Understanding Telemedicine: Reflections on a Danish Attempt to Introduce a Videoconference Service Between Two Hospitals

Understanding Telemedicine: Reflections on a Danish attempt to introduce a videoconference service between two hospitals

Arjen P. Stoop, MA, PhD Finn Kensing, MA, PhD

1. Introduction

Notwithstanding the successes of telemedicine within for example radiology, cardiology or dermatology, there is a big discrepancy between the promises in published papers and conferences regarding telemedicine and the status of telemedicine applications in practice [1-3]. The ‘track record’ of telemedicine, in other words, is not too good. How can this discrepancy be explained? Are the promises of telemedicine unrealistic, are the users unwilling, or are daily health care practices too complex for telemedicine to become successful?

In this paper we reflect on these questions based upon a literature study and upon preliminary findings from a telemedicine project that is still going on in

Denmark between The University Hospital in Copenhagen (Rigshospitalet) and

Bornholms Hospital. Bornholm is an island close to Sweden that is a part of Denmark.

We compare the reasons for the limited use of telemedicine often mentioned in the literature with our experiences and data from the project. We especially react to the assumption that the use of telemedicine itself is unproblematic and that implementation of telemedicine is hampered by ‘external’ circumstances like willingness of politicians to invest money or knowledge and willingness of users. We show that by focusing on such external circumstances as the reasons for the limited success of telemedicine - without reflecting on the necessary conditions for the fruitful implementation and use of

1 telemedicine – the successful development of telemedicine services is hindered instead of stimulated.

1.1 The telemedicine context between The University Hospital and the outer regions

The University Hospital in Copenhagen, with 1100 beds and about 7500 employees, is a tertiary hospital that delivers highly specialized care to patients within Denmark, including the Island of Bornholm, Greenland and the Faro Islands. The political constellation between Denmark and Greenland and the Faro Islands is special:

Greenland and the Faro Islands are self-governed which means that they for example are responsible for their education system and social welfare. Other parts of the political system, i.e. defense and foreign politics are taken care of together.

Regarding health care there has always been a close collaboration between these two outer regions and The University Hospital. The University Hospital has for example two coordinators especially dedicated to visiting patients and their relatives from these two countries. In addition, there is a patient hotel that gives patients the opportunity to stay very close at The University Hospital without the need to stay at a hotel (for example when their investigations take place on separate days). The amount of patients that visit The University Hospital from these outer regions is considerable. In

2006, for example, 4060 patients visited The University Hospital: 2531 from the Island of Bornholm, 599 from Greenland and 930 from the Faro Islands. To give an impression of the distances patients have to travel to get to The University Hospital: the island of Bornholm is about 35 minutes by plain, the Faro islands are about three hours from Copenhagen by plain and Greenland is about four hours by plain.

2 Besides the distance to Copenhagen, these outer regions are hardly comparable with Denmark looking at for example size, culture and psychological

‘closeness’ to Denmark. Greenland, for example, is many times the size of Bornholm and the Faro Islands. Even though it is more close to Sweden than Denmark, Bornholm is considered to be just as Danish as the other parts of the country, in contrary to

Greenland and the Faro Islands. On Greenland and the Faro Islands, for example,

Danish is the second language. Despite these differences, the amount of inhabitants

(between 40.000-50.000) and the circumstances under which the local hospitals in these outer regions and The University Hospital work together, are partly comparable. First, the hospitals in these outer regions are relatively ‘unspecialized’ compared to The

University Hospital. Several medical specialties are not represented (especially on

Greenland and Bornholm), partially caused by problems of recruiting personnel but also because of the Danish governments’ decisions on what patients are allowed to be treated where and how. Cancer patients, for example, are not allowed to be operated or radiated on the island of Bornholm. The problem of a lack of specialization is partially solved by sending consulting physicians from Denmark to these outer regions on a regular basis.

Second, because of the relatively low degree of specialization, the distance to

Copenhagen, and the considerable amount of patients that are sent to the University

Hospital there is increasing pressure on the potential use of telemedicine.

The above-mentioned contextual characteristics have lead to many telemedicine projects between The University hospital and these outer regions (we will not go into the use of telemedicine between The University Hospital and other Danish hospitals on the shore). Between The University Hospital and the island of Bornholm, for example, it is because of telemedicine that diabetes patients do not have to travel to

3 Copenhagen for routine controls of their eyes. In addition, two trauma systems using a special camera are installed on Bornholms Hospital (for eye investigations and for teeth investigations) that make it possible to send pictures to the first aid department of The

University Hospital. Between The University Hospital and the Faro Islands and

Greenland, for example, PACS is used to transmit pictures. As often with telemedicine systems, very few are anchored in the daily practices (for example the use of PACS and the fundus camera to diabetes patients), many other systems are installed but hardly or never used, or uninstalled again after a while.

1.2 Background of this study

In this study, the primary focus has been on exploring the potentials of more telemedicine ‘traffic’ between The University Hospital and Bornholms Hospital. In case of successful implementation the project was meant to investigate the telemedicine potentials on the Faro islands and Greenland in the same way. More specifically, the management of The University Hospital and the management of Bornholms Hospital decided in 2005 to explore the possibilities of using a videoconference system. The videoconference system was meant to supplement or replace existing ambulatory routine control visits (in which there is no need of physical contact) at The University

Hospital. The system would make it possible for patients to go to their local hospital, instead of traveling to Copenhagen. A local doctor was meant to be present during the consultation. The assumption was that the system would save a considerable amount of expenses for transport and that especially patients and perhaps doctors at both ends

(Bornholms Hospital and The University Hospital) would be interested. Patients would not have to travel to Copenhagen any more and the local doctors would get the

4 opportunity to work together more closely with their ‘expert’ colleagues and by doing this, enhance their knowledge. The assumption that it was in patients’ interests to implement a videoconference system was seen as crucial and was based on the impression that relatively many patients traveled to Copenhagen only for a blood sample or a five-minute conversation with their doctor and were dissatisfied with that.

The use of a videoconference system to replace the existing time consuming and costly way of consultations, therefore, seemed to offer a good solution for these visits.

2. Methods

A review of the literature was carried out. Further, we used both qualitative and quantitative methods for the empirical study. We gathered data by studying the Hospital

Information System in order to find the number of patients from the island of Bornholm visiting The University Hospital, for how long and what the reason was for their visit. In addition, we held two workshops to find out whether there was a clear need to use telemedicine: One for both medical specialists and managers and one for the medical specialists only. Furthermore, we talked to management, health care professionals and patients at both hospitals individually. We asked management and health care professionals whether they could see any potential in telemedicine and if so, for which

(groups of) patients and whether they were interested in a pilot project. We asked patients whether they were of the opinion that traveling to The University Hospital was cumbersome and whether they would prefer to go to their local hospital, if they could see and talk to their consulting physician using telemedicine. Finally, on the basis of these qualitative data, we made a questionnaire that we sent to all the patients from

Bornholm that visited the The University Hospital during the period 01/11-2006 until

5 15/12-06. We asked them about their experiences of traveling to the University

Hospital, their experiences with the treatment, whether they preferred the University

Hospital or their local hospital, and whether they could imagine talking to their consulting physician by using a camera and a microphone. Because of the argument we want to make in this paper and because the data from the questionnaire have not yet been fully analyzed, our argument will be based on the analyses of the Hospital

Information System and the workshops and interviews with health care professionals and managers.

It should be mentioned that the authors each played a role in the project analyzed here. The first author was the project manager, while the second author took part in formulating the application that led to the financing of the project, and subsequently was a member of the steering committee.

3. Results

First, we present often mentioned promises as described in the literature. Then we present findings from an analysis of the initial phase of our telemedicine project applying an analytical framework presented by one of the reviewed papers.

3.1 Promises and problems of telemedicine documented in the scientific literature

Within the literature, symposia and congresses around the world, telemedicine is seen as key in solving many (potential) current and future problems in health care.

Telemedicine should make it possible to ’survive’ in the modern world by solving problems as shortage of personnel, reducing expenditures, equitable access to specialized clinical expertise, distribution of knowledge and teaching on locations that

6 are hard to reach [4]. In addition, telemedicine is seen as a way to solve healthcare’s growing problems like aging, the increasing amount of chronically ill, and the trend to centralize highly specialized units. The county of Fynen in Denmark, for example, has been very active in designing and implementing telemedicine throughout the years. A report published in December 2006 stresses that: ‘There are no hindrances left of technical, technological or digital character. It is about finding the necessary financial resources and to make sure that healthcare professionals in the hospitals and policy makers on a local level see the potential of telemedicine and act according to it.’

(Translated from Danish) [5]. Other authors focus more on the kinds of services telemedicine can offer: ‘… it is no longer a serious barrier for remote patients to receive prompt specialist medical care nearer to home, including certain surgical procedures.

Indeed, information technology now enables providers and patients to interact with each other and to gain instant access to a wealth of information to facilitate the delivery of quality health care in a cost-effective manner.’ [6]. Importantly, the explicit claim is made here that telemedicine is able to solve many care problems that can be found in current health care systems: distance, timeliness, communication, access to information, quality and costs.

How come telemedicine is used in so few cases as it is currently, if the potentials are so big? Importantly, as also other authors have concluded, there seems a clear publication bias within the field [7]. As with IT systems in general, seldom one finds publications in which a clear and thorough analysis is given about a telemedicine application that turned out to be a failure, though it is well known that many systems fail in practice [3,

8, 9]. In the international literature, several explicit and implicit external ‘brake blocks’

7 are seen as the core reasons for the limited use of telemedicine in practice. In the above- mentioned report of the county of Fynen, for example, the message is clear: the

‘hindrances’ the authors mention, are related to the willingness of the users to take notice of all the possibilities telemedicine offers and to act upon them. In addition, those that are able to facilitate the users (the policy makers on a local level) should take their responsibility more seriously. Furthermore, in an analysis of unsuccessful teleconsultations [10], Krupinski et al. conclude that 43% of the unsuccessful consultations at one of the sites were attributable to patient factors, such as failing to attend the appointment. Better communication, possibly in the form of explicit and frequent reminders, may improve patient take-up of telemedicine, according to these authors. The reasons why patients do not show up and whether this is caused by the patient’s dissatisfaction with the system, remains unclear. Finally, by referring to

Mitchell et al. [11], Larcher et al. conclude that ‘ … the many benefits of telemedicine will be realized only if the technology can be easily integrated into existing work practices.’ [12].

Even though we do agree that this is a condition sine qua non for successful telemedicine, the main point we want to make here is that in most of the literature telemedicine as a concept is not elaborated upon. This holds for the unproblematic representations of telemedicine as well as for the often-superficial explanations of the limited use of telemedicine. That is, the necessary conditions for successful use and the underlying assumptions are not explicated - let alone discussed.

8 3.2 The ‘concept’ Telemedicine

The focus on the user and the environment (e.g. relevant decision makers, politicians) in explaining failure in the field of telemedicine is not new. In fact, Diane Forsythe described this problem within medical informatics already in 1992. She focused on knowledge-based Artificial Intelligence systems. From a designer perspective, the problem of the ‘unwilling’ user is described as the problem of ‘user-acceptance’ and

‘end-user failure’. Forsythe stressed however that systems are not being accepted because they do not meet the needs of users caused by the way in which problem formulation, system design, system building and evaluation are understood and carried out in medical informatics [13]. Blaming the user, in other words, does not make sense.

Within the field of telemedicine however, very few authors have elaborated on the character of telemedicine services. May et al. describe several general conditions as mandatory for a system to stabilize and than normalize as a means of service delivery. The authors describe for example how important it is to have a link with a policy agency to sponsor the implementation effectively and to make sure that structural legitimation takes place [14]. Lehoux et al. specifically describe the theory of use behind telemedicine, i.e. its rationale and the manner in which physicians are expected to use it in their daily activities [4]. Looking at our preliminary data, exactly this focus can help us explain our findings. In short, the authors conclude three problems that are specifically related to the way telemedicine, often implicitly, is presented.

First , telemedicine is often presented as a solution, without taking a precise evaluation in consideration of the type and number of cases for which remote advice is sufficient to solve a patient’s health problem, given the available resources in a

9 local hospital. On the one hand, the technology relies on the idea that the remote physician is isolated, less competent and confronted with complex cases s/he cannot handle. While on the other hand it is expected that technical (specialized investigative techniques, like MR) and personnel (specially trained technicians and nurses) resources are available to deal with these cases by using telemedicine. Both assumptions are often not valid in practice.

Second , the theory of use overestimates the extent to which physicians need telemedicine, and underestimates the social rules that shape clinical practices and referral strategies. That is, in practice it is hard to find physicians that feel a strong need to use telemedicine. The ‘need‘ for telemedicine has, as some have concluded, been too much ‘technology driven’, instead of ‘clinically pulled’ [15]. Instead of the clinicians’ needs, the technological promises are taken as a starting point. Ignoring the clinicians’ needs, however, is a recipe for failure [3]. In addition, the use of telemedicine changes existing referral routines and poses new questions regarding for example delegation of responsibilities and rules for the management of differing clinical opinions. These kinds of changes, as many IT projects in health care have shown, are crucial for its success.

Not paying explicit attention to these changes, consequently, is to deny an essential part of clinicians’ work and therefore doomed to fail.

Third , the theory of use behind telemedicine appears to underestimate the wish and need for physicians to investigate the patient instead of using a human intermediary. The reason for this preference is that dealing with one’s own subjectivity is seen as acceptable, valued and unavoidable, but relying on someone else’ subjectivity may create anxiety in a clinician. This clarifies why the utilization of telemedicine is problematic in most specialties, except radiology, dermatology and (some parts of)

10 cardiology since these specialties rely on transmitting images and objective data. In other words, the authors conclude that the (implicit - since it is seldom explicated) rationale behind the use of telemedicine is highly problematic in daily practice.

3.3 Analysis of the initial phase of our telemedicine project

Here we apply the theory of use as presented above to the initial phase of the telemedicine project between The University Hospital of Copenhagen and Bornholms

Hospital. When we reflect on the theory of use, what do we see? Can the theory of use explain the data and experiences we have gathered until now? We analyze our preliminary data to reflect on the three main problems as described within the theory of use. We show how important it is to work with a sufficient ‘fit’ between the rationale of a telemedicine initiative and the manner in which physicians are expected to use it at the remote site (Bornholms Hospital) and especially at the ‘hub’ site (The University

Hospital).

Problem one: Type and number of cases

Problem one of the theory of use refers to one of the problems we had in our project; how to select a suitable patient group? We started to discuss the possibilities of using telemedicine between Bornholms Hospital and The University Hospital with several of the clinicians on the island of Bornholm. Even though we had intense contact and some of them were very enthusiastic about the idea of using more telemedicine between the two hospitals, they could not point at a suitable patient group from their point of view

(for example because the volume was too little). Analyzing the data from the Hospital

Information System showed, in addition, that the patients that visit The University

11 Hospital often need a special kind of treatment or follow-up. There appeared to be relatively few patients that traveled to The University Hospital without the need for something special – apart from an oral consultation with their doctor. The main problem is, clearly, that if there is not enough volume of patients, it is almost impossible to expect that the telemedicine service can become a success. Firstly, when there is a low volume of patients, the ‘business case’ of the telemedicine service is hard to make. Low numbers of patients mean that the advantages (for example reduction of traveling costs) do not outweigh the investments (buying equipment, educating personnel, maintenance etc.). The importance of this issue is illustrated by the increasing amount of papers that stress the need for valid cost-effectiveness analyses [16-20]. Secondly, and from the clinician’s perspective more important, with a low volume of patients it becomes hard to incorporate the new ways of working in daily practice. A relevant organizational issue is for example how to create and fill time slots for using the telemedicine service

(especially in real-time situations where both ends need to be available at the same time) if there are not enough patients to incorporate the service in a structural way [14]. In addition, a low volume of patients generates the problem of not getting enough routine in using the equipment which in practice leads to hesitations of using it.

Problem two: Overestimation of the extent to which physicians need telemedicine

Problem two is clearly recognizable in our project. The initiators of the project assumed that especially oncology doctors would be interested in using a videoconference system.

Cancer patients that are under regular supervision would in that case only have to travel to their local hospital on Bornholm where they would have the possibility to talk to their physician at The University Hospital using a videoconference system. This assumption

12 was based on both informal contacts with the doctors at both hospitals as well as on a rough analysis of the HIS. From the HIS it appeared that cancer patients are clearly the biggest group of patients that travel to The University Hospital. Moreover, the initiators’ impression was that a relatively large part of this patient group traveled to

The University Hospital only to talk to their medical specialist, without physical investigations. Finally, Bornholms Hospital argued that they received complaints of patients that could not understand why they had to travel to The University Hospital for only a conversation without physical examinations.

When the project started, however, these assumptions appeared problematic. First, the doctors at the University Hospital claimed that patients in this patient group are too ill and probably will not feel comfortable with using a videoconference system. These patients need ‘intimacy’ that is impossible to generate by applying a videoconference system according to the doctors. Second, the cancer doctors at The University Hospital explained that they often have long, intensive conversations with these patients that are hard to imagine by using a videoconference system. It is clear that problem two of the theory of use is applicable in this situation: the cancer doctors – justified or not – did not feel the need of using a videoconference system for this patient group, despite the potentials from a technical and organizational point of view.

Problem three: The wish and need for physicians to investigate the patient instead of using a human intermediary

The third problem of the theory of use was also highly recognizable in our study. The cancer doctors stressed that it – from a professional point of view – was impossible and

13 irresponsible to replace their ‘live’ contact with patients by using a videoconference system. The reason for this is that many patients had to be examined physically and that it is crucial that this is done by the same doctor . Another doctor, as they claimed, cannot detect small changes in for example the size or shape of a tumor. Just as pointed out by

Lehoux et al, the doctors we tried to recruit to our project perceived dealing with their own subjectivity as acceptable, valued and unavoidable, but did not feel comfortable with relying on someone else’ subjectivity. Even though, as is the case in our project, these colleagues considered each other as highly respected and trustworthy.

Summarizing, the fit between a relevant patient group, enthusiastic doctors at both ends and a sound ‘business case’, appeared to be absent in the first phase of our project. What can we conclude from our results? First, we can conclude that the often-mentioned reasons for failure of telemedicine services as described above (‘external hindrances’ in terms of unwilling users and unknowing politicians) are at best only partially valid. The cancer doctors’ arguments were strongly comparable with the problematic assumptions regarding telemedicine as described by Lehoux et al. Second, we can conclude that the project group – despite the initial plans – has been in time to change the course of the project: no equipment has been purchased yet, no patients have been included yet etc.

The price, however, has been that several months of our time was used to meet with the project group and steering group and work on a Project Initiation Plan that never was fully executed and had to be rewritten. Consequently, a lot of energy was lost, which caused some members of the project group to become more skeptical about the relevance of spending time on the telemedicine project. Even though the project group

14 has been in time to change course – there are enough resources left – this has been an

‘expensive’ learning experience.

4. Discussion

On the basis of an analysis of our telemedicine project and supported by the literature, we claim that depicting telemedicine as unproblematic as it is often done, is problematic in three ways. First, the fact that the concept telemedicine often is not specified in terms of type of system, type of service or relevant patient groups, makes it almost impossible to discuss the precise pros and cons of the different telemedicine services. While for example tele-radiology, tele-dermatology and tele-cardiology are relatively unproblematic, the benefits of videoconference systems vis-à-vis face to face consultations, have yet not proven to offer surplus value [21].

Second, by depicting telemedicine as unproblematic and merely a matter of willingness of politicians and users, one is underestimating the complexity of the implementation of these systems. Implementing telemedicine involves a lot of

(practical) questions like finding and defining a suitable patient group, sufficient volume, personnel resources (e.g. amount, qualifications, continuity) etc.

Underestimating these elements clearly enhances the chance of a telemedicine project to become a failure. And failure has many consequences: Money is wasted, employee and management become disappointed and unwilling to try out new initiatives for quite a while and – on a more general level - budgets for further development of telemedicine might be in danger. The literature shows how far-reaching the consequences of failed IT systems can be. In a study about the implementation of a Computerized Physician Order

Entry (CPOE) system in Holland for example, the management of the hospital decided

15 to stop the implementation and abandoned the system after nine years of unsuccessful implementation. After this decision, the management of the hospital decided not to invest in IT at all for the next coming years [22]. Unfortunately, these examples are not unique. The problematic character of the development and implementation of Electronic

Patient Records (EPR) and its consequences, another example, is seen in many countries. Even though telemedicine projects are often not as big as many other IT projects (like CPOE or EPR implementations), the political pressure and available resources are in general also less, so the consequences are comparable.

The final problem of depicting telemedicine as unproblematic is that one misses the chance of learning from the implementation process that – as is shown in practice – practically always is cumbersome. When telemedicine as a starting point is seen as unproblematic, the consequence is that there is no focus on all the small iterative, incremental steps that are crucial for successful implementation. Aiming at big changes as often is done now, almost makes it impossible to celebrate small, but crucial improvements. As is known from the quality improvement literature, in many circumstances the most powerful way to make changes in current practices is to conduct small, local tests-Plan-Do-Study-Act (PDSA) cycles-in which one learns from taking action. The telemedicine literature, however, is dominated by outcomes or summative studies that often say little about how particular outcomes are achieved [14]. For many system improvements, PDSA cycles are more appropriate and informative than either formal studies with experimental designs (such as randomized trials) or the mere implementation of changes without reflection on the necessary conditions or evaluative measurement [23]. In practice this means for example that it is wise to focus on those health care professionals that are willing to try out new telemedicine initiatives, with a

16 few patients. Doing a small scale local test can give you insight in the eligibility of the equipment, the type of patient, the conditions for improvement etc. Of course, one could say that depicting the use of telemedicine as unproblematic does not exclude the awareness of the importance of learning in detail from the implementation. In practice, however, this combination is hardly seen. This is not to say that one should not be ambitious regarding the (future) use of telemedicine, on the contrary. Some forms of telemedicine have proven to be that successful that they are sometimes not even considered telemedicine any more (e.g. the use of PACS).

So who can use the results of our study? Our results are especially relevant for those that are considering introducing a telemedicine service. First, we advice to do a thorough comparison of the current non-telemedicine situation and the potential telemedicine situation. Which possible benefits can be obtained by the telemedicine service and by whom? Are there eligible patient groups and if so, how big are they?

What successful examples can be found in the literature? And even more important, are those that are in favor of the potential telemedicine service the actual users - the clinicians and the patients - or is the interest in the system of a managerial kind? The latter has been the case in our project and has clearly proven to be problematic. From an organizational point of view, second, it is most valuable to learn from attempts to change current practices in order to generate a better understanding of the functioning of the organization. In order to do this, it is important to be realistic about ones ambitions.

The more unrealistic ones ambitions are, the bigger the chance is that the telemedicine service will become a failure and the smaller the possibility is to learn from small steps in the desired direction. Looking at the current literature in telemedicine, one has to conclude that modesty should be key in ones ambitions. Again, that is not to say that for

17 example the management of the hospital should not have ambitions regarding telemedicine, but we stress that it is important to have a realistic vision and strategy to realize those ambitions. The promises expressed by the proponents of telemedicine, we conclude, have to be treated very cautiously in that process.

Aknowledgements

This project is made possible by a grant from The National Board of Health. The authors would like to thank Karen Marie Lyng from the IT University and Ole Bergsten and Malene Mols from The University Hospital for their comments on this paper.

18 References

1. Brown, N.A., Information on telemedicine. J. Telemed. Telecare 11 (2005) 117- 26. 2. Grigsby, J., et al., Chapter 7: The Diffusion of Telemedicine. Telemed. J. e- Health 8 (2002) 79-94. 3. Wooton, R., J. Craig, and V. Patterson, eds. Introduction to telemedicine. Second edition. Royal Society of Medicine Press Ltd: London, 2006. 4. Lehoux, P., et al., The theory of use behind telemedicine: how compatible with physicians' clinical routines. Soc. Science Medicine 54 (2002) 889-904. 5. Sundheds-telematik, C.f., Fynsk telemedicinsatsning 2004-2006 - det kom der ud af (The telemedicin-effort on the island of Fynen 2004-2006 - these are the results). 2006. 6. Heinzelmann, P.J., et al., Clinical Outcomes Associated with Telemedicine/Telehealth. Telemed. J. e-Health 11 (2205) 329-347. 7. Bensink, M., D. Hailey, and R. Wooton, A systematic review of successes and failures in home telehealth: preliminary results. J. Telemed. Telecare 12 (Suppl. 3) (2006) 8-16. 8. Stoop, A.P., A. Van't Riet, and M. Berg, Using IT for Patient Education: Realizing surplus value? Pat. Educ. Couns 54 (2004) 187-195. 9. Stoop, A.P., R. Bal, and M. Berg, OZIS and the politics of safety: Using ICT to create a regionally accessible patient medication record. Int. J. Med. Inform. (76S) (2007) 229-235. 10. Krupinski, E.A., et al., An analysis of unsuccessful teleconsultations. J. Telemed. Telecare 10 (2004) 6-10. 11. Mitchell, B.R., J.G. Mitchell, and A.P.S. Disney, User adoption issues in renal telemedicine. J. Telemed. Telecare 2 (1996) 81-86. 12. Larcher, B., et al., An evaluation of the use of and user satisfaction with a teleconsultation system in oncology practice. J. Telemed. Telecare 8 (Suppl. 2) (2002) 28-30. 13. Forsythe, D.E., Blaming the user in medical informatics: The cultural nature of scientific practice. Knowl. and Soc. 9 (1992) 95-111. 14. May, C., et al., Why do telemedicine systems fail to normalize as stable models of service delivery? J. Telemed. Telecare 9 (Suppl. 1) (2003) 25-6. 15. Wyatt, J., Commentary: Telemedicine trials-clinical pul or technology push? BMJ 313 (1996) 1380-1381. 16. Sicotte, C., et al., A cost-effectiveness analysis of interactive paedriatic telecardiology. J. Telemed. Telecare 10 (2004) 78-83. 17. Hailey, D., The need for cost-effectiveness studies in telemedicine. J. Telemed. Telecare 11 (2005) 379-83. 18. Doolitttle, G.C., et al., A cost analysis of a tele-oncology practice in the United States. J. Telemed. Telecare 10 (Suppl. 1) (2004) 27-29. 19. Mair, F.S., A. Haycox, and T. Williams, A review of telemedicine cost- effectiviness studies. J. Telemed. Telecare 6 (Suppl. 1) (2000) 38-40. 20. McCue, M.J. and S.E. Palsbo, Making the Business Case for Telemedicine: An Interactive Spreadsheet. Telemed. J. e-Health 12 (2006) 99-106.

19 21. Currell, R., et al., Telemedicine versus face to face patient care: effects on professional practice and health care outcomes (Review). The Cochrane Collaboration, 2006. 22. Aarts, J.E.C.M., Understanding implementation: a sociotechnical appraisal of the introduction of computerized physician order entry systems in Dutch and American hospitals, iBMG. Doctoral thesis Erasmus University Rotterdam: Rotterdam, 2005. 23. Berwick, D.M., Developing and Testing Changes in Delivery of Care. Ann. Intern. Med. 128 (1998) 651-656.

20 What was known: • The promises of telemedicine, according to the proponents of telemedicine, are big. • Telemedicine services in which images and objective data are transmitted are much more successful than for example videoconference services that involve real-time contact with patients.

What is new: • The ‘Theory of use’ behind telemedicine can explain the problematic character of implementation and anchoring of telemedicine services. • Failure of telemedicine implementations have potentially many consequences: money is wasted, employee and management become disappointed and unwilling to try out new initiatives for quite a while and – on a more general level – budgets for further development of telemedicine might be in danger. • The promises expressed by the proponents of telemedicine have to be treated cautiously.