The diffusion of telemedicine and ehealth in Norway: a comparative case study analysis of the successes and failures of applications

The aim of the Diffmed project has been to explore how telemedicine and e-health has been introduced and received in Norwegian health care during the last 20 years. The study was initiated on the background of a growing critique of pilotism in health ICT, and a call for more large-scale implementation of ICT in the sector. The comparative case study has concentrated on two main topics; A) patient involvement and B) the dynamics between professional power, health policymaking and management. We found htat the patient perspective on telemedicine and e-health differs from professional and economic perspectives and expectations of increased efficiency and financial gain. For the patients it is the aspect of care that is important when they receive health ICT. We therefore argue that the patient perspective needs to be included in earlier stages of e-health design and development. There is an under-exploited potential in ICT for care (Andreassen, 2012; Andreassen and Lundvoll Nilsen, 2013; Andreassen, 2014). Related to our second topic; the dynamics between professional power, health policymaking and management, we revealed three interesting connections. First, the reception and extensiveness of e-health solutions needs to be explained in light of health sector power structures. We did a comparative study of to cases from Norwegian telemedicine; telestroke and teledermatology. Drawing on French sociologist Pierre Bourdieus concepts and theories we illuminated how telemedicine both disrupt and might itself be disrupted by existing power struggles in the health care sector. When state promotion of e-health brings new actors and new positions into the sector this causes changes and tensions. The introduction and reception of telemedicine and e-health thus needs to be understood as related to other contemporary developments in health care. The edited Norwegian volume ´Samhandling for helse: Kunnskap, kommunikasjon og teknologi I helsetjenesten´ (Tjora, 2013) gives a good overview. Second, we revealed that running ICT projects has become a normalised practice in health care management. ICT innovation is done through projects that are run alongside, although in cooperation with, day to day routine work. This is useful for management and administration on several levels, but it also delays expected diffusion of technology (Andreassen, Kjekshus and Tjora, submitted publication). A third finding was that the medical context, i.e., the nature of clinical work that is to be performed, is of importance for the use and non-use of telemedicine. E.g, the need for, and use of videoconferencing equipment is completely different in acute vs non-acute clinical work (Lundvoll Nilsen and Andreassen, 2013). The results from the Diffmed project give a more nuanced and complex explanation of how telemedicine and e-health intervenes in health care compared to previous debate. Up until now the literature has been dominated by the overall question of what (and how) e-health adds to clinical practice, and the potential for improvement and more effective practice has been discussed on this basis. The findings from Diffmed illuminates how the diffusion of e-health also needs to be explored in relation to a) patients everyday perspectives, and b) changes in health sector power-structures. These are new angles in contemporary e-health debate, and we expect them to become important for future discussions on how to succeed with e-health implementation, as well as for the detailed planning of new telemedicine and e-health solutions in the years to come.

The aim of DIFFMED is to identify factors that promote and hinder the diffusion of telemedicine, by detailed analysis of a number of case studies. The main question we ask is: how and why do telemedicine/ehealth (hereafter 'telehealth') applications (proj ects) succeed and fail. On basis of interview-, observation- and document studies of 10 telehealth applications, we will not only identify relevant factors, but also develop concepts to understand the challenges, within two main themes (A; patient involve ment and B; dynamics between professional power, health policy and management). Results from the study will be of major importance for the understanding of how information technology may better support organising, integrating, managing, financing, deliver ing, and securing high-quality health and care services. Norway's application of telemedicine has been in the international front. With a strong international team on the DIFFMED project, we will also be able to strengthen health-related social research on the impact of telemedicine. Hence, the project have both academic relevance for the nuanced assessment of telemedicine, and health-related, economic, and political relevance for the future of telemedicine.