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    This article was downloaded by: [Macquarie University]On: 04 September 2013, At: 06:25Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

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    Transcending the Technology

    of Telemedicine: An Analysis of

    Telemedicine in North CarolinaPamela Whitten , Beverly Davenport Sypher & James

    D. Patterson

    Published online: 10 Dec 2009.

    To cite this article: Pamela Whitten , Beverly Davenport Sypher & James D.

    Patterson (2000) Transcending the Technology of Telemedicine: An Analysis of

    Telemedicine in North Carolina, Health Communication, 12:2, 109-135, DOI: 10.1207/S15327027HC1202_1

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    Transcending the Technology ofTelemedicine: An Analysis of

    Telemedicine in North Carolina

    Pamela Whitten

    Department of Telecommunication

    Michigan State University

    Beverly Davenport Sypher

    Department of Communication Studies

    University of Kansas

    James D. Patterson II

    Department of Communication

    University of Kansas

    This study investigated the telemedicine program at East Carolina University School

    of Medicine. In-depth interviews, organizational texts, and archival recordsprovided

    data for a case study that sought to understand what telemedicine is to organizational

    members and how they came to create this contextual reality. The goal of this study

    was to apply interpretive paradigmaticassumptions in theprivileging of telemedicine

    as the very context of the organization. The findings explain how organizational

    members make sense of this new way of providing health care. Organizational mem-

    bers talk revealed that telemedicine is multifaceted: It is access, an economic tool,

    education, technology, and a grant activity. With the single exception of technology,

    these themes emerged equally, regardless of whether the telemedicine provider was

    located at the urban hub site or the rural spoke site. Interestingly, members at both lo-

    cations talked about critical events in relation to receipt of grant or financial support

    for new projects. Implications for future research are advanced.

    People who live in rural or remote areas simply do not have the range of health care

    services available to their neighbors in more urban areas. Estimates reveal that

    there are more than 28 million Americans living in medically underserved rural

    communities (Office of Technology Assessment, 1990). This population is served

    HEALTH COMMUNICATION, 12(2), 109135Copyright 2000, Lawrence Erlbaum Associates, Inc.

    Requests for reprints should be sent to Pamela Whitten, Department of Telecommunication, Michi-

    gan State University, East Lansing, MI 488241212. E-mail: pwhitten@pilot.msu.edu

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    by health care systems plagued with professional isolation, limited access to spe-

    cialists, inadequate numbers of primary care physicians, declining hospital use,

    discontinuity of care when patients are transferred to tertiary centers, financial dif-ficulties, and trouble recruiting and training physicians (Kane, Morken, Boulger,

    Crouse, & Bergeron, 1995). Although levels of severity differ, virtually all rural

    communities share similar problems. Ironically, the very people who need health

    care the most have the least access to specialized care.

    Telemedicine offers one possible solution to some of the problems that cur-

    rently plague rural health care. More than 2 decades ago, Park (1974) defined

    telemedicine as the utilization of interactive or two-way television to provide

    health care. In only a few years, Bennet, Rappaport, and Skinner (1978) expanded

    the concept with the term telehealth, which included education, administration,and patient care. Since its inception in the early 1970s, telemedicine programs

    have been springing up at a record pace, with the number of North American pro-

    grams doubling each year since 1993.1 In the United States alone, federal financial

    support for telemedicine exceeded $85million in 1994 (Perednia & Allen, 1995).

    Perednia and Allen (1995) argued that even though there is increasing evi-

    dence that managerial and administrative issues play a vital role in the effective-

    ness and utilization of telemedicine services, we have paid too little attention to

    the influence of leadership, organizational, and training factors on the success or

    failure of modern telemedicine programs. The new technology has for the mostpart overshadowed the creative and recreative human aspects involved in ac-

    complishing the task for which it was developed. What we do not yet understand

    are issues related to the socially constructed realities of these telemedicine orga-

    nizations and how they come to be understood and managed. The context has

    created new ways of organizing, replete with age-old issues of organizational

    power and influence, definitions of the situation, members roles in the social

    situations they create, and relationship development and maintenance. The pur-

    pose of this study is to demonstrate how communication plays a central role in

    the creation and maintenance of a telemedicine organization. This case study fo-cuses on the telemedicine program of Eastern Carolina University (ECU) School

    of Medicine. The research goal is to determine what organizational members

    perceive telemedicine to be, how they understand and describe how tele-

    110 WHITTEN, SYPHER, PATTERSON

    1Therapid growthandhigh visibilityof telemedicineprojects hide an important issue: Relatively few

    patients arebeingseenvia telemedicine. In1993, theaverage numberofpatientphysician consultations

    was about 200 per program among the 10 North American interactive mediated programs. Typically,

    thesewere composed of about four linked remote sites. If the most active program, whichsaw1,000 pa-

    tients in 1993, is excluded, then the average drops to fewer than 150 consultations per program in thatyear. Preliminary figures for 1994 suggested that underutilization continued to be a problem (Allen &

    Allen, 1995). In almost every telemedicine program, teleconsultation accounts for less than 25% of the

    useof the system (Perednia & Allen, 1995). Instead, the majorityof online time is used for medical edu-

    cation and administration.

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    medicine gets done, and what they understand to be the critical events leading

    to the origin and evolution of their program.

    DEVELOPMENT OF TELEMEDICINE

    Telemedicine techniques have been under development for the past 4 decades.

    Wittson and colleagues were the first to employ telemedicine for medical purposes

    in 1959 when they set up telepsychiatry consultations between the Nebraska Psy-

    chiatric Institute in Omaha and the state mental hospital 112 miles away (Wittson,

    Affleck,& Johnson, 1961). In the sameyear, Montreal, Quebec was thesite for pio-

    neer teleradiology work (Jutra, 1959), and in the 1970s, there was a flurry oftelemedicineactivity.Several majorprojects developedin North America andAus-

    tralia, including the Space Technology Applied to Rural Papago Advanced Health

    Care project of the National Aeronautics and Space Administration in southern Ar-

    izona; a project at Logan Airport in Boston, Massachusetts; and programs in north-

    ern Canada (Dunn et al., 1980).

    The 1960s, 1970s, and 1980s exhibited a series of telemedicine pilot and

    demonstration projects. With the exception of the 20-year-old telemedicine pro-

    gram at Memorial University Hospital of Newfoundland, none of the programs

    begun before 1986 has survived (Grigsby & Kaehny, 1993). However, the 1990shave proven to be a period of rapid growth. In 1990, there were 4 active

    telemedicine programs. In 1994, there were 26 such programs, and by March

    1998, there were over 150 telemedicine programs (Allen & Grigsby, 1998). The

    creation of many of these programs was sparked by clinical needs in rural areas.

    Although data are limited, early reviews and evaluations of these programs sug-

    gest that the equipment was reasonably effective at transmitting the information

    needed for most clinical uses and that users, for the most part, were satisfied

    (Conrath, Puckingham, Dunn, & Swanson, 1975; Dongier, Tempier,

    Lalinec-Michaud, & Meunier, 1986; Fuchs, 1974; Murphy & Bird, 1974). How-ever, when external sources of funding were withdrawn, the programs simply

    folded. Whereas Perednia and Allen (1995) attributed the failures to costbenefit

    analysis, other researchers pointed to limited physician acceptance (Michaeis,

    1989). How telemedicine comes to be defined and organized is yet another ex-

    planation of how, and if, it will be sustained.

    The implementation of telemedicine raises important questions about just what

    it is, how it can be used, and how it can be incorporated into national and local

    health care systems. Firsthand observations of viable programs provide baseline

    data for understanding how this new technology has created a new health care con-text. It is becoming increasingly clear that funding levels are just one of the many

    dimensions across which telemedicine programs differ. Although we know a good

    deal about the hardware that makes telemedicine possible, we have just begun to

    TELEMEDICINE 111

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    investigate how communication with and about this technology produces the orga-

    nizational structures that make it possible. To understand the organizational aspect

    of telemedicine is to acknowledge the communicative foundation for organizing ingeneral and accomplishing telemedicine in particular. More specifically, how we

    talk about telemedicine reveals the reality we have constructed. Thus, how organi-

    zational members frame, discuss, and label telemedicine appears important to un-

    derstanding this context.

    Telemedicine was generally designed to serve remote areas, so differences in

    perspective are likely to exist between those serving and those served. We cannot

    understand the telemedicine context without understanding both perspectives.

    Equally important is how organizational members view and enact telemedicine.

    These assumptions guided the development of the following research questions(RQs):

    RQ1: Whatare recurring themes in organizational members descriptions of

    telemedicine? What are recurring themes in organizational members

    descriptions of the purpose and goals of telemedicine?

    RQ2: Do themes and terms differ between telemedicine providers in rural

    and urban sites? Do themes and terms differ by type of work per-

    formed or position?

    RQ3: How do organizational members describe how telemedicine gets de-livered?

    METHODS AND PROCEDURES

    Telemedicine lends itself to qualitative study, as it desperately needs what Van

    Maanen (1979) referred to as a descriptive focus. To date, most telemedicine

    research has had a technological focus. We know a good deal about bandwidths

    and resolution but little about the human dimensions that make the practice pos-sible. To understand how organizational members come to understand their or-

    ganization, we looked for distinct patterns of assumptions, norms, and values by

    employing a case study strategy that analyzed interviews, organizational texts,

    and archival data. As a method, the case study provides a chunk of reality

    (Lawrence, 1953, p. 215) or a touchstone of reality (Haytin, 1988, p. 41) that

    is epistemologically in harmony with the readers experience (Stake, 1978, p.

    5) and make[s] visible the qualitative features of organizational life (Sypher,

    1990, p. 3). This case study attempted to answer how and why a specific

    telemedicine organization developed the way that it did. It addresses a contem-porary problem that has potential relevance transferable to other health contexts.

    Through the use of multiple methods, this case focused on the way communica-

    tion shapes and reflects what a telemedicine organization is.

    112 WHITTEN, SYPHER, PATTERSON

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    Interviews

    For this case study, the researcher conducted 25 in-depth interviews with study par-ticipants. The researcher interviewed all key staff employed in the ECU

    telemedicine office, including the director, scheduler, technician, grant manager,

    and clerical staff. In addition, the researcher interviewed four of the most active

    consulting telemedicine physicians. Of the 25 interviews, 12 were conducted in

    North Carolina. Of these 12 North Carolina interviews, 10 were conducted

    face-to-face in a private office with three physicians, two administrators, two tech-

    nicians, a scheduler, and a clerical staff member and 2 interviews were conducted

    privately over the telemedicine system with two remote site nurses. The remaining

    13 interviewswere conducted via telephone. These phone participants included sixrural nurses, four rural physicians, one rural physicians assistant, and anECU phy-

    sician and technician. The interviews ranged in length from 20 min to 2 hr; not

    surprisingly, the interviews with physicians tended to be the shortest. All respon-

    dents agreed to be recorded, and interviews were transcribed verbatim.

    A focused, open-ended interviewing structure was chosen so that respondents

    could introduce ideas (Mishler, 1986), the researcher could discover how people

    think and what unique perspectives they hold (Patton, 1990), and to encourage

    the participants to name their own worlds (Mishler, 1986). A general interview

    guide was employed as a framework for all of the interviews (see Appendix forthe interview guide). Over 20 hr of interviews produced almost 400 pages of text

    for analysis.2

    The 400 pages of text from the 25 transcribed interviews were content ana-

    lyzed for themes, a single assertion about some subject (Holsti, 1969, p. 116).

    Themes were mutually exclusive, multiple indications of the same theme were

    counted only once, and elaborations of the themes determined its categorical fit.

    Holsti explained that application of the theme as the unit of analysis is appropri-

    ate for research that is attempting to gauge beliefs, attitudes, and perceptions. In

    line with the goal of privileging the voices of the organizational members, a

    TELEMEDICINE 113

    2With the addition of DS3 links over an asynchronous transfer mode (ATM) network, this is the only

    telemedicine program in the world operating simultaneous T1 lines, microwave, and DS3 ATM links.

    The host site of this telemedicine program (the ECU School of Medicine) has constructed four individ-

    ual 6 12ftmodulesto givethe consultingphysiciana soundproofarea to interview a patient located ata

    remote site. The physician sits at one end of the module and uses two-way interactive video, audio, and

    digitized data. The modules house a camera, monitor, close-up or graphic monitor, microphone, lights,

    diagnostic tools, graphic camera, and a direct-line telephone. The rural or remote telemedicine sites uti-

    lize existing clinic space in the remote hospital or clinic. All facilitiesof a remote clinic are present withthe addition of camera, monitor, close-up or graphic monitor, microphone, lights, diagnostic tools,

    graphic camera, facsimile,digitaldata, anda direct-line telephone. Thepresentinghealthprovider (phy-

    sician assistant or registered nurse) uses two-way interactive video, audio, and data, and has a direct in-

    terface to all equipment used for the transmission.

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    theme was captured in a phrase or several sentences. Two coders independently

    sorted 20 units into five thematic categories resulting in a 90% intercoder reli-

    ability and a Cohens kappa of .86.3

    Organizational Documents and Archival Records

    Organization documents provide historical data, long-lasting information, and in-

    formation available only in written form. Because documentary evidence is likely

    to be relevant for every case study topic (Yin, 1994), the researchers requested a

    sampling of all documents from the telemedicine program, but an examination of

    the departments files produced very few examples. What was available was usedto corroborate and augment the evidence gathered during the interview phase. Or-

    ganizational documents examined in this study included a mix of proposals, user

    monthly reports, and Web pages.

    Archival records were also collected for this case study to verify interviewee re-

    ports of activity within the telemedicine programs life. Archival records exam-

    ined included organizational records, maps and charts, lists of provider and patient

    names, and procedures.

    Telemedicine Program at the ECU School of Medicine

    The telemedicine program at the ECU School of Medicine was chosen as an impor-

    tant point of inquiry for several reasons. First, the telemedicine program is fairly

    new but is established enough to have some stability in routine, procedures, and

    staff. Second, the demographics of North Carolina make it an ideal area to study the

    114 WHITTEN, SYPHER, PATTERSON

    3Several rules were created for coding these themes. First, all themes were mutually exclusive with

    no data being coded into more than one theme. The decision was made to count a theme one time for an

    individual member, even when multiple statements were made that fell under that themes classification,

    becauseintervieweesrepeated thesame description of telemedicineatdifferentpointsthroughout thein-

    terview. For example, the theme access was only counted one time when the same person described

    telemedicine atone point during the interviewas the way we makeit easier for the patient toseethe doc-

    tor and then later described telemedicine as something that has really increased their (patients)

    chances to beseen bya specialist. A third rule concerned whichtheme toprivilege if more thanone was

    made in the same statement. This rule was defined in response to the many statements, which included

    mention of the technology involved. It was decided that these statements would only be coded as tech-

    nologyifnootherdescriptionof telemedicine were provided.Forexample,when a respondent describedtelemedicine as a telephone with a little videoits just a videophone, the statement would be coded

    as technology. However, when another respondent described telemedicine as a mechanism by tele-

    phone lines that patients can receive treatments at outlying centers without going to the actual medical

    center, itwascodedas accessbecause therespondent elaborated beyondjust thementionof technology.

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    growing problems of rural health care, because this region is one of the most un-

    healthy in the nation.4

    In 1991, the North Carolina Department of Corrections invited all of the medi-cal schools in North Carolina to participate in a telemedicine project that would not

    directly benefit most citizens of eastern North Carolina but, if it worked, could be

    used as a model for the health access problems facing other sections of the popula-

    tion. After careful consideration, the ECU School of Medicine was the only medi-

    cal school in the state that accepted the invitation.

    Administration at the ECU School of Medicine decided to house telemedicine

    within the Center for Health Sciences Communication. In 1992, the ECU School

    of Medicine began providing telemedicine consultations to the North Carolina De-

    partment of Corrections at Central Prison in Raleigh, North Carolina, located 100miles away. Telemedicine was implemented as a cost-effective way to bring medi-

    cal specialists into the prison by avoiding the need to transport the patients outside

    the prison system with the associated risk, eliminating the cost for two guards and

    a state vehicle. The prison telemedicine project ultimately spurred the develop-

    ment of procedures, technology, and protocol for deployment of telemedicine into

    rural hospitals and clinics in North Carolina. It also provided the background

    against which future understandings were created. Physicians see and talk to pa-

    tients via the telemedicine link and then diagnose and prescribe medications when

    necessary. Physicians and nurses also have access to digital stethoscopes, a graph-ics camera, and a miniature, handheld dermatology camera to aid in patient exami-

    nations. As of the time of this study, more than 500 patient consultations and more

    than 200 continuing education programs have been provided via telemedicine for

    the prison and rural outreach sites. A unique aspect of the ECU telemedicine pro-

    gram is the assortment of network and hardware that have been integrated.5

    TELEMEDICINE 115

    4Specifically, eastern North Carolina is one of the most unhealthy regions in the nation. In 1988, for

    example, North Carolina had the countrys highest infant mortality rates. Yet, eastern North Carolinas

    infant death rate was even worse than the states average and was 28% higher than the U.S. rate

    (9.9/1000 live births, U.S.; 12.2/1000 live births, North Carolina; 12.7/1000 live births, eastern North

    Carolina). Death rates for heart disease and cancer are higher in eastern North Carolina than in the state

    as a whole; only 3 counties in the regionare below the states rates. The worst rates in North Carolina for

    death due to diabetes, chronic liver disease and cirrhosis, and nephritis are found in this eastern,

    29-county region.5Validity and reliability of interview data are sometimes challenged because the researcher is influ-

    encing the typeof information obtained (Patton,1990) by the questionsshehas selected toaskand byaf-

    fecting what actually occurs during an interview. In an effort to enhance both the reliability and validity

    of the interview date, this investigator employed several steps. First, all responses were consideredwithin the special context that existed for each interview interaction (Fitch, 1994; Mishler, 1986). Sec-

    ond, the researcher attempted to minimize any fear that respondents might have about reprisal by man-

    agement foranyresponsesby assuring participants that they were permitted to participate in theresearch

    andthattheconfidentialityoftheirresponseswasofthehighestprioritytotheresearcher(Mishler,1986).

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    The actual planning of North Carolinas telemedicine program began in 1991,

    and the first patient was seen in 1992. Almost everyone was aware of the prison

    project that led to the birth of telemedicine. As one respondent explained, theprison contract is credited as being the project that enabled telemedicine to be born

    and allowed ECU to grow telemedicine to meet its mission of serving eastern

    North Carolinato help meet the demand of primary care physicians in the rural

    area and the total isolation that a lot of them feel.

    What is interesting in these descriptions of the origin is the implication that ECU

    isthebastardorlast-choicemedicalschoolinthestate.Itwasthelastchoiceofthe

    Department of Corrections, yet ironically it proved to be the innovative program

    willing to try something new. One urban member said, What I told you earlier I

    think is very significant about Duke and Chapel Hillneither of them wanted toworkwiththeprisontodotelemedicine,sotheycamedowneasttothestepchild.

    In 1993, the programs directorship was expanded to include a physician. One

    year later, ECU received a grant from the Health Care Finance Administration

    (HCFA) to bring on two rural telemedicine sites in Williamston and Ahoskie. Re-

    spondents explained that these two sites were selected because ECU had a stan-

    dardized residency program already established there. An urban physician stated

    that in addition to attending rounds via the system and then once or twice a week

    theyre [the residents] also precepted or they have network meetings with their in-

    structors back here (at ECU). This urban physician also explained that the resi-dents benefited in sitting in on those consults referred to specialists because its

    an opportunity to learn from the consultation not just send your patient to so

    and so and get a letter back, but participate in the consults.

    Additional grant funding in 1995 made it possible to add three new sites. In a

    few years the telemedicine program included six remote sites. It became obvious

    to the participants of this telemedicine program that someone was needed to super-

    vise and manage all of the grants, making this growth possible.

    Once hired, the new grant manager outlined in a memo the teams first tasks:

    We have begun to formally define the roles/responsibilities of the rural

    telemedicine coordinators (RTCs) (per RTC meeting on 9/27). This will be

    very beneficial to all of us (GO Team and RTCs). It is now time we do the

    same for ourselves. While the operation of the grants has been clicking right

    along with no major problems, I feel WE can take grant operations to an en-

    tirely different level with a better understanding of our individual and corpo-

    rate roles and responsibilities.

    Part of the RTCs new responsibilities included looking for additional busi-ness. The technical projects ECU tackled were also critical incidents in the prog-

    ress of the program. One was dubbed the docking station. As one interviewee

    explained

    116 WHITTEN, SYPHER, PATTERSON

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    What were saying is lets look forward ten years and see what really makes

    senseonthenetwork.Well,Imconvincedeverythingweredoingrightnow

    is wrong. The way were doing it is right in that it fits the need today, but thiswhole thing is going to end up on the Internet delivery system. Thats whats

    goingtomakeitworkinthehome.Thatswhatsgoingtobringthecostdown,

    sowhatwecan donow thatgetsus there quicker.Sowestart developingthese

    vision pieces the dockingstation which are these centers thathaveinputde-

    vicesandcancollecteverypieceofinformationatoneplace,atonetimethe

    vision is that all this stuff is interconnected I think we can fast forward this

    thinglightyears.Ithinkthestuffweredoingrightnowiswhatwehavetodoto

    get through the next two to three years, but lets not get stuck in this shitbe-

    cause this aint right.

    Thus, urban practitioners find themselves with a host of critical incidents that have

    shaped who they are and what they do. With these turning points comes the implicit

    understanding that the essence of telemedicine will continue to be constructed and

    reconstructed by what they do and say. In the next section we discuss the specific

    findings of this case study analysis.

    RESULTS

    Taken together, analyses of interviews, organizational documents, and archival

    data were cataloged according to purpose. Information within these texts was com-

    pared to data provided from the interviews. The results of these analyses supported

    and corroborated the results from the interview data. To understand how these or-

    ganizational members view a telemedicine program, the following section is orga-

    nized around the three RQs proposed.

    RQ1: Whatare recurring themes in organizational members descriptions of

    telemedicine? What are recurring themes in organizational members

    descriptions of the purpose and goals of telemedicine?

    Five distinct themes emerged to answer this question. Participants described

    telemedicineasaccess, aneconomic tool, education, technology, or a grant activity.

    The access category contained all references to telemedicine as the availability of

    health care to patients who would not have had access or convenience without

    telemedicine. An economic tool was the theme that captured all perceptions, which

    explained telemedicineas an entity that offered an economic advantageor solution.

    Education encompassed all perceptions of telemedicine as providing educational

    opportunities for health providers. Technology served to includeall descriptions oftelemedicineasstrictlyhardwareortelecommunications.Finally,agrantactivityin-

    cludedallperceptions that telemedicineexists in accordance with the grant funding

    that secured its beginning.

    TELEMEDICINE 117

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    Telemedicine as Access

    Every participant talked about telemedicine as access for patients or residentsof re-mote areas. For the purposes of this analysis, the access theme encompassed all re-

    sponses that described telemedicine as the source of care that would otherwise be

    unavailable or difficult to attain. Access was commonly talked about in relation to a

    place. The overwhelming feeling that telemedicine represents a place is evidenced

    by the fact that almost all of the respondents discussed telemedicine in this way.

    However, this notion of place had several meanings for organizational members as

    is evidenced in the language they used: Care was either emanating from a place (the

    medical center) or being delivered to a place (a rural site).

    In one sense of place, the provider at the urban site is the focal point. As variousinterviewees explained, telemedicine is reaching out, connecting, linking,

    or carrying health care from the medical center to those in need. For these re-

    spondents, the medical center (as the provider) is the privileged sense of place.

    Other respondents claimed that telemedicine allows patients to leave their local

    town without actually leaving town. One respondent explained that telemedicine

    may be the only way they [patients] get out of town. A rural respondent also il-

    lustrated this perspective by stating that telemedicine has allowed patients to

    reach specialists who dont come here to our hospital.

    A second conception of access placed telemedicine in the rural or remote healthcare facility. Telemedicine is seen as health care services at home or in the re-

    mote community that would not otherwise have access to medical care. Partici-

    pants talked of telemedicine as moving the specialist or the medicine to the patient

    without anyone having to drive, without them having to come to us, without

    the specialist having to worry about making a living in that area. In this way,

    telemedicine was a way for people to stay at home in their communities with

    their health care providers in their offices.

    Thus telemedicine as access can be located at the remote site or the hub site, or

    both. Even though there were differences in real space, every single organizationalmember described telemedicine as access located in a place. Many participants

    made reference to both places when describing telemedicine as access.

    Telemedicine as an Economic Tool

    For 80% of the respondents, telemedicine was a tool for economic advantage.

    These economic benefits ranged from discussion of direct financial rewards to ac-

    knowledgment of benefits that ultimately could result in financial gain through ei-

    ther revenue generation or cost savings.In terms of direct cost savings, respondents described telemedicine as a reduc-

    tion in (patient) transfer which is what HCFA is trying to preach eliminating re-

    dundancy in medical testing and avoiding duplication of services when two

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    providers are talking to each other. As one participant explained, the prison

    prides itself to be the most pressing evidence of a cost-effective delivering of

    health care using telemedicine.Keeping patients in town was also viewed as a potential way to save money for

    the health care system: I think with telemedicine you really could manage some-

    ones care and keep them in the community and save the overall system a whole lot

    of money, said one participant. Another economic advantage was saving dollars

    by catching illnesses before they are too advanced. An urban physician stated that

    telemedicine will save the system money in that patients who would not normally

    see a specialist til they were dying could be saved early by telemedicine catching

    and intervening early.

    In addition to saving health care dollars, telemedicine was also described as aneconomic opportunity. For example, telemedicine could increase revenue for rural

    hospitals by keeping patients: Its just a matter of keeping them [patients] in their

    own county and keeping their dollars there. Urban respondents mentioned this

    same perspective: The main goal is to keep the university productive, or from

    the hospitals viewpoint, they see it as a way to bring in more patients to extend

    their catchment area. Several respondents implicitly, if not explicitly, said they

    saw telemedicine in terms of dollars or increasing utilization. One rural nurse

    hoped telemedicine would bring more clients into her facility: But definitely they

    [her urban hospital] see more of an avenue with public health in the area and hav-ing it more utilized by public health making referrals to us. After learning of the

    potential for child psychiatric consultations via telemedicine, one rural nurse ex-

    citedly anticipated an increase in consults: I kind of got excited because I think

    Ive found an area that maybe we can increase consults.

    Telemedicine as Education

    Sixty-four percent of the respondents talked about telemedicine as something that

    benefits them educationally.Worth noting is thedirectionof theeducational oppor-tunities. Regardless of the type of education discussed later, all respondents talked

    about telemedicine as education for health care providers in rural or remote areas.

    One comment that exemplifies this unidirectional learning came from an urban

    physician who said

    In fact, its immediateCME[continuing medical education6] for thereferring

    physician. You teach them the way you think. You teach them how you

    would approach this, what you would do and then what you would recom-

    mend. He can ask you questions right there.

    TELEMEDICINE 119

    6Continuing medical education refers to thecontinuing education required by allphysiciansto main-

    tain their licensure.

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    Respondents views of the educational opportunities provided by telemedicine

    range from formal continuing education to serendipitous learning through partici-

    pation in telemedical activities. Unfortunately, however, urban physicians andother health providers did not mention the educational opportunities from which

    they might benefit. Just like access, providers saw education as flowing from the

    hub out.

    In terms of the formal education, respondents explained that telemedicine pro-

    vides continued education required for health practitioners to maintain their

    licensure and exposure to grand rounds from ECU. One rural physician explained

    that telemedicine is an avenue for receiving vital information to stay abreast of all

    the medical changes that are going on. An internal newsletter dated February

    1996 explained that telemedicine allows for easy delivery of continuing educa-tion course work and special programming such as lectures and forums at the

    School of Medicine.

    Telemedicine was also given credit for serving as a formal educational resource

    for the residents located at two sites that have a rural residency program. One ur-

    ban physician explained that the purpose of telemedicine is to support the rural

    residency program. One urban organizational member even claimed that the

    telemedicine program would not really be possible the way its set up now without

    telemedicine. A rural physician stated that telemedicine existed to facilitate the

    residency program. I think that anything over that is gravy. Another waytelemedicine supports the medical residents is by enabling them to participate in

    complex consults. One ECU support member explained, I can put them in front of

    the camera and my instructor on the other end can say right on or dead wrong.

    Lets rewind and look at this again. So it became a real tool for them.

    Telemedicine was also credited with serendipitous educational results. One ur-

    ban physician explained that telemedicine gives the more isolated physicians the

    opportunity to interact with their specialist peers and to learn from that experi-

    ence. In the same vein, a rural physician stated that I learn a lot when we discuss

    a case. Its improved my horizon. Another rural physician cited the educationalbenefit because they learn from communicating with other physicians. One rural

    nurse saw an educational benefit for her because when youre at a clinic such as

    we are, you dont get exposure as far as the different things that you do in a hospi-

    tal. [Telemedicines] increasing my nursing skills a whole lot from where they

    may have been. Thus, telemedicine as education means (a) formal educational

    programs to rural physicians and residents and (b) experiential learning that results

    from participating in health encounters.

    Telemedicine as Technology

    Just over half of the organizational members described telemedicine solely as a

    piece of hardware or telecommunication link. The support staff located at ECU

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    takes great pride in their creativity and technical prowess. One member stated,

    Were such a creative bunch wecan do things like this coast-to-coastATM that

    took tons of work and all sorts of creative problem solving. An internal memofrom the Dean of the School of Medicine stated, ECUs Telemedicine program

    has been widely recognized nationally and internationally for its innovative appli-

    cation of technology in healthcare. Several of the comments describing

    telemedicine as technology seemed to reflect this pride. For example, toward the

    end of an interview, one urban physician told the interviewer that

    The thing about our program we havent talked about that is unique is the hy-

    brid nature of our technologies so we have four technologies and thats

    been a real challenge to get all those pieces to talk to each other.

    In general, there was much talk of technology across themes. However, most

    who mentioned any technology did so in conjunction with a benefit such as access

    or education. However, half of the respondents discussed telemedicine strictly in

    terms of the technology at least one time during their interview.

    Telemedicine as a Grant Activity

    A little less than half of the telemedicine providers described telemedicine in termsof the grant that served to actually bring telemedicine to their facility. All of the

    telemedicine sites in this studywere funded solely by a federal grant, except for the

    prison site, which is totally funded by a state contract. It is not surprising then that

    telemedicine is often thought of as a grant. Because of the funding, several respon-

    dents expressed concern about the survival of their telemedicine program. One ur-

    ban physician stated that all was

    fine as long as the grant money is there, but once that grant money starts dry-

    ingupyoure notgoingto be funded indefinitely. Youve really got to havesome sortof game plan if you want to keep the system for making sure some-

    how it supports itself.

    An urban support staff member expressed frustration with the grants and money

    piece of this: Here were four years into this and if I walked away right now this is

    over. This does not have a life of its own and thats really frustrating. An urban

    physician thinks telemedicines destiny is in the organizations hands. He claimed

    that when the grant money is done, if we havent done our homework right, the

    whole systemwillcollapse. Ifwehavedone our homework right, itwill fit right intomanaged care.

    The terms of the grant also impact how telemedicine actually gets delivered.

    One rural nurse explained that one drawback in the grant occurred because they

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    put [that] you had to be an RN or higher to actually [present] the patient consulta-

    tions. This presents a problem because in rural areas RNs are hard to find to

    do that. Another grant condition that certainly impacts telemedicine concernspayment; the grants pay for all patient consults. Several of the rural coordinators

    use this condition as a selling point to persuade patients to use telemedicine. One

    referring rural provider thinks that telemedicine will not be used as frequently once

    the grants end. We really do have a lot of poor people here So having a free

    consult with a specialist, theyre saving several hundred dollars by getting that ser-

    vice without having to pay for it.

    RQ2: Do themes and terms differ between telemedicine providers in rural

    and urban sites? Do themes and terms differ by type of worked per-formed or position?

    Perceptual Differences Based on Location

    Urban and rural respondents were fairly consistent in their interpretations of

    telemedicine. All respondents described telemedicine as access. The only excep-

    tion was the focus on the technology. More than 75% of the urban respondents saw

    telemedicine as technology, whereas only 31%of the rural respondents described it

    thatway.Because personnel at the hub siteeitherare engineers or workclosely withthem, it is not surprising that more hub participants would talk about telemedicine

    as technology.

    To determine if rural participants talked about each telemedicine theme signifi-

    cantly more or less than urban participants, chi-square analyses were performed

    for each of the five themes. Only one theme, technology, emerged as significant,

    2(1, N= 12) = 4.16, p < .05. Table 1 displays the distribution of units among rural

    and urban participants and results of the chi-square analyses.

    122 WHITTEN, SYPHER, PATTERSON

    TABLE 1Distribution of Themes Among Rural and Urban Respondents

    Respondents

    Rural Urban

    Theme Number % Number %

    Access 13 100 12 100

    Economic took 9 69 10 83

    Education 9 69 7 58Technology 4 31 9 75a

    Grant activity 6 46 6 50

    a2 of 4.16, p < .05.

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    Perceptual Differences About Process

    The ECU physicians had a much narrower explanationfor the process of deliveringtelemedicine, which centered on their involvement with a consult. For the urban

    physician, the process seems to be encapsulated to fit around the specific

    telemedicine role. There was virtually no discussion of the pieces of this process

    that are taken care of by other members of the telemedicine organization. When

    asked specifically to name the people who work with the physician to perform

    telemedicine, three of the four physicians named the two program directors and the

    scheduler. Only one of the physicians also named the technicians as well as ac-

    knowledged a person on the remote end.

    The support telemedicine staff from the rural or remote sites responded from adifferent perspective from their urban counterparts when asked to walk through a

    case. Interestingly, six of the eight respondents (75%) did not provide a delineated

    sequence of events for providing telemedicine. Instead, they picked a recent pa-

    tient and narrated how telemedicine was done to these patients.

    RQ3: How do organizational members describe how telemedicine gets de-

    livered and how is this different from traditional health care?

    Almost without exception, respondents confidently discussed the process ofdelivering or doing telemedicine. Not surprisingly, each of the support staff at

    ECU spoke about the process of doing telemedicine in great length. This group

    alone collectively provided more than 20 pages of interview text about how they

    do telemedicine. What is similar across their responses is the step-by-step proce-

    dures they described, even though the interviewer simply asked them to give her a

    case and tell her what happens.

    Comments About the Process

    The most commonly acknowledged problem mentioned by almost half of the re-

    spondents concerned scheduling. A 1995 internal memo documented the problem:

    Problems getting Telemed consult requests to the coordinator. Continues to be a

    problem from thescheduling office. A rural physician said the hardest part is set-

    ting up a time when the consultant and the physician on our side are together. In

    addition to schedule problems, there were also complaints about the inflexibilityof

    thecurrent schedulingprocess. Onerural physician expressedthat the telemedicine

    process would be better

    if telemedicine would work on the basis that I would get an instant referral to

    anyplace at any time. I mean not to any place, but the necessary subspecialist

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    at any time. If I would see a patient today and I would tell you OK, we have

    got another opening in an hour where you will be seen by telemedicine too.

    That would be something I would like because then I would be able to settlethe issue in one setting.

    A little more than one third of the respondents complained about technical diffi-

    culties. As one respondent said, there are a whole host of technical problems.

    Never works all the time. It does not work when all the dignitaries are here to see it

    work. Another respondent talked about equipment glitches.

    There was also frustration about getting health providers encouragement. Al-

    most 30% of the organizational members discussed the challenges they faced in

    trying to persuade physicians and patients to accept telemedicine as a viable healthcare alternative. One urban support member explained, Telemedicine is in its in-

    fancy, and therefore nobody knows how to do it or what they should be doing.

    Another urban support member talked about doctors not being real excited about

    the system. Having to convince them that there is good in it and it can work in their

    favor.

    A final problem mentioned by three telemedicine providers concerned the ex-

    pectation that they do so much work. One rural nurse said, Probably my biggest

    complaint is the amount of time. If I had somebody who could help with this

    even on a half-time basis that would be fine. About 15% of the respondentsstated that performing the actual consult was the easiest part. One urban physi-

    cian claimed its going in there, sitting down in the room, talking, its not hard.

    Theyve made it easy. Two respondents claimed that the easiest part was actu-

    ally making the referrals.

    The management difference, however, was seen as one of a personal context.

    Even though most respondents placed a beginning and an ending to the

    telemedicine consult, their descriptions of the process and its attendant problems

    evidences an understanding of the complexities and ongoing processes involved in

    making telemedicine possible. Very few (10%) felt that telemedicine was only in-teraction via video. Theoretically, one staff member pointed out, its just man-

    agement of disease. Not surprisingly, 60% of all respondents specifically

    mentioned the lack of hands-on care, and another 20% mentioned that the doctor

    and patient are not physically together. Their examples regarding this major differ-

    ence were not subtle. For example, some respondents acknowledged that they had

    to rely on other health providers in ways they would not have to in a traditional

    consult. As one urban physician explained

    If we see a scaly lesion on the face, we want to know if its thickening or not.We have lost that capability and we rely on the people on the other end. Of

    course, if its someone we know and trust, we rely on them more than if its

    somebody we dont know.

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    In addition to the clinical information denied from physical presence, some physi-

    cians pointed out the relational disadvantage of providing care at a distance. One

    physician stated that its against everything that were taught as far as touching thepatient hands on developing that kind of rapport with the patient the stuff that

    were taught is part of being a doctor. Others viewed the lack of touch as the limit-

    ing factor for telemedicine.

    Another physician explained how telemedicine changes the actual consult

    interaction:

    And the big thing Ive noticed was how much I glance when Im talking to

    Mrs. Smith. Im looking at her arms and looking at her face and looking for

    skin cancers or a rash. Telemedicine is much more pointed. You talk to thepatient and then you break off and say, Ok, I need to look at her, or show me

    her cheek and you lose that sort of incidental quality and it becomes very

    pointed.

    On the other hand, one urban support member felt that

    Rather than being impersonal, in some ways it can be more personal the

    [consulting] doctor is here. Hes not going tobe distractedbyother things .

    I found that doctors wanted to take more time and speak over the network. Ithink theyre so concerned in establishing a personal relationship that they

    spend more time with clients.

    Rural nurses saw similar potential benefits because there are providers at both

    ends, physicians talk more, and more people are involved overall. One felt that in

    order for telemedicine to work better we have to develop ways that the informa-

    tion flow happens a lot better. A rural nurse explained the following:

    Granted, the physician who is on the telemedicine gets to ask anything he orshe wants but that physician generally does not have access to as much of

    the medical record as someone who would see our patients in person.

    As one rural physicians assistant stated, there are certain kinds of things you cant

    do through telemedicine. Hands on kinds of things so there is always going to be

    a place for actual in-person referrals.

    DISCUSSION

    In part, this project has been an adventure in exploring organizational sense mak-

    ing.The researchers havesought togainanunderstanding of how telemedicine pro-

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    viders structure the unknown (Waterman, 1990, p. 41); how they (organiza-

    tionalmembers) constructwhat they construct, whyandwith what effects(Weick,

    1995, p. 4). This study reveals many important lessons about the invention andcontextualizing of telemedicine in North Carolina. Taken together, the results of

    this study indicate how and why individuals organize this particular telemedicine

    program. The differences between rural and urban practitioners understanding of

    telemedicine suggest more deeply rooted conceptions of health care delivery and

    particularly telemedical healthcare.This technologyappears to have created a hier-

    archical context, constructed with a sense of place where people are actedonver-

    sus acted with, in which new kinds of relationships are formed with unique rela-

    tional demands and in which ground and figure both literally and figuratively

    constantly shift. The communication possibilities and contrast demand ourattention.

    Hierarchical and Unidirectional Conception of Telemedicine

    Talk from people at both rural and urban sites evidenced a rather hierarchical, uni-

    directional conception of telemedicine. They all agreed that it begins at the rural

    center, but power resides at the urban hub. Given the hub-and-spoke metaphor that

    characterizes this innovation across programs, the perceived power is rather pre-

    dictable. Even though the consult is initiated at the rural sites, the specialty physi-cians think they control all activities. They control scheduling functions at their

    own hub site, as a telemedical event cannot take place until it fits into their sched-

    ules. They provide the expertise during a medical consult to the patient at a remote

    site. They also pass down their wisdom by educating health providers at remote

    sites. Nobody talked of potential insight and information that remote providers

    could share with specialty physicians. In essence, this telemedicine activity is

    thought to emanate from the hub site via theconsultants. Rural support staff are im-

    plicated as less powerful in this hierarchy. The rural telemedicine coordinators re-

    port (at least 50% of the time) to the grant operationsmanager atECU.Theyare toldhow to schedule consults, how to collect feedback, and what to do during the 20 hr

    per week they devote to telemedicine. For the most part, power and control can be

    found in Greenville, the urban hub of North Carolina.

    Burrell (1988) explained that power and control do not reside within things

    (such as technology); they reside in a network of relationships which are system-

    atically connected (p. 227). Time will tell how these relational networks will

    change. Perhaps the referring physicians will flex their muscles as they come to

    recognize that they are the true gatekeepers. After all, most of these people told us

    that telemedicine actually starts with the referring physicians decision to send apatient to a specialist. Although on the surface it might look as if the rural sites

    have no power to initiate change, a deeper reading suggests they actually hold the

    key to the existence of this organization.

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    A Sense of Place

    North Carolinians descriptions of telemedicine activity were filled with a sense ofplace. They situated telemedicine delivery in a remote clinic or in the tertiary medi-

    cal facility. One is either fortunate enough to have the convenience of staying at

    home or privileged enough to receive the quality of care that is found at a tertiary

    facility. There is not yet a new sense of a place in which health encounters occur.

    Perhaps this is because patients and providers still must physically sit in a medical

    facility to do telemedicine. As we watch telemedicine shift into the home (Allen,

    1995), perhaps these perceptions will be altered, but for now telemedicine is as

    much a sense of place as it is a new technology.

    Acted On Versus Interacted With

    Within this context, telemedicine emerged as something that is done to people.

    Szasz and Hollender (1993) acknowledged the traditional notion of health delivery

    where thedoctorpatient relationshipdependson what the doctor does. With a non-

    traditionalmedium, things do not appear to be much different. In thehills of eastern

    North Carolina, specialists do telemedicine to patients. Patients are acted on, not

    interacted with. From their explanations, one would not expect particularly highlevels of patient satisfaction with telemedicine, but research does not bear this out.

    According to Allen et al. (1994), telemedical patients are moderately satisfied.

    Other research has shown that patients also are often satisfied with the traditional

    medical care they receive from providers. However, they are less than pleased with

    the warmth (Daly & Hulka, 1975), level of friendliness (Korsch & Negrete, 1972),

    or interpersonal involvement and expressiveness (Street & Wiemann, 1987) of

    physicians. Research already has demonstrated that patients are unhappy with the

    traditional way that medicine gets done to them, but they are generally satisfied

    with the medical care. This telemedicine seems to beno exception, eventhough thisstudy does point to the possibility of more patient involvement and more physician

    interactions.

    New Relationships

    The telemedicine providers in North Carolina organize telemedicine in a manner

    that appears to change relationships and communication practices in seemingly

    positive directions. Some physicians are enticed by the notion that their patients donot disappear into a black hole when they refer them to a specialist. Instead, with

    telemedicine, the rural physician can actually be present during the specialty con-

    sult andobtain immediate feedback about thepatientscondition. The telemedicine

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    context also sets the scene for the development of new relationships. Health com-

    munication research has shown us that effective health care relationships provide

    many health-related benefits,whereas the failure to establishvital relationshipscanactually hinder the accomplishment of health care delivery goals (Cline, 1983;

    Kreps, 1988). With telemedicine, referring and consulting physicians can meet

    face-to-face and come to know one another. Only through telemedicine can a re-

    ferring physician actually come with a patient to his or her specialty consultation.

    Telemedicine sets the scene for a give-and-take of information and support be-

    tween physicians and other health providers. Patients can also bring in their fami-

    lies to participate in consults resulting in relationships between physician and fam-

    ily member.

    Some physicians at ECU were incredulous at the new way they were doingmedicine in the telemedicine context. Doing telemedicine means trusting in ways

    never taught in medical school, they said. Suddenly, a physician must rely on the

    touch of a health provider he or she does not work with closely. Suddenly we see

    a mammoth contextual difference between traditional and telemedical care:

    Telemedicine as a context can only exist with this trust as a core component.

    A Shifting Context

    Healthproviders in North Carolina have alsocreated a context for telemedicine that

    seemingly holds a higher standard than required for the practiceof doing traditional

    medicine. We saw this displayed in frustration expressed about scheduling and co-

    ordinating information transfer.Forsome reason, this context expects patient infor-

    mation to be more accessible via telemedicine than traditionally. The created con-

    text dictates that any physician who has less than total knowledge about all aspects

    of a patients health should be frustratedwith this system. Yet, whathealth provider

    in traditional medicine has access to this type of information? The process of faxing

    or mailing patient records can be complex and exceedingly slow in traditionalmed-icine.Yet, the telemedicine context dictates higher expectations of almost instanta-

    neous retrieval, and the expectation is that this happens before, during, and after the

    consult.

    Initially, telemedicine in North Carolina was about doing consults within a

    prison setting. Suddenly a medical director was hired, and telemedicine was about

    outreach and education. New sites were established, and telemedicine became a

    process of scheduling and coordinating. A grant operations manager came on

    board, and telemedicine became a GO Team project. The impending onset of

    managed care came crashing into North Carolina, and telemedicine became a solu-tion for the financial constraints of medicine. The director of the telemedicine pro-

    gram had a vision for a docking station, and telemedicine became the mechanism

    to transition medicine into the next century for North Carolina.

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    This case study has provided story after story of how organizing has impacted

    the people who do the organizing, whereas the people who do the organizing have

    simultaneously impacted the very organizing process (Giddens, 1979). Within de-velopment of this context, it is simply impossible to separate the individuals from

    the organizing process. For example, more than 60% of the consults performed at

    ECU have been done by a handful of dermatologists who are telemedicine champi-

    ons. Much of this context would have been different if the physician champions at

    ECU had been emergency physicians. The process of scheduling and coordinating

    telemedicine simply would not be the same.

    These health care providers warned us in their own way not to expect this con-

    text to remain static. They told us that they were looking for more members and

    more types of applications as well as more business. They told us that they wereconcerned about the plight of this organization when grant monies disappeared.

    They told us they were keeping an eye toward tomorrow as they do telemedicine

    today. They also joyfully bragged about their accomplishments and their fun of

    communicating like the Jetsons. They tantalized us with their excitement and

    worried us with their frustrations. They taught us that to understand the

    microaspects of delivering telemedicine, we must understand the macroaspects of

    organization.

    But we must heed their caution that this context is constantly changing. It is im-

    portant to note that contextual change does not just happen because time passes.One must look to symbolic interactionist theory (Mead, 1934) to understand that

    contexts are social in nature and change through social interactions. From an

    interactionist perspective, human beings continuously rely on communication to

    create and transform complex worlds of interaction. Contextualization is the active

    and interactive creation of context through human interaction (Lutfiyya, 1987).

    Because social context is both socially constructed and fluid, it must be assumed

    that the telemedicine program located in North Carolina is going through a contin-

    uous process of recontextualization.

    This case study illustrated the inseparability of communicating and organizing.Communication is not just some vehicle that facilitates the life cycle of an organi-

    zation. Instead, communication serves as the foundation of the organizing process.

    The creation, maintenance, and understanding of telemedicine at ECU occurs

    throughrelationship building, shared constructions of hierarchies and power struc-

    tures, the development of trust between providers that enables telemedicine activ-

    ity to actually occur, and the creation of expectations that guide the norms and

    membership roles for mutually acceptable delivery of this service. Indeed, it is

    through communication, through the sharing of evolving understandings of

    telemedicine, that these organizational members perform the continuous processof organizing.

    Perhaps the most important lesson provided by this case study is the reminder

    that we can study specific contexts, we can get excited about new technologies and

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    organizations, but we can never stray too far from the universal role played by

    communication. It is through communication that we mutually create understand-

    ings about innovations such as telemedicine and ultimately come to organize our-selves to perform as an organization. Communication is the basis for trust,

    relationship development, power and hierarchy issues, development of job norms

    and role expectations, and how we arrive at shared understandings of what our or-

    ganizations are. To understand any phenomenon, we must understand how people

    organize, how they make work orderly.

    IMPLICATIONS

    Because of the descriptive nature of this study, specific implications for future

    telemedicine researchbecameevident. This section seeks to engage the readers in-

    quiry by providing specific examples of those things that make telemedicinediffer-

    ent and howthese examples may serve to impact traditional medicine. The purpose

    of this research project in some ways transcends telemedicine and can be applied to

    any health care or technological study. Clearly, we need a better understanding of

    telemedicine, or any health delivery system, in terms of its organizational or social

    context. Conrath, Dunn, and Higgins (1983) issued a warning to future

    telemedicine researchers:

    A technology does not stand alone. Neither should it be evaluated alone. Its

    use takes place in a socialcontext and has aneffecton that system. Toassume

    otherwise, or to assume the consequences are irrelevant, or to assume that

    they can only be good, is to place man as the servant of machine. Conscious

    effort has to be made to ensure that the situation is the reverse. (p. 201)

    Thisstudy has heldas its premise that toprivilege the technology of telemedicine

    over the context of a telemedicine organization would be a grave mistake. In linewiththisapproach,telemedicineshouldbeviewedinanewway.Ratherthantalking

    about telemedicinein thetraditional manner asthedeliveryof medical servicesvia

    telecommunications technologies, this study creates a new dialogue in which

    telemedicine becomes many things ranging from access to a grant activity. The

    study of other health care technologies in this manner offers the potential for a new

    understanding of the health services we have available to us.

    Results from this study illustrate the potential role the telemedicine context

    may play in our changing expectations of health care. The organizational members

    in this telemedicine program indicated through their comments a shifting in thevery paradigm of health delivery. Taken further, these results indicate that the pro-

    cess of communicating telemedicine is actually shifting the health care paradigm.

    Traditional medicine may alter as a result of new relational expectations suggest-

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    ing new solutions and presenting new problems for health care. For example, hav-

    ing referring and consulting health providers both present during a consult

    complicates the scheduling of a telemedicine event. At the same time, it enhanceslearning and potentially improves health care. Also, the literal dependence by a

    consulting physician on the hands of the rural medical presenter has necessitated

    the need for consultant and practitioner to dedicate time to know one another, so

    that the practitioner comes to understand what the consultants hands would do

    and feel; thus, they develop trust and a sense of the other. Because of these rela-

    tional shifts, the dynamics of the medical encounter as we currently understand it

    may ultimately shift and change who has control.

    To suggest that telemedicine may play an important role in shifting perceptions

    of what health care is and how it should be done has profound implications on thefuture direction of telemedicine research and perhaps health communication re-

    search more generally. First, it necessitates a more contextual approach to the

    study of health care. For example, mass media are often credited with reducing the

    entire world to a virtual global village. However, if we look back before this time

    of national town meetings, we find evidence of local town meetings where par-

    ticipation and interaction were key (Wiezenbaum, 1991). Second, telemedicine

    may alter the current modes of social behavior in health care. This could take the

    form, as exemplified through ECU, of health providers who traditionally did not

    work with one another, forming relationships that strengthen patient care by trulyfacilitating a team approach to health care. Or perhaps, telemedicine will lead to

    changing expectations that will impact providerpatient communication. Will the

    patient only develop a relationship with the health provider actually touching him

    or her? Research looking at telemedicine from the patients perspective will be

    needed to fully understand this reinvention. Perhaps patients will eventually care

    little about ever being in the same room as a physician. Perhaps they will sacrifice

    a physicians touch for the convenience and immediacy of being able to see their

    physician from their own home or the collaborative team efforts possible and nec-

    essary through this medium. If the contextualization of telemedicine does lead to arecontextualization of health care, communication researchers will play a vital role

    in explaining how health care is reinvented through changing social interactions

    and expectations. In short, traditional medicine may take on a new face as health

    providers absorb new relational elements into their delivery of medicine and pa-

    tients create a new understanding of what constitutes a medical encounter.

    Practical Implications for Telemedicine Practitioners

    The results of this analysis indicate several practical implications for telemedicinepractitioners. First, the success of telemedicine programs depends largely on

    well-defined roles and responsibilities. For example, the perceived beginning and

    endingpointsdiscussedinthearticleguidedjobrolesandresponsibilitiesastheyde-

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    terminedthescopeofjobfunctionsforeachindividual.Inthisprogram,participants

    indicated thatdoing telemedicine meant much more than turning on the equipment.

    It indicated that someone had to educate providers about potential issues oftelemedicine and that they had to schedule consults and persuade users, both physi-

    cians and patients.

    Second, the results of this study indicate that context plays a crucial role in the

    success of telemedicine programs. Thus, organizations must choose leaders who

    fit well with the goal and mission of the program, or who construct goals and mis-

    sions and choose team players willing to and able to accomplish them. Is the goal

    of the telemedicine program programmatic or protocol? Programmatic goals focus

    on service and demand leaders with medical and administrative backgrounds. Pro-

    tocol goals focus more on technical features and demand leaders who possessstrong technical skills.

    Finally, the results of this study indicate that conductinghealth careviatelecom-

    municationschanges managerssupervisoryroles.Forexample,nursesat ruralsites

    donotworkformallyfortheurbandoctorsconductingthesessions.Issuesofcontrol

    and direction change as a result of providing telemedicine, and these issues indicate

    thatmanagersalsomustchangehowtheysuperviseindividualswhodonotformally

    work for them. In addition, these results indicate telemedicine programs increase

    levelsof interdependencyamong healthcare providers. Thus, training should focus

    onestablishingtrustbetweenprovidersandonaidingmanagersindealingwiththesecontrol issues. In this study,accessemerged as an importantfeature of telemedicine

    programs, indicating that traditional notions of structure often do not apply.

    Telemedicine links facilities and people that normally are not linked by the formal

    structure. Practitioners need to develop training systems and adopt management

    practices that focus on the informal structures that emerge from doing telemedicine

    and likewise reexamine new structures that emerged through these interactions.

    At its premise, this study adopted the assumption that an organization does not

    precede communication and subsequently become supported by it. Instead, an or-

    ganization is simultaneously born through communication and constructed by it.This study sought to document this phenomenon by identifying the context of a

    specific telemedicine organization. Organizations and communication can no lon-

    ger be viewed as mutually exclusive. Instead, they are inextricably intertwined and

    can be understood through the context that evolves from their unity. Much like

    Dewey (1916) argued, Society continues to exist not by communication, by trans-

    mission, but in communication, in transmission (p. 4).

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    APPENDIX (Whitten, 1996)Interview Protocol

    How would you define telemedicine?

    What do you normally call what I am referring to as telemedicine?When did telemedicine begin in eastern North Carolina? Why was telemedicine

    created in eastern North Carolina?

    How does telemedicine differ from traditional medicine?

    Give me a case and tell me what happens. What kinds of decisions have to be made

    to make this happen? Who makes these decisions?

    When does care begin for a telemedicine client? When does it end?

    Whatdo yousee as theoverall purpose of providing telemedicine to the residents of

    eastern North Carolina?List thepeople who workwithyou toprovidetelemedicine and describe their jobs.

    What kind of individual and organizational goals do people have who provide

    telemedical care?

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    Who is in charge of telemedicine?

    What is the easiest part of using/doing telemedicine?

    What is the hardest part of using/doing telemedicine?

    When you have a problem of some kind with telemedicine, who do you call? How

    helpful is this person/office in resolving your problem?

    What kinds of problems have you encountered in the past when using

    telemedicine?

    If you could change one thing today about telemedicine at ECU, what would it be

    and why?

    Who do you consider to be your supervisor? Is it the same person when youre in-

    volved in telemedicine? If not, who do you consider to be your supervisor intelemedical situations? Who is your bosss boss?

    Who are your clients and where do they come from? What do your clients hope to

    get from their telemedical experience?

    Ifa new coworkerasked you todescribeyour job,whatwould you tellhim orher?If

    thiscoworker thenasked you what its like toworkhere, how would you respond?

    Pretend for just a moment that I am a prospective telemedical patient and I ask you

    to explain to me how being treated telemedically will work? How would you de-

    scribe it to me?What ifyou wereonanairplaneand the personnext toyou started a conversationby

    asking what you do for a living, and you proceeded to tell him or her about your in-

    volvement with telemedicine. As the director of Medical Grants R Us, your fellow

    passenger expresses interest and wants to hear more. How would you sell

    telemedicine to him or her?

    What channels or ways do you commonly use to communicate with other people

    who provide telemedical care? What kinds of things do you communicate about?

    Can you givemesomespecificexamplesof recent thingsyouhavetalked about.?

    Whats it like to administer (do) telemedicine to patients?