With that in mind, it is likely that the telenephrology system fi t in well during the daily work routine; most clinicians and physicians used the system during offi ce hours, spending less than 10 minutes on a consultation and nephrologists responded quickly. ...
Purpose:
A Web-based consultation system (telenephrology) enables family physicians to consult a nephrologist about a patient with chronic kidney disease. Relevant data are exported from the patient's electronic file to a protected digital environment from which advice can be formulated by the nephrologist. The primary purpose of this study was to assess the potential of telenephrology to reduce in-person referrals.
Methods:
In an observational, prospective study, we analyzed telenephrology consultations by 28 family practices and 5 nephrology departments in the Netherlands between May 2009 and August 2011. The primary outcome was the potential reduction of in-person referrals, measured as the difference between the number of intended referrals as stated by the family physician and the number of referrals requested by the nephrologist. The secondary outcome was the usability of the system, expressed as time invested, the implementation in daily work hours, and the response time. Furthermore, we evaluated the questions asked.
Results:
One hundred twenty-two new consultations were included in the study. In the absence of telenephrology, 43 patients (35.3%) would have been referred by their family physicians, whereas the nephrologist considered referral necessary in only 17 patients (13.9%) (P <.001). The family physician would have treated 79 patients in primary care. The nephrologist deemed referral necessary for 10 of these patients. Time investment per consultation amounted to less than 10 minutes. Consultations were mainly performed during office hours. Response time was 1.6 days (95% CI, 1.2-1.9 days). Most questions concerned estimated glomerular filtration rate, proteinuria, and blood pressure.
Conclusion:
A Web-based consultation system might reduce the number of referrals and is usable. Telenephrology may contribute to an effective use of health facilities by allowing patients to be treated in primary care with remote support by a nephrologist.
... Other ways to enhance physician acceptance are to have support from a sponsoring Organisation, provide structural legitimacy and a cohesive network. [15] Video conferencing as an operational, research and educational tool in wound care It has been demonstrated that students who participated via videoconferencing remotely asked four times as many questions of the faculty, and vice versa faculty to students, than occurred when students were physically present in the operating room. Feedback from the study shows that students gain more from the TM experience than from being physically in the operating room as measured by several objective and subjective criteria. ...
The escalating physiological, psychological, social and financial burdens of wounds and wound care on patients, families and society demand the immediate attention of the health care sector. Many forces are affecting the changes in health care provision for patients with chronic wounds, including managed care, the limited number of wound care therapists, an increasingly ageing and disabled population, regulatory and malpractice issues, and compromised care. The physician is also faced with a number of difficult issues when caring for chronic wound patients because their conditions are time consuming and high risk, represent an unprofitable part of care practice and raise issues of liability. Telemedicine enhances communication with the surgical wound care specialist. Digital image for skin lesions is a safe, accurate and cost-effective referral pathway. The two basic modes of telemedicine applications, store and forward (asynchronous transfer) and real-time transmission (synchronous transfer, e.g. video conference), are utilized in the wound care setting. Telemedicine technology in the hands of an experienced physician can streamline management of a problem wound. Although there is always an element of anxiety related to technical change, the evolution of wound care telemedicine technology has demonstrated a predictable maturation process.
... Telehealth accomplishes delivery of care virtually by means of telecommunication technology [1][2][3][4][5]. Potential advantages of telehealth include improved clinical outcomes, reduced number of unplanned hospital and A&E admissions, allowing clinicians to monitor patients' health and deal with case load more efficiently; and enable patients to be more independent and self-manage their conditions [6,7]. ...
Telehealth is heralded as a panacea to control burgeoning demand on healthcare resources and lack of streamlining in care delivery. However, evaluating the effectiveness of telehealth on health and care delivery outcomes through randomized controlled trials (RCTs) has been an issue of contention. This research investigates the issues that affect telehealth evaluation. The strategy adopted in this research involved conducting a qualitative longitudinal case study, in the UK. Data was collected through focus group discussions and interviews; and analyzed thematically. The results of this research indicate that there are both practical and methodological issues that affect evaluation of telehealth through RCT in healthcare. Addressing these issues is vital in order to understand how an evaluation strategy should be deployed, and whether it is suited to the healthcare context.
... As described above, experience with telemedicine increases a physician's predisposition to use telemedicine in their practice and even augments the breadth of implementation in different facets of his or her practice. Other ways to enhance physician acceptance is to have support from a sponsoring organization, provide structural legitimacy and a cohesive network (May et al, 2003). ...
... Looking now at the question of what constitutes a receptive service model [78,79], we see this as a pair of challenges, again with social and technical components: "Knowing when to use early detection monitoring" and "Knowing how to respond". ...
To propose a research agenda that addresses technological and other knowledge gaps in developing telemonitoring solutions for patients with chronic diseases, with particular focus on detecting deterioration early enough to intervene effectively.
A mixed methods approach incorporating literature review, key informant, and focus group interviews to gain an in-depth, multidisciplinary understanding of current approaches, and a roadmapping process to synthesise a research agenda.
Counter to intuition, the research agenda for early detection of deterioration in patients with chronic diseases is not only primarily about advances in sensor technology but also much more about the problems of clinical specification, translation, and interfacing. The ultimate aim of telemonitoring is not fully agreed between the actors (patients, clinicians, technologists, and service providers). This leads to unresolved issues such as: (1) How are sensors used by patients as part of daily routines? (2) What are the indicators of early deterioration and how might they be used to trigger alerts? (3) How should alerts lead to appropriate levels of responses across different agencies and sectors?
Attempts to use telemonitoring to improve the care of patients with chronic diseases over the last two decades have so far failed to lead to systems that are embedded in routine clinical practice. Attempts at implementation have paid insufficient attention to understanding patient and clinical needs and the complex dynamics and accountabilities that arise at the level of service models. A suggested way ahead is to co-design technology and services collaboratively with all stakeholders.
... More recently in their investigation of factors associated with successful telemedicine systems, May et al. discovered that clinician predisposition toward using telemedicine was one of the factors necessary for regular employment of that system, along with a sponsoring organization, structural legitimacy, and cohesive network. 3 A key problem restricting the use of telemedicine is that there is very little information on how using this healthcare network system specifically changes the attitudes of healthcare providers. There have been numerous studies of the attitudes of healthcare providers toward telemedicine that are exploratory and cross-sectional in nature. ...
A longitudinal study was conducted in which the pre- and post-telemedicine encounter attitudes of healthcare providers were compared in order to ascertain whether and how experience with telemedicine changes their attitudes toward telemedicine. Attitudinal changes of providers who had used telemedicine previously were compared to those experiencing telemedicine for the first time. Data were gathered from the providers in two telemedicine programs located in Georgia and Nebraska. Both used real-time videoconferencing and peripheral devices to conduct telemedicine consultations. A total of 87 providers completed questionnaires just prior to and immediately after each telemedicine encounter in their respective programs. The questions focused on the expected impact of telemedicine on their productivity and ability to prescribe treatment. A 3-point scale was used to measure the responses. More than three quarters (79.3%) of the providers did not change their attitudes subsequent to the use of telemedicine. There was no significant difference between first-time users and those who had experience (p = 0.392). The shift in attitude in the minority (n = 18) of providers who did change their minds after the telemedicine encounter was more positive among those who used telemedicine for the first time as compared to those with experience. Contrariwise, those with experience became more negative (p = 0.025). This finding suggests that experience with telemedicine results in more positive attitudes that may not be realized in subsequent interactions with the technology.
... But other work has shown how, across systems that provide real-time contact between doctors and patients, normal patterns of interaction in the clinical encounter are threatened or disrupted ( Miller, 2001). Normalization in the clinic was threatened by the tendency of telemedicine systems to be fragmented experiments running parallel to 'real' services, but also by the absence of powerful policy sponsors ( May et al., 2003b). If real-time interactivity in electronically mediated doctor-patient encounters has been proved difficult to implement, evaluate and accommodate in the NHS, image based diagnostic services have become possible. ...
'Modernization' is a key health policy objective in the UK. It extends across a range of public service delivery and organizational contexts, and also means there are radical changes in perspective on professional behaviour and practice. New information and communications technologies have been seen as one of the key mechanisms by which these changes can be engendered. In particular, massive investment in information technologies promises the rapid distribution and deployment of patient-centred information across internal organizational boundaries. While the National Health Service (NHS) sits on the edge of a pound sterling 6 billion investment in electronic patient records, other technologies find their status as innovative vehicles for professional behaviour change and service delivery in question. In this paper, we consider the ways that telemedicine and telehealthcare systems have been constructed first as a field of technological innovation, and more recently, as management solutions to problems around the distribution of health care. We use NHS responses to chronic illness as a medium for understanding these shifts. In particular, we draw attention to the shifting definitions of 'innovation' and to the ways that these shifts define a move away from notions of technological advance towards management control.
In this chapter, I review the literature of guidelines, frameworks and theories used in telehealth service implementation, operation and evaluation. Guidelines contain instructions written by health professionals on what to do or what not to do when operating telehealth services. Through examining such guidelines, I uncovered some of the processes and practices applied to telehealth services. Policymakers advocate visions for improvement of healthcare access and increased system efficiency arising from telehealth services. Providers seek to ensure that healthcare is effective and safe. Issues raised in this literature about the application of telehealth services include aspects such as quality and safety, responsibilities of clinicians and ethical considerations such as privacy and confidentiality and management of liability or risk. Hitherto, the norms of medical practice have been place-based. This chapter charts how these norms have responded to the introduction of separated care using telehealth services.
The UK’s National Health Service (NHS) is undergoing great reform. Driven by a demand for higher quality health care provision, information and communication technologies (ICT) are increasingly being used as tools to realize this change. We have investigated the use of remote patient monitoring (RPM), using wireless and broadband networks, in three community care homes between July 2003 and January 2006. The aim of the project was to determine for what conditions and in which setting the RPM was most useful and to establish an organizational and clinical infrastructure to support it. Evaluation of the project demonstrated clinical benefits such as the early detection of cardiac events, allowing prompt intervention and routine monitoring of other conditions. A change in work practices resulted in a more collaborative approach to patient management and led to an increase in communication between health care professionals from different sectors, as well as the establishment of protocols for seeking advice. Technically, the equipment largely met the users’ needs. In conclusion, the monitoring proved a useful tool for the management of chronic diseases and has great potential to contribute to the reform of the NHS.
Telehealth and telecare have been heralded as major mechanisms by which frail elderly people can continue to live at home but numerous pilot studies have not led to the adoption of these technologies as mainstream contributors to the health and social care of people in the community. This paper reviews why dissemination has proved difficult and concludes that one problem is that these technologies require considerable organisational changes if they are to be effective: successful implementation is not just a technical design issue but is a sociotechnical design challenge. The paper reviews the plans of 25 health communities in England to introduce integrated health and social care for the elderly. It concludes that these plans when implemented will produce organisational environments conducive to the mainstream deployment of telehealth and telecare. However, the plans focus on different kinds of integrated care and each makes different demands on telehealth and telecare. Progress on getting mainstream benefits from telehealth and telecare will therefore depend on building a number of different sociotechnical systems geared to different forms of integrated care and incorporating different forms of telehealth and telecare.
The increasing number of elderly people in need of health and social care is putting pressure on current services to develop better ways of providing integrated care in the community. It is a widely held belief that e-health technologies have great potential in enabling and achieving this goal. This chapter reviews a number of technologies used for this purpose: telecare, telehealth, telemedicine, electronic patient record systems, and technologies to support mobile working. In each case, technocentric-design approaches have led to problematic implementations and failures to achieve adoption into the routine of delivering healthcare. An examination of attempts to implement major changes in the service delivery of integrated care shows that e-health technologies can be successfully implemented when they are seen as an intrinsic part of the creation of a complete system. However, the design process required for successful delivery of these services is challenging; it requires sustained and integrated development work by clinical staff and technologists coordinating their work on process changes, organisational developments, and technology implementations.
The increasing number of elderly people in need of health and social care is putting pressure on current services to develop better ways of providing integrated care in the community. It is a widely held belief that e-health technologies have great potential in enabling and achieving this goal. This chapter reviews a number of technologies used for this purpose: telecare, telehealth, telemedicine, electronic patient record systems, and technologies to support mobile working. In each case, technocentric-design approaches have led to problematic implementations and failures to achieve adoption into the routine of delivering healthcare. An examination of attempts to implement major changes in the service delivery of integrated care shows that e-health technologies can be successfully implemented when they are seen as an intrinsic part of the creation of a complete system. However, the design process required for successful delivery of these services is challenging; it requires sustained and integrated development work by clinical staff and technologists coordinating their work on process changes, organisational developments, and technology implementations.
The focus of this chapter is to asses a new model of care in dementia, particularly Alzheimer's Disease (AD). According with sociotechnical approaches, the authors describe a proof of concept, Information and Communication Technologies (ICT) intervention, as a technical and organizational model of robust, reliable, and efficient clinical practice to meet the medical, psychological, and social needs of AD people and their family. The authors also propose the "Identification-Recognition-Evaluation-Application Model" as process methodology in a telemedicine project. In this perspective, the technology has to be analyzed as technology-in-use, a process coming out from an ecology of specific actions and actors. Finally, the authors describe their experience of a longitudinal study in which ICT networking technologies are used to implement coping strategies, in order to improve the quality of life of AD families.
How can you make the best use of patient data to improve health outcomes? More and more information about patients' health is stored on increasingly interconnected computer systems. But is it shared in ways that help clinicians care for patients? Could it be better used as a resource for researchers? This book is aimed at all those who want to learn about how IT is transforming the way we think about medicine and medical research. The ideas explored here are taken from research carried out around the world, and are presented by a leading authority in Health Informatics based at University College London. This comprehensive guide to the field is split into three sections: • What is health informatics? - an introduction • Techniques for representing and analysing patient data and medical knowledge • Implementation in the clinical setting: changing practice to improve health care outcomes Whether you are a health professional, NHS manager or IT specialist, this book will help you understand how data can be managed to provide the information you and your colleagues want in the most helpful and accessible way for both you and your patients.
Telehealth and telecare have been heralded as major mechanisms by which frail elderly people can continue
to live at home but numerous pilot studies have not led to the adoption of these technologies as mainstream
contributors to the health and social care of people in the community. This paper reviews why dissemination
has proved difficult and concludes that one problem is that these technologies require considerable organisational changes if they are to be effective: successful implementation is not just a technical design issue but is a sociotechnical design challenge. The paper reviews the plans of 25 health communities in England to
introduce integrated health and social care for the elderly. It concludes that these plans when implemented
will produce organisational environments conducive to the mainstream deployment of telehealth and telecare.
However, the plans focus on different kinds of integrated care and each makes different demands on telehealth
and telecare. Progress on getting mainstream benefits from telehealth and telecare will therefore depend on
building a number of different sociotechnical systems geared to different forms of integrated care and incorporating different forms of telehealth and telecare.
Introduction
While it is predicted that telecare and other information and communication technology (ICT)-assisted services will have an increasingly important role in future healthcare services, their implementation in practice is complex. For implementation of telecare to be successful and ensure quality of care, sufficient training for staff (healthcare professionals) and service users (patients) is fundamental. Telecare training has been found to have positive effects on attitudes to, sustained use of, and outcomes associated with telecare. However, the potential contribution of training in the adoption, quality and safety of telecare services is an under-investigated research field. The overall aim of this study is to develop and evaluate simulation-based telecare training programmes to aid the use of videophone technology in elderly home care. Research-based training programmes will be designed for healthcare professionals, service users and next of kin, and the study will explore the impact of training on adoption, quality and safety of new telecare services.
Methods and analysis
The study has a qualitative action research design. The research will be undertaken in close collaboration with a multidisciplinary team consisting of researchers and managers and clinical representatives from healthcare services in two Norwegian municipalities, alongside experts in clinical education and simulation, as well as service user (patient) representatives. The qualitative methods used involve focus group interviews, semistructured interviews, observation and document analysis. To ensure trustworthiness in the data analysis, we will apply member checks and analyst triangulation; in addition to providing contextual and sample description to allow for evaluation of transferability of our results to other contexts and groups.
Ethics and dissemination
The study is approved by the Norwegian Social Science Data Services. The study is based on voluntary participation and informed written consent. Informants can withdraw at any point in time. The results will be disseminated at research conferences, peer review journals, one PhD thesis and through public presentations to people outside the scientific community.
The use of structuration theory in the field of information systems is long debated. Questions on its applicability and suitability
have led to many insightful studies and papers in this area. We, in this chapter, draw on these studies and provide a complementary
view on use of ST in studying IS deployment. While doing so, we draw on Giddens’s recent work and utilise telehealth implementation
case study as an example.
KeywordsStructuration theory-Telehealth-Technology acceptance
The widespread use of consumer-oriented information communication technologies (ICTs) such as cell phones, iPods and other electronic data devices is changing the way consumers think about and interact with healthcare. In light of this technology boom, a new field for researching, planning and implementing ICTs in healthcare has emerged called 'eHealth'. Effective eHealth implementation requires a patient-centred approach to care, with health professionals utilising technology to share clinical information and guide patient self-care. This may include the use of electronic health records (EHRs), phone and text messaging interactions and web-based communication applications. Anticipated benefits of eHealth are improved patient access and choice, enhanced communication between professionals and improved health outcomes. However, the introduction of ICTs to the complex healthcare environment may also lead to disruptions, distractions or errors. To implement eHealth in a safe and effective way, the development of a comprehensive agenda for research, planning and implementation is essential.
This study proposes a prototype framework (THEMIS) for estimating algebraically the success (S) of the electronic health collaborative services (e-HCS) and examines two hypotheses: first, that the S estimation of an e-HCS, developed by a third-party vendor, demands a 'shrunk formative model' and second that causal relationships between the involved dimensions (FFP, CO, COSTS) do exist, and their parameters affect the S - from weakly to strongly and vice-versa. A formative model was shrunk to generate three causal dimensions ('Collaborators Objections', 'Costs', 'Fitness for Purpose'). Then, the new framework (THEMIS) was enriched with a causal loop diagram, a prototype scoring method, (termed 'polarisation method') and 42 questions. In order to investigate the feasibility of the THEMIS framework, we estimated the S of 15 e-HCSs and the algebraic outcomes (E(S)) were compared - one by one - with usage categories produced by a commercial software. Our findings supported the initial hypotheses. The S was estimated with accuracy; for the e-HCSs with a weak E(S) the commercial software verified that they remained idle several times during the 11-month evaluation period, whereas the e-HCS with a strong E(S) the commercial software verified that they were used frequently. Frameworks, such as the one proposed, which are based on both qualitative and quantitative methods, may provide significant support on the S estimation field.
Health-e-Access, an urban telemedicine service, enabled 6,511 acute-illness telemedicine visits over a 7-year period for children at 22 childcare and school sites in Rochester, NY.
The aims of this article were to (1) describe provider attitudes and perceptions about efficiency and effectiveness of Health-e-Access and (2) assess hypotheses that (a) providers will complete a large proportion of the telemedicine visits attempted and (b) high levels of continuity with the primary care practice will be achieved.
This descriptive study focused on the 24-month Primary Care Phase in the development of Health-e-Access, initiated by the participation of 10 primary care practices. Provider surveys addressed efficiency, effectiveness, and overall acceptability. Performance measures included completion of telemedicine visits and continuity of care with the medical home.
Among survey respondents, the 30 providers who had completed telemedicine visits perceived that decision-making required slightly less time and total time required was slightly greater than for in-person visits. Confidence in diagnosis was somewhat less for telemedicine visits. Providers were comfortable collaborating with telemedicine assistants and confident that communications met parent needs. Among the 2,554 consecutive telemedicine visits attempted during the Primary Care Phase, 2,475 (96.9%) were completed by 47 providers. For visits by children with a participating primary care practice, continuity averaged 83.2% among practices (range, 28.1-92.9%).
Providers perceived little or no advantage in efficiency or effectiveness to their practice in using telemedicine to deliver care; yet they used it effectively in serving families, completing almost all telemedicine visits requested, providing high levels of continuity with the medical home, and believing they communicated adequately with parents.
This paper describes communication in the physical examination phases of telemedicine consultations.
Using the method of conversation analysis, we draw on 10 telemedicine consultations (five telecardiology and five televascular) between primary and tertiary care in the UK.
Physical examination is absent in telecardiology consultations. In televascular consultations the professionals try to compensate for the lack of physical proximity by getting involved in a form of collaboration that constitutes a novel environment for all. Separated from the patient by physical space, the specialist orchestrates the positioning of the patient, the camera and the primary care nurse's activity via the use of a video-link.
Telemedicine offers primary care nurses a unique opportunity to engage in active collaboration with hospital specialists. The nurses' examination skills are recruited because physical examination is conducted from distance and the specialist cannot touch the patient or see parts of the body with ease. We speculate that difficulties with the physical examination may have contributed to the relatively slow adoption of telemedicine.
The analysis reveals some new communication practices that participants in telemedicine are called to adopt. This can be used to inform training interventions that focus both on patient and professional.
Avhandlinga er rettet mot å forstå hvordan teleradiologiske tjenester i nord norsk røntgentjeneste ble etablert og virket over en periode på ca 5 år. Siktemålet har både vært å beskrive utforming av de nye praksisene i lys av hvordan de interagerte med gjeldende orden, og å komme nærmere en forståelse av hvordan utfordringer i røntgentjenesten ble berørt. Avhandlinga har derved et evalueringsaspekt. Det samfunnsvitenskapelige temaet som har vært behandlet er rasjonalitet; fornuftsforståelser, nærmere bestemt utvalgte trekk ved begrepet som kan gjenfinnes som spor i praksiser og i omtale av tjenestenes virkemåte. Spørsmålene har vært hvilke forståelser som har fått gjennomslag i utformingsprosessene, om det er skapt noen nye forståelser i de relativt fastholdte tjenestene og hvordan sammenhengene har vært mellom fornuftsforståelse og måten utfordringer i tjenestene er blitt berørt, for eksempel om de er løst, forsterket eller om det er kommet nye til. Teleradiologi er en viktig del av de dels gjennomgripende endringene som skjer i helsevesenet. Endringene skjer gjennom relasjoner mellom minst tre dynamiske områder, eller sfærer med dels egne logikker. For det første gjeldende orden: faglig, med stadig bedre behandlingsmetoder, i tillegg til institusjonell, økonomisk og juridisk orden. For det andre oppgavene: økt press p.g.a. eldrebølgen og øking i antallet pasienter med kroniske lidelser, og for det tredje IKT, som både kan oppleves som mulighetsskaper for deling av spesialistressurser, nye tjenestemodeller og selvhjelp - og som tvingende endringskraft og aggressiv industri. Empirisk beskrives 5 dels overlappende og dels autonome teleradiologiske praksiser som utformes gjennom ulike samspill. Feltet framstår i perioden med økt kompleksitet, der det kan være vanskelig å få øye på både hva som driver endringer, og resultatene i lys av de utfordringene som skulle løses. Det beskrives klare løsninger knyttet til spesialisthjelp i akuttsituasjoner, til administrasjon av pasienter og til umiddelbar tilgang på røntgeninformasjon. Noen utfordringer øker, for eksempel presset på spesialisttjenestene. Nye skapes, for eksempel spenninger mellom prioriteringer og interesser der tiden brukes til forhandlinger. Videre i forholdet mellom nye oppgaver og belønninger som dels blir utydelig og kan oppleves urettferdig. I praksisene spilles det ut en overgangstilstand mellom gamle og nye forståelser av fornuft, mellom opprettholdelse av gjeldende orden, forsøk på å bryte ut og etablere det som oppfattes som gode tjenester, og mellom ulike bestrebelser på dominans på internlogiske premisser.
This article discusses the relationship between a deconstructivist method in science and technology studies (STS) and the more recent moves towards a reconstructivist engagement with science and science policy making. Drawing on examples from the author's own research, the article identifies three forms of engagement and their relative utility and limitations. The article argues that these are typical of STS work that seeks direct engagement with science policy making and which could form the basis for a more "serviceable STS" that retains its critical and independent perspective on science. The paper concludes by arguing that the analysis has important implications for the ways in which STS expertise can articulate with science policy making.
Se presenta una metodología para la introducción progresiva y ordenada de servicios específicos de e-Salud para el seguimiento extrahospitalario de pacientes crónicos. Identificado como un modelo de pasos con filtro para la gestión del proceso global de introducción, se presenta formalmente estructurado en tres pasos: 1) exploratorio (fase de proyecto piloto); 2) evaluación en profundidad (fase de ensayo clínico), y 3) despliegue (fase de uso tutelado). En la primera fase, controlada por el equipo de I+D, los criterios predominantes son los de funcionalidad y utilidad de las tecnologías involucradas. En la segunda fase, controlada por una Agencia de Evaluación de Tecnologías Sanitarias, prevalece el criterio científico asociado con los resultados obtenidos en el ensayo clínico. La tercera fase es controlada por decisiones de las administraciones sanitarias sobre la introducción de nuevas tecnologías y su financiación. Se describen los requerimientos de la plataforma tecnológica diseñada para soportar los proyectos y ensayos de las fases 1 y 2. Como ejemplo de actuación en la fase 2 se describe un ensayo sobre hipertensión arterial.
Qualitative studies can help us understand the "successes" and "failures" of telemedicine to normalize within clinical service provision. This report presents the development of a robust conceptual model of normalization processes in the implementation and development of telemedicine services.
Retrospective and cumulative analysis of longitudinal qualitative data from three studies was undertaken between 1997 and 2002. Observation and semistructured interviews produced a substantial body of data relating to approximately 582 discrete data collection episodes. Data were analyzed separately in each of three studies. Cumulative analysis was conducted by constant comparison.
(1) Implementation of telemedicine services depends on a positive link with a (local or national) policy level sponsor. (2) Adoption of telemedicine systems in service depends on successful structural integration so that development of organizational structures takes place. (3) Translation of telemedicine technologies into clinical practice depends on the enrollment of cohesive, cooperative groups. (4) Stabilization of telemedicine systems in practice depends on integration at the level of professional knowledge and practice, where clinicians are able to accommodate telemedicine through the development of new procedures and protocols.
A rationalized linear diffusion model of "telehealthcare" is inadequate in assessing the potential for normalization, and the political, organizational, and "ownership" problems that govern the process of development, implementation, and normalization need to be accounted for. This report presents a model for assessing the potential for successful implementation of telehealthcare services. This model defines the requirements for the successful normalization of telemedicine systems in clinical practice.
A methodology is presented for a smooth, orderly implementation of specific e-Health services for monitoring chronic patients outside of the hospital setting. Identified as a stage-gate model for the management of the overall implementation process, this methodology is presented formally structured into three steps: a) exploratory examination (pilot project stage); 2) in-depth evaluation (clinical trial stage); and 3) deployment (guided use stage). In the first stage, controlled by the R+D team, the predominant criiteria are the functionality and usability of the technologies involved. In the second stage, controlled by an associated Health Technology Evaluation Agency, the predominant criterion is the scientific aspect related to the results obtained in the clinical testing. The third stage is controlled through decisions made by the health administrations as to the implementation of new technologies and the financing thereof. A description is provided as to the requirements of the technological platform designed to serve its the medium for the projects and tests from stage 1 and 2. As an example of what is done in stage 2, a description is given of a trial related to hypertension.
The adoption of telehealthcare in the United Kingdom has been slow and fragmented. This paper presents a structural explanation for this by contrasting contending themes in recent UK health policy. It is argued that the conflict between trends towardsmodernizationand demands forevidence-based practicehave made it difficult for a major policy agency to emerge that can sponsorservice development, and so proponents of telehealthcare have been forced to situate their work within the domain of R&D. This has led to a fragmented field of practice characterized by short-term and small-scale projects.
Evaluation is an essential component of the introduction of new technologies, treatment modalities and models of service delivery across the health-care sector. Such work attracts significant levels of public funding, but little attention has been paid to understanding evaluation as more than a set of applied methodological activities. This paper sets out an agenda for a more complex and richer understanding of evaluation as a set of professional and organizational dynamics.
New telecommunications technologies promise to profoundly change the spatial and temporal relationship between health professional and patient. This paper reports results from an ethnographic study of the introduction of a videophone or 'telemedicine' system intended to facilitate faster and more convenient referral of patients with anxiety and depression in primary care, to a community mental health team. We explore the reasons for contest over the telemedicine system in practice, contrasting professionals' critique of the technology in play with a more fundamental problem: the extent to which the telecommunications system threatened deeply embedded professional constructs about the nature and practice of therapeutic relationships.
Background:
Appropriate information flow is crucial to the care of patients, particularly at the interface between primary and secondary care. Communication problems can result from inadequate organisation and training, There is a major expectation that information and communication technologies may offer solutions, but little reliable evidence. This paper reports the design and performance of a multi-centre randomised controlled trial (RCT), unparalleled in telemedicine research in either scale or range of outcomes. The study investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing to perform joint tele-consultations as an alternative to general practitioner referral to the hospital specialist in the outpatient clinic.
Methods:
Joint tele-consultation services were established in both the Royal Free Hampstead NHS Trust in inner London, and the Royal Shrewsbury Hospitals Trust, in Shropshire. All the patients who gave consent to participate were randomised either to joint tele-consultation or to a routine outpatients appointment. The principal outcome measures included the frequency of decision by the specialist to offer a follow-up outpatient appointment, patient satisfaction (Ware Specific Questionnaire), wellbeing (SF12) and enablement (PEI), numbers of tests, investigations, procedures and treatments.
Results:
A total of 134 general practitioners operating from 29 practices participated in the trial, referring a total of 3170 patients to 20 specialists in ENT medicine, general medicine (including endocrinology, and rheumatology), gastroenterology, orthopaedics, neurology and urology. Of these, 2094 patients consented to participate in the study and were correctly randomised. There was a 91% response rate to the initial assessment questionnaires, and analysis showed equivalence for all key characteristics between the treatment and control groups.
Conclusion:
We have designed and performed a major multi-centre trial of teleconsultations in two contrasting centres. Many problems were overcome to enable the trial to be carried out, with a considerable development and learning phase. A lengthier development phase might have enabled us to improve the patient selection criteria, but there is a window of opportunity for these developments, and we believe that our approach was appropriate, allowing the evaluation of the technology before its widespread implementation.
The objective of this study is to provide a systematic review of studies on patient satisfaction with telemedicine. The review included empirical studies that investigated patient satisfaction with that telemedicine service. The search strategy involved matching at least one of 11 'telemedicine' terms with one of 5 'satisfaction' terms. The following databases were searched: Telemedicine Information Exchange (TIE) database, MEDLINE, Science Citation Index (SCI), Social Science Citation Index (SSCI), Psycinfo, and Citation Index of Nursing and Allied Health (CINAHL). A highly structured instrument was used for data extraction. The review included 93 studies. Telepsychiatry represents the largest portion of these studies (25%), followed by multispecialty care (14%), nursing (11%), and dermatology (8%). Real-time videoconferencing was used in 88% of these studies. Only 19 (20%) included an independent control group, including 9 (10%) randomized control trial (RCT) studies. One third of studies were based on samples of less than 20 patients, and only 21% had samples of over 100 patients. Aspects of patient satisfaction most commonly assessed were: professional-patient interaction, the patient's feeling about the consultation, and technical aspects of the consultation. Only 33% of the studies included a measure of preference between telemedicine and face-to-face consultation. Almost half the studies measured only 1 or 2 dimensions of satisfaction. Reported levels of satisfaction with telemedicine are consistently greater than 80%, and frequently reported at 100%. Progression of telemedicine services from "trial" status to routine health service must be supported by improved research into patients' satisfaction with telemedicine. Further investigation of factors that influence patient acceptance of telemedicine is indicated.
A pilot study was carried out in preparation for a full-scale randomized controlled trial of teleconsultations versus routine outpatient consultation. The method of study recruited sufficient numbers of patients and avoided selection bias. Over five months, 439 referrals were received, but 297 patients were not eligible to enter the trial because they did not fall within the specialties/consultants included in it. Of the 132 referrals entering the trial, 62 were randomized to the intervention group and 70 to the control group. Consent to participate in the experimental arm of the trial was obtained for all but 13 patients. The results also suggested that patient satisfaction with teleconsultation may exceed that with conventional outpatient consultation, with a strong indication of overall time savings for patients.
New telecommunications technologies promise to profoundly change the spatial and temporal relationship between health professional and patient. This paper reports results from an ethnographic study of the introduction of a videophone or 'telemedicine' system intended to facilitate faster and more convenient referral of patients with anxiety and depression in primary care, to a community mental health team. We explore the reasons for contest over the telemedicine system in practice, contrasting professionals' critique of the technology in play with a more fundamental problem: the extent to which the telecommunications system threatened deeply embedded professional constructs about the nature and practice of therapeutic relationships.
Telecommunications systems seem to offer health care providers, professionals and patients a plethora of opportunities to respond to social and geographical inequalities in health care provision, and a new field of health care endeavor has emerged--'telemedicine'. This paper presents results from a three year ethnographic study of the development and implementation of telemedicine systems in a British region. We explore how attempts to put into service one 'telemedicine' system failed to get beyond the draft of a written protocol. Our analysis focuses on the contests between clinicians, technical experts and external evaluators over what kinds of knowledge and practice count in developing a protocol and evaluating a clinical intervention. We show how the introduction and implementation of 'hard' technologies (systems hardware) can be undermined in practice by 'soft' technologies (the practices through which evaluative knowledge is produced).
The current model of general practitioner referral of patients to hospital specialists in the UK is sometimes associated with unnecessary duplication of investigations and treatments. We aimed to compare joint teleconsultations between general practitioners, specialists, and patients (virtual outreach) with standard outpatient referral.
Virtual outreach services were established in London and Shrewsbury. The general practitioners referred 3170 patients, of whom 2094 consented to participate in the study and were eligible for inclusion. 1051 patients were randomly assigned virtual outreach, and 1043 standard outpatient appointments. We followed up the patients for 6 months after their index consultation. The primary outcome measure was the offer of a follow-up outpatient appointment. Analysis was by intention to treat.
More patients in the virtual outreach group than the standard group were offered a follow-up appointment (502 [52%] vs 400 [41%], odds ratio 1.52 [95% CI 1.27-1.82], p<0.0001). Significant differences in effects were observed between the two sites (p=0.009) and across different specialties (p<0.0001). Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ear, nose, and throat surgery and orthopaedics than in the other specialties. Fewer tests and investigations were ordered in the virtual outreach group by an average of 0.79 per patient (0.37-1.21, p=0.0002). Patients' satisfaction (analysed per protocol) was greater after a virtual outreach consultation than after a standard outpatient consultation (mean difference 0.33 scale points [95% CI 0.23-0.43], p<0.0001), with no heterogeneity between specialties or sites.
The trial showed that allocation of patients to virtual outreach consultations is variably associated with increased offers of follow-up appointments according to site and specialty, but leads to significant increases in patients' satisfaction and substantial reductions in tests and investigations. Efficient operation of such services will require appropriate selection of patients, significant service reorganisation, and provision of logistical support.
We used qualitative research to evaluate the experience of the participants in teleconsultations between primary and secondary care. Semistructured interviews were conducted with 15 hospital specialists, 24 general practitioners and 30 patients. Focus groups were also held with hospital specialists (two groups), general practitioners (six groups) and administrative staff (five groups). Sixty teleconsultations in six different specialties were video-recorded. Early findings show that the participants (hospital specialists, general practitioners and patients) had different perceptions of the same teleconsultations. Furthermore, the participants perceptions of consultations differed from those of the researchers.
In the UK, few telemedicine applications have endured beyond the trial phase. It is commonly said that lack of evidence is responsible for the lack of implementation. This assumes that evidence will lead to implementation. Studies show that this is naive, especially in organizations like health-care systems, which are characterized by professional dominance. Furthermore, other research indicates that the nature of the changes experienced by clinicians in telemedicine experiments is sometimes limiting compared with conventional practice. This presents a dilemma for evaluation since it cannot reliably take place until a particular technique has become stable and accepted into the daily routine. A programme of selected case studies is recommended to develop knowledge of how telemedicine can become a taken-for-granted part of medical care.
Telehealthcare is a rapidly growing field of clinical activity and technical development. These new technologies have caught the attention of clinicians and policy makers because they seem to offer more rapid access to specialist care, and the potential to solve structural problems around inequalities of service provision and distribution. However, as a field of clinical practice, telehealthcare has consistently been criticised because of the poor quality of the clinical and technical evidence that its proponents have marshalled. The problem of "evidence" is not a local one. In this paper, we undertake two tasks: first, we critically contrast the normative expectations of the wider field of Health Technology Assessment (HTA) with those configured within debates about Telehealthcare Evaluation; and second, we critically review models that provide structures within which the production of evidence about telehealthcare can take place. Our analysis focuses on the political projects configured within a literature aimed at stabilising evaluative knowledge production about telehealthcare in the face of substantial political and methodological problems.