"Slow and steady wins the race" : a case study on infrastructural development of telemedicine services at Dhulikhel Hospital, Nepal

The use of ICT in the medical field has given rise to a new dimension so called telemedicine. Telemedicine is not a new concept, but the level of use differs between the developed and the developing countries, because of the limited infrastructural development and high expenses of technology in the later case. Though it is certain that using ICT in healthcare will improve health status of the nation, answers to the questions like which technology to choose; and what strategy to follow in order to achieve maximum benefit from minimum investment is still under consideration for developing countries. This study was carried out at Dhulikhel Hospital to explore the infrastructural development of telemedicine, its usage, benefits and users’ perspectives on the stability and sustainability of the services in future with context to hospitals in Nepal. A qualitative method with interpretive research approach was chosen for the study using informal discussions, observation and semi-structured interviews with open-ended questionnaires as data collection tools. The empirical findings have been generalized via Information Infrastructure (II) and Actor Network Theory (ANT) as theoretical framework. The findings from the study indicate that telemedicine is not simply technology; rather it is teamwork which requires good relationship between the users and good understanding of the setup. Furthermore, the study concludes that even a simple technology if implemented with proper vision and strategy can save many lives, and sustainability with telemedicine for developing countries can be achieved through slow and steady progression. Key words: Telemedicine, Nepal, sustainability, strategy, slow and steady progression

Implementing Open Network Technologies in Complex Work Practices: A Case from Telemedicine

New non-desktop technologies may turn out to be of a more open and generic nature than traditional information technologies. These technologies consequently pose novel challenges to systems development practice, as the design, implementation, and use of these technologies will be different. This paper presents empirical material from a project where multimedia technology was introduced into a complex medical work practice (surgery). The implementation process is analyzed at the micro-level and the process is found to be highly complex, emergent, and continuous. Using actor-network theory, we argue that conceptualizing the process as cultivating the hybrid collectif of humans and non-humans, technologies and non-technologies (Callon and Law 1995) is a suitable and useful approach. This concept may capture the open-ended and emergent nature of the process and indicate the suitability of an evolutionary approach

(Dis)abling Effects of Technology Use and Socio-material Practices

This paper reports on observations and discussions conducted through a weekly technology support service at a residential care facility for senior citizens. The intention with the fieldwork was to get a better understanding of the knowledge and relations seniors, living in smart homes, have with modern digital technologies. The findings are presented in the form of two vignettes and analysed through the lens of actor-network theory. The analysis shows how the use of technology is immersed in a web of socio-technical relations. It also shows that these relations contribute to dynamically enable or disable actors in a variety of ways. The contribution of this work is to give some reflections on how socio-technical structures affect the character of ability and disability, and the implications this has for the design of welfare technology

Mutual Shaping of Tele-Healthcare Practice: Exploring Community Perspectives on Telehealth Technologies in Northern and Indigenous Contexts

In Canada, northern and Indigenous communities face well documented challenges to accessing healthcare services prompting the urgent need to adopt alternative and innovative solutions to overcome barriers of limited access due to geographic distance, physician shortages, limited resources, and high cost of service delivery. Telehealth – the means of delivering health care services and information across distance – promises to augment services to address some of these barriers and has been increasingly relied upon to bridge healthcare service gaps. Despite the promise of telehealth, notable utilization barriers and structural constraints remain that challenge long-term sustainability. Little is known about how well these technologies work from community telehealth users’ perspectives. Current work in the area has tended to focus on the increased efficiency and cost effectiveness of telehealth in facilitating healthcare services, with less focus on users’ perspectives obscuring the important roles played by users and technologies. In sum, more work needs to be done to present a complete picture of users’ experiences and community needs – a gap this dissertation aims to tackle. In doing so, this research captures a snapshot of community perspectives from four Northern Saskatchewan communities, drawing attention to users’ experiences in relation to the social and technical factors shaping telehealth use. Working in partnership with the communities of Hatchet Lake Denesuline First Nation, the Northern Villages of Île-à-la-Crosse and Pinehouse Lake, and the Town of La Ronge, and external stakeholders/knowledge users working directly with these communities, this work resulted in valuable insights into the user-technology interface. Emerging from community concerns with accessing healthcare services and education/training, the goal of this project was to better understand strengths and barriers for telehealth use. Methodologically, the personal accounts and lived experiences of telehealth users were explored using qualitative methods grounded in Community-Based Participatory Research (CBPR) and decolonizing methodologies utilizing Constructivist Grounded Theory (CGT) that is drawn from interpretive-constructivist epistemological frameworks. In-depth, semi-structured qualitative interviews/focus groups with 24 telehealth users, field notes and general observations provided the basis for data collection, and NVivo 12 was used to organize, iteratively code and analyze community insights. Thematic analysis and socio-technical mapping explored themes across community contexts and provided understanding of the interrelationship of shared and unique insights whereby community telehealth users’ voices guided interpretations. This dissertation highlights the importance of community collaborations and identifies the strengths and barriers for utilizing telehealth within northern and Indigenous contexts. Using theoretical frameworks drawn from Science and Technology Studies (STS), this dissertation makes the argument that users and technologies play significant roles in shaping tele-healthcare practice – a mutually co-constitutive relationship embedded within larger socio-structural systems that pose varying constraints. Analysis revealed that users and technologies mutually shape tele-healthcare practices and care experiences – i.e. technologies shape patients’ and local/remote providers’ use of the system in enabling/constraining ways and users shape technologies through reconfiguration or “tinkering”. A mutual shaping approach following the relational/performative view of socio-technical agency serves as a pathway for examining socio-cultural factors shaping how technologies are designed, implemented, and used, and alternatively how technologies shape practice and meanings of socio-technical spaces. Further, it is argued that understanding the context in which telehealth technologies are situated and experienced will be increasingly critical as technological systems play greater roles in service delivery

Evaluation of the Rural-Telemedicine program in Nepal : study from the selected districts

Telemedicine is growing both in developed and developing countries and has remained as an integral part of health care delivery system. It includes different health activities and medical services that take place at distance. In the developing countries it supports to improve the accessibility, quality and efficiency of the healthcare services and also reduces the cost of service. It also supports to improve the administrative as well as technical aspect of healthcare system. Government of Nepal has also implemented the rural-telemedicine program in thirty rural-districts hospitals for providing specialist health care services and also to improve the accessibility of health services for the rural community peoples. Methods: This study explores the existing situation of the rural telemedicine program and the challenges and limitations related with its implementation. Similarly it has also highlighted the roles and responsibilities of the government to improve the program. The study data and information were collected from the selected rural-telemedicine sites and it includes various respondents who were involved in the program and were working at various levels under the government health system. This is a qualitative study with interpretative case study approach. This approach is used since it supports to explore and understand the study area and produce deep insights into the context. For collecting the study data, multiple data collection tools (Semi-structured interview, site observation and discussion) were used. The collected data and information were analyzed and interpreted based on the preconception of the researcher and by comparing them with the concept provided by the Information Infrastructure (II) Theory and Actor-Network Theory. Results: Study findings shows that the rural-telemedicine service is necessary and important to improve the accessibility and provide specialized healthcare services to the rural community peoples. It has connected the rural-district hospitals with the tertiary level hospital and also supported the health personnel working in the rural areas to get necessary medical support. However the program is facing various challenges due to the lack of sufficient infrastructure and technology that are needed to support the program. Similarly the study findings show that various other factors have also affected the rural-telemedicine program. Such factors are related with the weak policy of government on rural-telemedicine program, limited fund, lack of trained and motivated human resources, frequent and unplanned transfer of the health personnel, unsatisfactory incentives for those health personnel involved in the program and not having supportive environment. Conclusion: Government need to improve on the existing policy and provide sufficient attention to the program. It is necessary to strengthen the infrastructure and technology and make them user-friendly and culturally adjustable. Similarly it should be cost effective and affordable and supportive to the local technology. For the sustainability of the program, government should also focus on the promotional activities and conduct networking and partnering with the related private organizations and external development partners. Similarly regular training and attractive incentives should be provided to the health personnel to motivate them to work in the rural areas. Government also needs to focus on conducting regular supervision, monitoring and evaluation of the program so that it will provide opportunity to gradually develop the program and timely address the related limitations and challenges. Keywords: Rural-telemedicine, challenges and limitation, role of government, sustainability, Nepa

Designing Cost-Effective Telemedicine Camps for Underprivileged Individuals in Less Developed Countries: A Decomposed Affordance-Effectivity Framework

Free telemedicine camps (telecamps) are emergent joint initiatives of healthcare organizations, national and local governments, and not-for-profit nongovernmental organizations (NGOs) with the goal of alleviating the health divide for underprivileged individuals in rural areas of less developed countries. Our study seeks to understand the effectiveness of physician-patient communication at telecamps with several salient characteristics: rural underprivileged patients, physicians in remote cities, and frugal telemedicine technology—specifically, videoconferencing—deployed in Hospitals on Wheels and appropriated by operators. We adopt a multiple-actor perspective, propose a decomposed affordance-effectivity framework, and combine variance and process perspectives to examine the phenomenon of interest. We collaborated with Apollo Hospitals, a leading hospital system in India, and collected multisource data from two major telecamps in rural South India. Based on an analysis of survey data from 216 telecamp participants through a variance perspective, we found support for the fit of patient-perceived media richness with two contingency factors—(1) disease diagnostic complexity and (2) patient healthcare needs fulfillment—in influencing patient satisfaction with teleconsultation. Based on an analysis of 46 sessions of teleconsultation video archives through a process perspective, we found that technology appropriation is realized through verbal and nonverbal communication events between patients and physicians, with on-site operators playing multiple roles that serve as “compensatory user effectivity.” Our findings yield theoretical and practical implications for how effective telemedicine encounters using frugal technologies can be designed in combination with other cost-effective support personnel resources to broaden healthcare access for underprivileged individuals in less developed countries and, more broadly, to actualize technology affordances in use situations involving multiple actors

Telemedicine in interdisciplinary work practices: On an IT system that met the criteria for success set out by its sponsors, yet failed to become part of every-day clinical routines

Background. Information systems can play a key role in care innovations including task redesign and shared care. Many demonstration projects have presented evidence of clinical and cost effectiveness and high levels of patient satisfaction. Yet these same projects often fail to become part of everyday clinical routines. The aim of the paper is to gain insight into a common paradox that a technology can meet the criteria for success set out at the start of the project yet fail to become part of everyday clinical routines. Methods. We evaluated a telecare service set up to reduce the workload of ophthalmologists. In this project, optometrists in 10 optical shops made digital images to detect patients with glaucoma which were furth