Reports
Telemedicine normalisation: a new version of
an old problem?
Francesc Roig and Francesc Saigí
Abstract
The progress of e-health has raised hopes and expectations that challenges faced by healthcare systems
in the 21st Century (e.g. ageing populations, equality in access and budget restraints) can be overcome
through its application. Although the development of telemedicine began early in the 20th Century,
its incorporation into healthcare remains problematic and controversial. Despite the fact that many
proposed projects show potential for good clinical assessments and outcomes, most do not continue
beyond the feasibility phase. While managers and clinicians wait for definitive evidence to support the
implementation of telemedicine, findings from research conducted during the 1990s incorporating
information and communication technologies (ICTs) into the business world suggest that a different
approach could facilitate understanding of how telemedicine could be extensively implemented in
healthcare systems.
Keywords (MeSH): Telemedicine; Biomedical Technology; Medical Informatics; Health Care Economics and
Organizations
Supplementary keywords: e-Health; Technological Paradox
Information, communication
technologies and the promise of ehealth
The World Health Organization’s (WHO) ‘eHealth
Resolution’ recognised the contribution of information
and communication technologies (ICTs) to the delivery
of healthcare for the first time (WHO 2005). e-Health
was defined as a cost-effective and secure use of ICTs
to support health and health-related fields, including
healthcare services, health surveillance, health literature, and health education, knowledge and research.
Member states were urged to establish long-term
strategic plans to develop and implement e-health
and to build appropriate legal frameworks and infrastructure involving the public and private sectors. This
document provided a global strategy for e-health at the
highest level, requiring its General Director to promote
international multi-sectorial collaboration in offering
technological support to member states and facilitating
e-health integration in healthcare systems.
WHO’s interest in promoting and encouraging the
incorporation of ICTs in healthcare was shared by
other organisations. The European Union (EU)
established the ‘EU e-Health Action Plan 2004-2010’
to create the European e-Health Area (European
Union 2004), which responds to major challenges
confronting the health sector, and affirms that e-health
improves access to healthcare, boosts quality and
effectiveness of services, and provides an assurance
that, when combined with organisational change and
the development of new skills, e-health can help to
deliver better healthcare at lower cost within citizencentred healthcare delivery systems. Priorities are: (a)
to address common challenges and create the right
framework to support e-health; (b) to pilot actions to
encourage the delivery of e-health; and (c) to share
best practices and systems for measuring progress.
Six years later, the Conference Declaration about
European Co-operation on e-Health (European Union
2010) is still seeking standardisation and evaluation
of e-health with respect to health outcomes, benefits
and cost-effectiveness, including patient safety, accessibility to heath care and quality of health care. Political
will to promote and expand the use of ICTs in e-health
implementation has been fuelled by common problems
experienced by health systems in developed countries:
rising demand for healthcare and social services; an
ageing population; increasing mobility; management
of huge amounts of information; global competition;
and the need to provide the best possible healthcare
within limited budgets (European Union 2004).
Telemedicine and its normalisation
Telemedicine has pioneered ICT incorporation in the
health domain since the middle 20th Century when
distance data-transmission technologies were in use
(Bashshur, Reardon & Shannon 2000). Since then,
there has been a progressive increase in the number of
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telemedicine projects, scientific activity and research.
The Telemedicine Research Centre (Grigsby 2004)
identified 145 telemedicine-active programs, where
10 years earlier there had been only 10. Moser et al.
(2004) highlighted a consistent increase in telemedicine publications from a handful in 1990, to 100 in
1994, and over 800 in 1998. This number has been
more or less constant since then, totalling 5,911
assessments in 2003.
Despite increased activity in telemedicine and an
apparent determination to incorporate ICTs into health
systems, it continues to have only symbolic presence.
Many pilot projects and feasibility studies are started
but few telemedicine applications are incorporated
into healthcare delivery systems (Broens et al. 2007).
The general consensus is that implementation is slow
and difficult because of lack of scientific evidence to
support its effectiveness to provide either clinical or
cost benefits (Grigsby, Brega & Devore 2005). Health
Technology Assessment1 suggests that success of
telemedicine programs will be determined by clinical
results, although these are difficult to assess. Bashshur,
Shannon and Sapci (2005) concluded that with few
exceptions, research in this field has yet to produce
adequate empirical data to provide evidence for
clinical efficiency of telemedicine. Grigsby, Brega and
Devore (2005) pointed out that without rigorous, high
quality research to produce this evidence, telemedicine
will not be supported by professionals and decision
makers. Projects started and assessed are mainly
short-term or designed only for a pilot phase. Whetton
(2005) found that nearly two thirds of all communications presented to the 2004 International Conference
on Successes and Failures in Telehealth organised
by the International Society for Telemedicine and
e-Health were short-term projects. Such projects
produced only provisional results about feasibility of
technological applications and did not offer information about how they would work when they reached a
mature state. Therefore, we are facing a conundrum:
we hope that results from assessments will offer clear
advice about convenience and utility to definitively
facilitate implementation of health interventions, while
actual projects and assessments provide data based
on short-term projects and interventions only, which
change over time. This type of assessment, which can
be a useful determinant in certain health interventions, has not proved useful in ICT implementations.
Whetton (2005) pointed out that attempting to make
assessments using traditional models of health tech-
nologies assessment presents recurring difficulties.
Studies may be too descriptive, insufficiently rigorous
(e.g. too small a sample size, no control group), or
data may be inadequate to support research objectives (e.g. short-term projects with limited capacity for
analysis). Some authors have suggested that telemedicine assessment should learn from randomised clinical
trials methodology, the ‘gold standard’ in interventional studies in health technologies assessment, and
apply the same rigour in trial design, execution and
publication of results. Because of difficulties involved
in randomly assigning patients to control and interventional groups, obtaining sample sizes that are large
enough, and difficulties associated with implementing
double-blind studies (all fundamental features in
clinical trials), alternative methodologies have been
proposed, with quasi-experimental designs and the
use of administrative databases (Grigsby & Bennet
2006). Conversely, other authors have argued that
there are inherent problems with ICT assessment that
do not permit transference of traditional methodologies (Ammenwerth et al. 2003); that clinical trials are
devoted to objectively measuring effects of therapeutic
interventions and this would not be enough to ensure
that telemedicine applications achieve good outcomes.
The essential factors in the application and success
of telemedicine are strongly related to the conditions under which they are developed, as well as the
correlation between positive results from a clinical
trial and their application in the routine clinical
practice, aspects not usually considered in traditional
assessments. Some authors have proposed alternative models for assessing and evaluating complex
interventions in health care, the goal being to better
understand how new clinical techniques, technologies
and other complex interventions become normalised in
practice (May 2006; May & Finch 2009).
This situation highlights inherent difficulties in
assessing effects and results of ICT incorporation
into a specific activity. In healthcare, a sector with a
solid tradition of evaluation, relevance of these kinds
of assessments is so important that many governments create agencies to conduct specific research
and provide reports, and although not binding, these
reports are extensively used for decision-making. It is
difficult to find adequate methodological models to
undertake measurements that take into account the
peculiarities of technology beyond traditional health
interventions and include different activities; at times
with few characteristics in common.
1
A new version of an old problem
10
Health Technology Assessment is a multi-disciplinary field of policy analysis
that examines the medical, economic, social and ethical implications of the
incremental value, diffusion and use of a medical technology in healthcare
(see: http://inahta.episerverhotell.net/HTA/)
Is this so new and strange? Not really. In the business
world, in the late 1980s/early 1990s, investment in
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ICT was widely assumed to have enormous potential
to reduce costs and improve competition. However,
research did not show a relationship between ICT
investment and increased productivity. This was
referred to as the ‘technological paradox’, and it
generated alarm and discussion between researchers
and top managers (Brynjolfsson & Hitt 1996). The
technological paradox had its empirical origin in
the US in the 1970s, when it was observed that an
incremental investment in ICT did not translate into
a proportionate increase in productivity, especially in
the services sector. In fact, there was an unexplained
residual decrease in productivity when compared
with the first half of the post-war period, not only at
company level but also at the global economic level.
Moreover, this decrease coincided with the rapid
increase in ICT use. That reality brought prestigious
economists such as Nobel Prize winner Robert Solow
to affirm: ‘We see computers everywhere except in
productivity statistics’ (Solow 1987: 36). The idea
of a technological paradox was further reinforced by
studies in 1990s, which aimed to show a correlation
between ICT spending and productivity, but found no
positive correlation between these variables or that
their benefits outweighed costs (Yorukoglu 1998).
Most studies showed that ICT investment did not
create a significant increase in productivity or they
actually reduced it (Oz 2005); that residual return of
investment in ICT was lower than the residual return
of more conventional investments (Yorukoglu 1998).
It appeared that productivity vanishes in one of the
fastest and most comprehensive technological revolutions of human history (Castells 2000).
Research highlighted three key facts that lead to an
understanding of what was happening (Brynjolfsson &
Hitt 1996, 2000; Brynjolfsson 1998):
1. Methodological deficiencies and difficulties in
accessing the right data led to output not being
measured in the right manner. Traditional ways
of evaluating the relationship between inputs and
outputs failed to take into account non-traditional
sources of value.
2. There was a considerable time lag before it was
possible to observe and empirically measure
increases in productivity due to ICT incorporation
and diffusion in economic activities. It takes time
for changes in business processes to reveal ICT
benefits.
3. A significant component of ICT value was its
capacity to initiate organisational transformation
processes that drive change in business processes
and models. Thus, incorporation of ICT would not
produce an automatic increase of productivity but
it would be an essential component of a broader
system of organisational changes that would in turn
increase productivity.
Organisational transformations, the
key element
How can these key facts be applied to telemedicine
implementation and normalisation? Over the last
few years, a similar analytical approach has been
applied to ICT introduction in healthcare organisations, with studies devoted to identifying and assessing
organisational transformations brought about by
these technologies (Nicolini 2006; May et al. 2003;
Harrison, MacFarlane & Wallace 2002; Gagnon et al.
2004). Some of these studies address the issue from
a social perspective, with the basic assumption that
scientific knowledge and technologies evolve in a
concrete context. Here, the technological features of
the design or application and its outcomes can modify
implementation and acceptance, but whether it is
then used or ‘dropped’ is determined by the social
context in which the technology is implemented. This
approach casts doubt on the argument that the low
level of telemedicine implementation is due to lack of
sufficient scientific evidence. Instead, it suggests that
the real results will be achieved by interaction between
social, organisational and technological factors.
May et al. (2003), in a retrospective qualitative study of data from several telemedicine projects
obtained from 11 different locations in the UK,
concluded that the relatively poor telemedicine
implementation could be a consequence of a naive
development model, as far as it assumes that the
incorporation of telemedicine is a linear and rational
process, where high quality research will lead to a
quick acceptance of innovation and to its integration to
clinical practice. They proposed an alternative integral
model that defines five requirements for a project in
order for it to be adopted: implementation; adoption;
translation; stabilisation; and normalisation, the latter
being conditional on the previous four. Nicolini (2006)
studied four Italian telemedicine projects that ran
actively for a minimum of two years, with an aim to
understand the nature of organisational innovation
with the adoption of telemedicine, the characteristics
of using technologies, and the effects on traditional
medical practices. The author concluded that telemedicine creates significant changes in work processes,
and that these changes affect the material conditions
and professional relationships of clinicians in their
practices. From this analytical perspective, Broens et
al. (2007) proposed a layered implementation model
that changes focus from initial technological aspects to
organisational aspects as a project matures. From this
perspective, implementation of telemedicine processes
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requires a visionary approach, going beyond the traditional indicators used for assessments.
Conclusion
From what we have learnt about ICT incorporation
in the business world, it seems that implementation
of telemedicine in healthcare organisations requires
a different approach from that of traditional health
technologies. Difficulties in incorporating telemedicine
into clinical practice confirms that ICTs are not just an
instrument to automate or improve processes already
in place; they play a far more important role as facilitators of organisational changes, and these changes
will be the key factors that drive the full accomplishment of what telemedicine promises in relation to
equality, sustainability and quality. Therefore, a more
holistic approach is needed alongside a strategy that
keeps the particularities of ICT technologies in mind,
which changes the focus from production of evaluative evidence to consideration of the transformational
properties of ICT technologies and the organisational
processes linked to them. The authors argue that the
redesign of healthcare systems is not just something
that needs to be done to facilitate implementation of
ICT technologies and e-health; it is the critical factor
that will determine whether or not ICT technologies
and e-health succeed.
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Francesc Roig MSc
PhD Candidate, Health Sciences-Telemedicine Program
Universitat Oberta Catalunya (UOC)
Roc Boronat 117, 08017 Barcelona, Spain
email: [email protected]
Francesc Saigí PhD
Telemedicine Program Director, Health Sciences
Universitat Oberta Catalunya (UOC)
Roc Boronat 117, 08017 Barcelona, Spain
email: [email protected]
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