The work to make telemedicine work: A social and articulative view

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Abstract

This article contends that the take up of telemedicine results inevitably in the reconfiguration of the existing work practices and socio-material relationships. This new way of working triggers a variety of shifts in coordination mechanisms, work processes and power relationships in the health care sector. The paper, which is based on the findings of a research project conducted in Northern Italy, addresses three critical issues of telemedicine: the conflict between the scripts embodied in telemedicine technologies and the daily work practices of heath care professionals; the tendency of telemedicine to produce a delegation of medical tasks to non-medical personnel (and to artifacts); and the tendency of telemedicine to modify the existing geography within the health care environment. The paper contends that telemedicine presupposes and entails some significant changes in work processes which affect both the material conditions of the expertise which is supposed to be distributed, and the relationships between health care professionals and their practices.

Introduction

The great majority of existing research and practitioners’ literature on telemedicine adopts a clinical, technical, and economic approach. Social and organizational issues, albeit often mentioned, have been scarcely addressed (Chiasson & Davidson, 2004). In this article I shall argue that in order to understand some critical aspects of this new way of practicing medicine, we need to attend closely to the relationship between technology, work context and the structuration of organizational activities from a social and organizational perspective.

Using this perspective, and building on the result of a three years research, I will particularly contend that the take up of telemedicine results inevitably in the reconfiguration of the existing work practices, triggering a variety of shifts in coordination mechanisms and socio−material relationships.

The article is organized in the following way. I will start by introducing some of the fundamental tenets and potential benefits of a social and articulative view of telemedicine. I will then introduce the setting of a research conducted at four telemedicine sites in Northern Italy upon which the present discussion is based (Gherardi & Strati, 2004). The main characteristic of these sites was that operations had been in place for at least two years, that is, projects had progressed beyond (and successfully passed) the experimental and piloting stage. It takes in fact time organizational practices to start shifting and for social issues to emerge. I shall then proceed to discuss three of these issues, namely the consequences of the conflict between the scripts embodied in telemedicine technologies and the daily work practices of heath care professionals; the tendency of telemedicine to produce a delegation of medical tasks to non-medical personnel (and to artifacts); and the tendency of telemedicine to modify the existing geography within the health care environment. I will conclude the article by observing that the research dispels the widespread idea that telemedicine simply constitutes a way of distributing at a distance existing services. On the contrary, the data support the idea that telemedicine presupposes and entails some significant changes in work processes which affect both the material condition of the expertise which is supposed to be distributed, and the relationships between health care professionals and their practices.

Section snippets

A social and articulative view of telemedicine

Technological innovations in general, telemedicine being no exception, have always triggered contrasting reactions both in the general public and among members of the scientific community. When a significant technological breakthrough appears in the public sphere, opinions tend to polarize between optimists, who emphasize the potentialities of the new technology, and pessimists, who tend on the contrary to stress the difficulties and the potential barriers to the adoption of the new

Research setting and methods

The data discussed derive from a three years research project conducted in Northern Italy. The overall aim of the research was to deepen understanding of the nature of the organizational innovation introduced under the generic label of “telemedicine”, the characteristics of the technologies employed, and the effects on the existing medical practices.

The study focused in particular on four telemedicine initiatives: the evaluation of a teleradiology project; the observation and analysis of a

When technolgical scripts and daily practices do not match

One of the central ideas of the social and articulative study of technology is that all technical artifacts used in daily activity embody patterns of use and interactional scripts which reflect (to some extent) the views and intentions of their designers.

According to Akrich (1992; see also Hanseth & Monteiro, 1997), when designers conceive technical artifacts, they tend to define actors with specific duties, tastes, competencies, motives, aspirations, and preferences. A large part of the

Redistributing and delegating tasks

The ecological view of technology (and telemedicine) introduced above supports the notion that what we customarily call “work roles” are not fixed social positions determined by rules and prescriptions, so much as the result of the interaction and negotiation of a variety of dimensions and aspects which all concur to determine how the task at hand will be interpreted in the particular situated workplace. From this perspective, negotiating boundaries and positioning oneself vis-à-vis other

Redesigning the relationships between center and periphery

For many years the adoption of IT technologies in healthcare has been purported as a way of introducing a more even distribution of services, therefore improving the access of remote communities and patients (Brauer, 1992). This optimistic vision, however, is matched by a contrary view which claims that telemedicine might in fact deepen the existing inequalities. Cartwright (2000), for example, argues that telemedicine can be used as an excuse to reduce investments in local services, dividing

Concluding remarks

In this paper I have used a social and articulative approach for interrogating telemedicine as an ecology of human and non-human elements and exploring how it interacts, modifies, and interferes with the existing work practices, organizing processes, and larger institutional arrangements.

The use of such perspective permitted us to enrich and integrate previous studies on the organizational implications of telemedicine. These observations corroborate Aas (2001), Aas (2004) findings according to

Acknowledgements

The research was conducted while the author was at the Research Unit on Cognition, Organization Learning and Aesthetics of the Department of Sociology and Social Research of the University of Trento (Italy). Financial support was provided in part by a grant from the Provincia Autonoma of Trento (Italy), Progetto Scientifico No. 6 -2001. I wish to thank K. M. Gilbert for her editorial work. I am also grateful to the editor and the two anonymous reviewers for their constructive comments on a

References (44)

  • M. Bloor

    On the analysis of observational data: a discussion of the worth and uses of inductive techniques and respondent validation

    Sociology

    (1978)
  • G. Brauer

    Teleahealth: The delayed revolution in health care

    Medical Progress Through Technology

    (1992)
  • A. Bruni

    Shadowing software and clinical records: On the ethnography of non-humans and heterogeneous contexts

    Organization

    (2005)
  • A. Bryman et al.

    Business Research Methods

    (2003)
  • L. Cartwright

    Reach out and heal someone: Rural telemedicine and the globalization of US health care

  • M. Castells

    The rise of the network society

    (1996)
  • B. Dahlbom et al.

    Computers in Context: The Philosophy and Practice of System Design

    (1993)
  • K.M. Eisenhardt

    Building theories from case study research

    Academy of Management Review

    (1989)
  • J.J. Gibson

    The ecological approach to visual perception

    (1979)
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