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what are some merging healthcare technology system?

Virtual medical geographies:
conceptualizing telemedicine and
regionalization1

Malcolm P. Cutchin
Department of Occupational Therapy, University of Texas Medical Branch,
Galveston, TX 77555, USA

Abstract: Telemedicine is an innovation that is changing the geography of medical care
provision. Regionalization of care is one important type of geographical change resulting from
the implementation of telemedicine technology. This paper introduces a range of issues bound
up with telemedicine and medical care regionalization and offers a geographical conceptualiza-
tion of those issues through a synthesis of ideas from several literatures. It begins by providing
a background for regionalization and telemedicine. The paper continues by examining the
formation of ‘virtual’ regions and the problem of their internal integration and integration with
‘material’ regions of care. A penultimate section argues for the use of regional economic
geography and territoriality as contexts for understanding the continued growth and
development of telemedicine networks. As part of an overall critical challenge to the pro-
telemedicine bias in the medical care literature, the paper ends by suggesting the development
of a normative ethics by medical geographers.

Key words: telemedicine, regionalization, technology, virtual regions, networks, integration,
regional economic geography, territoriality, ethics.

I Introduction

During the last decade, telemedicine has emerged as a consequential innovation within
the medical care system. Telemedicine is expected to evolve into ‘a wide-spread and
permanent fixture of the medical care landscape’ (Grigsby, 1997: 318). Although
telemedicine may be defined as ‘the use of electronic information and communications
technologies to provide and support health care when distance separates the partici-
pants’ (Field, 1996), the most central form of telemedicine is the interactive video-
consultation between a distant specialist and the local primary care provider and

Progress in Human Geography 26,1 (2002) pp. 19–39

© Arnold 2002 10.1191/0309132502ph352ra

20 Virtual medical geographies: conceptualizing telemedicine and regionalization

patient. The implementation of this technology is geographically restructuring medical
care systems. Telemedicine’s impacts on the geography of medical care include the
reshaping of space-time and access to specialized care, the reformation of place and
medical care communities, the redirection of medical care regionalization, and the glob-
alization of care systems. Nonetheless, with only a few recent exceptions (Shannon,
1997; 2000; Mayer, 2000; Löytönen, 2000; Strömgren, 2000), geographers have paid little
attention to the implications for medical care, both positive and negative, arising from
telemedicine. Moreover, telemedicine research in general has all but ignored the
character of ‘virtual’ medical care regions and their integration with traditional care
regions (Bashshur et al., 2000). This paper will focus on telemedicine and the regional-
ization of care with particular attention given to the USA. Regionalization and telemed-
icine exist in a reflexive relationship to one another. The paper conceptualizes regional-
ization and telemedicine and their reflexive relationship through a synthesis of ideas
from several literatures.
While the paper’s primary focus is placed upon the medical care dimensions of

telemedicine and regionalization, it is important to provide some background for the
larger geographical contexts within which regional telemedicine systems and their
most important associated issues are situated – contexts that cannot be addressed in full
here. Therefore, a brief discussion of those contexts should be useful to set the stage for
both the arguments to follow and additional routes of further geographical inquiry into
telemedicine. Among the geographic contexts in which to place telemedicine, I will
briefly describe the rural, economic and ethical.
The restructuring of medical care in the USA via telemedicine is occurring most

frequently in a rural context. This restructuring process is qualitatively different than
that analyzed by Kearns and Joseph (1997) in New Zealand, but the outcomes in rural
communities may share many characteristics. It should be acknowledged that the
concept of rurality remains complex and problematic, but it still has value if recognized
as an entity arising from the social representations of space created by academic and lay
discourses (Halfacree, 1993). The specific rural context, then, shifts with the nature of
the local discourse and is thus able to account for the tremendous diversity in rural
settings and space. Indeed, despite the fact that in the aggregate American rural
populations remain poorer and less educated than urban ones, the range of rural
experience is broad (Economic Research Service, 1995). In addition, rural areas in the
USA and Europe are undergoing significant economic change and restructuring (Beyers
and Nelson, 2000; Marsden et al., 1990; Murdoch and Marsden, 1996) with differing
outcomes. Overall, however, American rural populations experience more serious and
severe health problems than urban populations (Gesler et al., 1992; Ricketts, 1999), and
much of that experience is exacerbated by poverty and the material circumstances that
accompany it (Schneider and Greenberg, 1992). Moreover, American rural populations
face inequalities in access to care when compared to their urban counterparts (Schur
and Franco, 1999; Ricketts, 2000). It is in this medical and wider rural context that
telemedicine plays a role in reshaping the space of care.
As just suggested, the question of telemedicine rests not only in a rural geographic

context but in an economic-geographic one as well. The role of important technological
advancements and their economic applications has been recognized as central in
development of the global economy and world-system (Hugill, 1993; Knox and Agnew,
1998). Indeed, technological systems, not unlike those used in telemedicine, have been

the primary engine of global economic change, although it is important to view them
as enabling rather than deterministic (Dicken, 1998). As I will argue, telemedicine
should be considered as an important part of the package of technologies and related
processes that shape emerging economic geographies. Such information technologies
serve to help firms – and I would include medical care firms – exploit geography better
(Charles, 1996). Furthermore, technology has been recognized as essential to regional
economic change (Malecki, 1997) and to the creative destruction and re-emergence of
regional economies (Florida, 1996).

Not independent from these contexts but distinct from them is the ethical context of
telemedicine. There are numerous questions that arise from two relevant themes
recently articulated by Proctor (1998): what is the place of ethics in geography, and what
is the place of geography in ethics? Whereas significant works by geographers are
emerging to address those questions (e.g., Proctor and Smith, 1999; Smith, 2000), the
relevant question for this paper is: how do we begin to think about telemedicine and
regionalization as ethical-geographic issues? Crampton (1999) provides some direction
by addressing the ethical dimensions of the internet, and two points are worth noting.
First, he suggests that technologies such as GIS or the internet give rise to competing
logics – totalizing and democratizing. Second, the utilization of new technologies
creates new practices and outcomes – ‘a geography of virtualization’ – that leads us to
ethical questions about connectivity and access. Some of the arguments below speak to
these ethical questions, if only implicitly. In sum, telemedicine resides within the con-
text of a geographical ethics similar to its technological brethren GIS and the internet.

This paper is organized into three sections (II, III and IV) with two subsections each.
Section II offers a more general conceptual basis for understanding regionalization and
telemedicine. The first subsection provides an overview of the question of regionaliza-
tion of medical care and its numerous meanings and underlying ideologies. The various
circumstances of regionalization are the backdrop for conceptualizing how telemedi-
cine is affecting, and more importantly, is likely to affect in the future, medical care
regionalization, and with it, the medical care system at larger and smaller geographic
scales. The second subsection reviews several recent geographical perspectives on new
communication and information technologies as an additional context for conceptual-
izing telemedicine and its virtuality.

Section III emphasizes the ways in which telemedicine creates both regions of care
and new problems associated with them. The first subsection explains how telemedi-
cine creates new geographies of care through the formation of virtual regions. In this
subsection, I discuss the ‘internal’ integration of virtual care regions and their prob-
lematical aspects. The second subsection covers the problem of ‘external’ integration
between the virtual and material networks. Although proponents of telemedicine
understand some of the hurdles to integration, geographers can extend and deepen
their understanding as well as add insight into other aspects of integration. An
overview at the end of that subsection provides a range of integration prospects and
problems.

Section IV concentrates upon the regional economic context for the current and future
implementation of telemedicine. The increasing role of telemedicine in hospital and
medical care networks in the USA also suggests the questions: why telemedicine and
why now? Beyond the more deterministic arguments for the implementation of
telemedicine technologies, medical care organizations may be viewed as firms in a

Malcolm P. Cutchin 21

22 Virtual medical geographies: conceptualizing telemedicine and regionalization

regional economic geography of care provision. In essence, there are many ways that
telemedicine may generate power for a medical care organization in a regional setting.
The first subsection will briefly develop how telemedicine can be viewed critically as an
enabling agent in strong economic competition among regional medical care agents.
The second subsection suggests territoriality as a central dynamic in telemedicine
systems and their economic geography. Telemedicine networks offer medical care orga-
nizations a way to define, expand and defend territorial control. Thus the regional
power of a large telemedicine hub becomes more than economic; it becomes political.
This subsection thus sketches how territoriality may add yet another important
dimension to geographical analyses of telemedicine.
The conclusions (section V) reiterate the key arguments and suggest linkages

between regionalization and other geographic aspects of telemedicine. Telemedicine
regions are only one piece of a complex geographical puzzle created by the technolog-
ical practice. Moreover, the paper concludes that geographers should not only concep-
tualize and theorize the new dynamics created by telemedicine but also develop
normative arguments for the possible outcomes of these new systems of care.
Philosophical bases that can support the technology-society-geography nexus will aid
us in conceptualizing and critiquing telemedicine. Perhaps more importantly, such
bases will assist us in arguing for and designing an ethical and just form of telemedi-
cine – one that upholds shared values of medical care delivery including accessibility
and equality of care.

II Conceptual bases of medical care regionalization and telemedicine

1 Regionalization of medical care: a multifaceted concept

The regionalization of medical care is not a new idea. Regionalization2 has been
implemented in many countries, and the meaning and utility of regionalization has
been discussed in the USA since the 1920s (Hassinger, 1982). The first generation of
telemedicine that developed in the 1970s failed because of financial, technical and
behavioral constraints (Bashshur, 1995). The rapid re-emergence of telemedicine
networks in the USA during the 1990s presents a new set of questions regarding both
regionalization and telemedicine. Although the academic literature does not cover the
relationship between telemedicine and regionalization to any significant degree, the
interplay between the two processes present conceptual and applied challenges to
medical geographers and health service researchers.
Non-geographers have contributed the bulk of ideas regarding regionalization in

medical care, and therefore have dominated the way we might think about the problem
in the USA. Beginning with the British Dawson Report of 1920, various US government
studies and programs relied upon some concepts of regionalization to suggest improve-
ments in the delivery of care to underserved groups. These planning efforts have been
extended by more critical assessments of the potential of regionalization. Eli Ginzburg
holds a prominent position among those who have contributed to our understanding
of the problems and prospects of regionalization. Ginzburg (1977) suggests that region-
alization is a slippery concept that varies from writer to writer. Regardless of definition,
the intention of regionalization programs is to improve access, quality, cost and equity
(Ginzburg, 1977). While the literature on regionalization acknowledges key intra- and

interorganizational components to some forms of regionalization, the primary process
is a geographic one. Regionalization programs can accentuate one or a combination of
the following: the distribution of physicians, the distribution of capital expenditures
and the control of patient movement within the system (Ginzburg, 1977).

Discussions of regionalization usually recognize that a vertically organized hierarchy
must be imposed across a landscape by ordering services spatially following the orga-
nizational structure and the regionalization emphasis (Lewis, 1977). Christaller’s con-
tribution to such thinking through his central place theory is recognized in the health
services literature (e.g., Hassinger, 1982; Luke, 1992) as well as the geographic literature
(e.g., Shannon and Dever, 1974). The net effect is argued as a ‘rationalization’ or
‘appropriate distribution’ of scarce resources to better meet the needs of a population in
a defined area (Ginzburg, 1977; Lewis, 1977).

A reorganization of delivery systems can thereby result in either decentralization or
centralization. One form involves the devolution of power at a larger scale to regional
entities resulting in decentralization (Sheps and Madison, 1977). Yet regionalization is
also used to describe the formation of regional coalitions of community-based organi-
zations to share resources and improve efficiencies (Sheps and Madison, 1977). The
perspective from which one views organizational change has much to do with how one
characterizes a regionalization process (Hassinger, 1982). Individualism and
‘community independence’ are often based in anti-centralization positions and are seen
as barriers to regionalization (Lewis, 1977).

More recently, regionalization has been discussed in terms of both multihospital
systems and community-based care. The former is a type of centralization as formerly
independent hospitals begin to share resources and identities as well as coordinate and
centralize decision-making (Luke, 1992). The latter suggests a decentralization of care
to local providers, citizens, and hospitals so that decision-making can be based in local
knowledge and local relationships (Hurley et al., 1995). Strangely enough, it appears
that both processes are occurring simultaneously in the USA. Nonetheless, local or
regional hospital systems have deeper ties to emergent telemedicine networks than
community-based systems, and hospital systems appear more central to regionalization
as set out by Ginzburg (1977).

Regionalization as an idea and a practice seems to evoke several ideologies. One
ideology of regionalization appears to focus on the rationalization of service distribu-
tion. This conviction tends to jibe with a welfare-based approach and government
objective of service equity across a bounded population. Arguments for regionalization
are also used to serve the needs of medical care organizations, particularly privately
owned ones. This cost-savings ideology is based more directly on the organization’s
ability to manage a regional system to save expenditures and increase net operating
results. A third regionalization ideology appears to be that of local control, where
community care offers greater equality of service provision. Rather than the state or
medical care organization, grass-roots health care advocates seem to promote this
ideology. The varied influence of these ideologies in a regionalization argument will
help to define the type of geographic changes to take place in the medical care system.

In Canada, regionalization has been implemented to a significant degree. The
provinces have taken different paths to regionalization, but a cost-savings ideology has
served as the primary motive for action across the country (Reamy, 1995) even if equity
and enhanced citizen participation are also part of provincial governments’ rationale

Malcolm P. Cutchin 23

24 Virtual medical geographies: conceptualizing telemedicine and regionalization

(Church and Barker, 1998). Some have found fault with the outcomes of this process,
focusing on the negative impact on rural communities as hospitals have been consoli-
dated and closed (James, 1999). Others have suggested that Canadian regionalization
faces significant hurdles in creating savings, efficiency and increased participation
(Church and Barker, 1998). Yet others view Canadian reforms as positive when
compared to the US situation because of the compensating effect of better access to
primary care in Canada (James et al., 1996).
The USA has not made significant progress in regionalizing its medical care system

for improved access, quality, cost or equity. Regions of differentiated care do exist in the
USA (e.g., Bohland and Knox, 1989), but such regions are not based as much on the goal
of creating organized, efficient patient care as they are on the historical development of
competitive advantage in a largely privately run, fee-for-service marketplace. This is
most evident in California where regionalization is driven ‘by managed care market
forces with significant limitations in access’ (James et al., 1996: 758). Moreover, there
have been barriers to achieving the advantages of such idealized, organized regional
systems. Beyond those discussed above, there is the lack of federal will, and thus power,
to affect change in a market-based system (Lewis, 1977; Ginzburg, 1977). There also is
the lack of initiative or momentum behind such a movement, both with the public and
within the medical sector (Sheps and Madison, 1977). In addition, there has not been the
requisite mechanism in place to provide the feedback needed by regional systems to
adjust and care for their populations effectively (Ginzburg, 1977). Finally, because the
USA does not, as does Canada, offer universal health insurance, enhanced primary care
access and organized referral systems, regionalization is unlikely to live up to the more
idealistic ideologies of rationalization and local control (Grumbach and Anderson,
1996).
This subsection has set out the basics of what analysts have suggested regionalization

could be, should be, and is. Furthermore, it has pointed to problems in forming a type
of regionalization that improves access, quality and cost of care. I will now turn to a
conceptualization of telemedicine vis-à-vis communications and information
technology. That discussion serves as a basis for understanding how telemedicine is
unfolding – and is likely to unfold – with respect to regionalization. While the
movement toward regionalization has remained a very gradual one, new networks,
and thereby regions of telemedicine, have been put in place across the USA.
Telemedicine is likely to accelerate health care regionalization in the USA. Because of
this and other developments, the rise of telemedicine generates conceptual and applied
challenges to medical geography.

2 Telemedicine as geographical technology

The re-emergence of telemedicine in the 1990s occurred for various reasons – some
related to need, others to the advance in telecommunications technologies and
networks such as the internet and world wide web. Telemedicine involves the use of
two-way interactive audio, video and/or computer technology to deliver care to distant
patients and facilitate the exchange of information between specialist and primary care
physicians (Bashshur, 1997). The result of telemedicine consultations is ‘virtual’
medicine – care that intends to be the same as if the doctor were physically present but

does not take place as a ‘material’ (physical) medical care consultation. This aspect of
telemedicine as virtual medicine necessitates a brief consideration of how it fits into
recent analyses of new communications technologies and associated geographies.

Hillis (1998: 543) argues ‘the issue of communications has been underpursued,
underexamined, and undertheorized by geographers’. Hillis (1998) suggests that,
because communication signals are not visible and because communications technolo-
gies have become ‘naturalized’, geographers have failed to critically assess the social
relations both informing and affected by communication technology use. One answer
is to try to understand the place-based processes bound up in the interaction of humans
and technology (Hillis, 1998). Batty (1997) adds to the understanding of how geography
might address this lacuna. He suggests (Batty, 1997: 340) that new information tech-
nologies have created a virtual geography which:

. . . is the study of place as ethereal space and its processes inside computers, and the ways in which this space
inside computers is changing material place outside computers. Around this Janus-like face of virtual
geography lies the study of the geography of computers and networks from a traditional, non-ethereal
standpoint.

Batty (1997) further articulates virtual geography to include place/space, cspace,
cyberspace and cyberplace. The first is the original domain of geography, whereas the
second entails abstractions of space inside computers and their networks. Cyberspace
includes the spaces that are created through intercomputer communication, and
cyberplace is the effect on place of cyberspace infrastructures.

Establishing the importance of geography within technology-society relations is one
step; another is how geographical theory might be created or used to understand these
relations. Graham (1998: 167) argues that ‘substitution and transcendence’ theories that
focus on the deterministic impact of information and communication on society are
utopian and highly problematic, often because of their reliance on metaphors that
mislead and ‘obfuscate the complex relations between new communications and
information technologies and space, place, and society’. The best theoretical solution
according to Graham lies in the ‘relational’ view that creates recursive and ‘recombina-
tory’ linkages between technologies and space and place – linkages that help us define
and understand effects of each on the other in an ongoing and changing way. Kitchin
(1998a; 1998b) also argues for a geographical analysis of cyberspace that is broad in its
inclusion of social constructivism, political economy, feminist and postmodern per-
spectives. Kitchin (1998a: 402) suggests that such an ‘integrative approach allows us to
deconstruct carefully the implications of cyberspatial technologies within the context of
the world we do live in and to understand the symbiotic relationship between the
virtual and nonvirtual worlds’. In particular, tensions between geographic centraliza-
tion and decentralization, along with questions of power and inequality, result from an
initial critical view of cyberspace (Kitchin, 1998a).

Together, Hillis, Batty, Graham and Kitchin make important conceptual and
theoretical contributions to a geographical understanding of the change in communica-
tion and information technologies during the last decade. Telemedicine technology
used in clinical care (e.g., diagnosis and therapy) is not yet as complex as the networks
and interactions considered by these scholars, such as those entailed in various aspects
of the internet. Telemedicine most commonly involves intranets with considerable
structure and limited flexibility. This point does not negate the fact that telemedicine is

Malcolm P. Cutchin 25

26 Virtual medical geographies: conceptualizing telemedicine and regionalization

developing in the direction of more flexible web and wireless structures (Shannon,
2000; Löytönen, 2000). Whether considering the more fixed or more flexible telemedi-
cine structures, however, medical geographers should heed these theorists’ arguments
because the innovation and implementation of telemedicine technologies produce
virtual medical geographies. Besides concentrating on the role of space and place in
understanding the reflexive role between telemedicine and society, medical
geographers need to address another important type of geography resulting from
telemedicine – the virtual region.

III Virtual regions, material regions and their integration

1 Virtual care regions and networks

By definition, telemedicine is regional.

A telemedicine system is an integrated, typically regional, health care network offering comprehensive health
services to a defined population through the use of telecommunications and computer technology.
(Bashshur, 1997: 9)

Although they may be constituted across geographical scales, telemedicine systems
usually rely on technological networks organized in a regional manner to deliver
virtual services to a population. This new ‘virtual care region’ is established in
conjunction with already existing, on-the-ground medical care facilities, the most
important being a tertiary care hospital. Such a hospital is normally at the center of a
function medical care region, serving as the highest-order facility that receives upward
referrals in a regional constellation of care providers and organizations. One regional
telemedicine system states the desire to ‘make telemedicine an ubiquitous part of
clinical practice’ (Telehealth Magazine, 2000). In effect, the proposal suggests that the
virtual network and region shall eventually be embedded within – indeed be the
backbone of – the entire existing brick-and-mortar network of a region. Moreover, the
implication is that the attainment of such a goal is entirely unproblematic. I argue,
however, that the advances in telemedicine notwithstanding, the virtual region of care
should not be taken-for-granted as a straightforward networking of an existing regional
system.
Networks underlie virtual regions of telemedicine, both in concept and in actual

infrastructure, and are thus fundamental to any understanding of telemedicine.
Networks on which telemedicine systems develop are structured predominantly in a
hierarchical manner with hubs and remotes (consulting and referring sites) forming the
essential nodes (Grigsby, 1997). Tertiary care centers have dominated the hub positions
to date, with some secondary care centers beginning to arise as secondary hubs (Adams
and Grigsby, 1995). Even though not put into practice in any sizable system,
‘distributed’ networks with less hierarchy and more capability of selected referral
patterns are thought to be a large component of telemedicine in the future (Grigsby,
1997).
Another issue that arises from an analysis of these exemplary networks is the areal

coverage vis-à-vis that of the material medical care system. There is a geographical non-
conformity of material and virtual regions – many places are left out of the region
defined by such networks. Many places currently fall in between the ‘spokes’ of the

telemedicine network.3 The arteries are in place, but not the capillaries, so to speak, and
thus a good deal of current access inequality in the USA exists. This phenomenon has
been noted in Australia as well (Mitchell, 1999). Perhaps an acceptable explanation for
the current situation is the novelty of the telemedicine networks; they just have not
developed enough to reach all the locations that they will eventually. Nevertheless, the
question remains: will the networks be diffuse and equitable? If other telecommunica-
tions networks are any precedent, many rural areas will not be included, just as the
most advanced telecommunications networks have bypassed many developing world
locations.

This concern about telemedicine has been raised in conjunction with innovation and
network theory. The success of telemedicine networks, and thereby the cohesion of
regions of care, depend not only upon the adoption of the innovation but also the
continued and useful implementation of telemedicine at the remote, referring sites
(Wells and Lemak, 1996). Moreover, referring providers must want to engage in an
equal …

International Journal of Technology Assessment in Health Care, 22:1 (2006), 136–142.
Copyright c© 2006 Cambridge University Press. Printed in the U.S.A.

Evaluating telemedicine: A focus
on patient pathways

Jane Coughlan, Julie Eatock, Tillal Eldabi
Brunel University

Evaluations of telemedicine have sought to assess various measures of effectiveness
(e.g., diagnostic accuracy), efficiency (e.g., cost), and engagement (e.g., patient
satisfaction) to determine its success. Few studies, however, have looked at evaluating the
organizational impact of telemedicine, which involves technology and process changes
that affect the way that it is used and accepted by patients and clinicians alike. This study
reviews and discusses the conceptual issues in telemedicine research and proposes a
fresh approach for evaluating telemedicine. First, we advance a patient pathway
perspective, as most of the existing studies view telemedicine as a support to a singular
rather than multiple aspects of a health care process. Second, to conceptualize patient
pathways and understand how telemedicine impacts upon them, we propose simulation
as a tool to enhance understanding of the traditional and telemedicine patient pathway.

Keywords: Clinical pathways, Computer simulation, Evaluation, Telemedicine, Patients

The telemedicine evaluation literature has grown substan-
tially from the advancement of a specific framework for
assessing telemedicine by the Institute of Medicine (IOM)
(16). This early report identified five dimensions important
to evaluating telemedicine: quality, access, cost, patient per-
ceptions, and clinician perceptions. However, a more recent
report by The Lewin Group (27) both confirmed and extended
these evaluation dimensions. It considered the properties of
these dimensions, in terms of measures and their impacts, but
also the methodology issues involved in evaluation. This di-
rectly responded to some disquiet expressed in the literature
over rigor and consistency that limited the generalizability of
some studies’ findings. In light of these concerns, we discuss
two possible improvements for telemedicine evaluation.

First, we argue that the focus of the evaluation itself
should be widened to look at telemedicine in the context
of the patient pathway (also known in the literature as the
clinical pathway) to understand its place along the patient’s
journey through the health service. Second, we put forward
simulation as a tool for evaluating telemedicine through its
representation of the patient pathway. Simulation will be
discussed as a viable methodology for addressing some of the
weaknesses documented in telemedicine evaluation, through
a review of the measures and methodologies used in the
assessment of telemedicine. The discussion of the potential

benefits of simulating patient pathways is supported by an
illustration—using leg ulcer sufferers as a case example—to
contribute to an understanding of care delivery by traditional
and telemedicine processes.

TELEMEDICINE EVALUATION ISSUES

Measures

Reviews of telemedicine evaluation are limited (1;12;25;27),
but those that do exist provide important overviews as to the
status of evaluations in terms of the measures and method-
ology used to assess telemedicine. Most evaluations have
sought to assess various quantitative measures of effective-
ness (e.g., diagnostic accuracy), efficiency (e.g., cost), and
engagement (e.g., patient satisfaction) to determine its suc-
cess. However, these studies have tended to focus on single
clinical contexts, specialties, and measures. To highlight the
problematic issues around the measures currently assessed
in telemedicine evaluation, we will briefly focus on three key
evaluation measures: (i) Diagnostic accuracy—this measure
has tended to overly dominate many studies’ outcomes (1);
(ii) Cost (and its associated variables, e.g., benefit, utility,
and so on)—many studies have equated a cost-saving as a
benefit, but with no reference to how it affects clinical out-
comes (28); and (iii) Patient satisfaction—this measure is the

136

Evaluating telemedicine

Table 1. Key Evaluation Methodology Issues for Telemedicine

Methodological Approach

Evaluation methodology issue Current telemedicine evaluations Simulation

Technological maturity
Progress of technology through its

lifecycle and the stage of evaluation
Often carried out as single case studies

of performance at too early or late a
stage and can often produce unduly
positive or negative findings (26)

Evaluates telemedicine along the
continuum of maturity from immature
prototypes to fully matured working
systems

Focus of evaluation
Scope of the evaluation from the

technology itself to its broader
context

The focus is predominantly placed on
the specifics of the technology itself,
as opposed to its organizational
impact (2).

Offers a more holistic approach, in
analysing the processes of care into
which telemedicine is situated, along
with key evaluation measures

Perspective of evaluation
Standpoint from which the benefits

of the technology are realized
A single perspective analysis is most

common, often to the point of
exclusion of the impact from an
alternative perspective (21)

Provides a multi-perspective analysis,
(depending on the model’s variables),
e.g., to reflect a patient/clinician view

Comparator
Definition of a suitable control group

with which to gauge the effect of the
technology’s intervention

Patients who are treated with and
without telemedicine and then
compared, are often not of a similar
level (8)

Allows a consistent way of performing
like-with-like comparisons as data from
a single set of patients can be run in both
the traditional and telemedicine models

Randomization
Assigning of participants to

experimental and control groups on a
random basis

This process is difficult to achieve as the
sample group in a study are generally
quite small, in some published cases
as few as ten patients (20)

Avoids randomization issues because a
single set of patients can be run in both
the traditional and telemedicine models

Time horizon
Duration of data collection in a study The focus has been on short-term pilot

projects, with a lack of follow-up (5)
Predicts future outcomes, applying the

analysis to gauge the long-term effects of
telemedicine implementation

most common evaluation undertaken, tends to produce con-
sistently positive results, but can often be misleading, as
patient satisfaction measures often fail to go beyond first
impressions (19).

A major reason for some of the limitations cited in the
research is that few high-quality studies exist (15). Despite
the usefulness of the clinical and economic data that have
been produced, the methodological paucity in the research
has somewhat undermined the value of the assessments un-
dertaken. This finding has resulted in calls for patients and
practitioners alike to remain skeptical over the professed
benefits of telemedicine compared with traditional face-to-
face patient care (12). In an attempt to manage some of the
methodological issues in telemedicine evaluation, simulation
is proposed as a potentially useful tool for producing more
robust findings.

Methodology

As a methodological approach, simulation revolves around
creating computer models of social structures and processes.
These models are subject to “simulation” that is experimen-
tation through the manipulation of variables (e.g., time and
cost) to understand the behavior of the model and evaluate

the extent to which it provides an accurate account of the
behavior of the observed system (13). In health care, simu-
lation has achieved some success as a problem-solving tool
(3). Moreover, as well as being able to incorporate the afore-
mentioned evaluation measures, it will be posited that simu-
lation modeling offers a systematic approach for addressing
key evaluation methodology issues that have been usefully
summarized by the seminal Lewin Group report (27). These
issues have been identified as technological maturity, focus
of evaluation, perspective of evaluation, comparator, random-
ization, and time horizon. Table 1 defines each of these issues
in turn, along with an example of how they are addressed in
current telemedicine evaluation studies and how simulation
can offer a potential solution to these challenging issues.

From Table 1, it can be seen that current telemedicine
evaluations largely fail to address the broader organizational,
clinical, and social processes that new technology impacts
upon. Some evidence that exists suggests that this is a crit-
ical issue and that the focus of the evaluation may be too
narrow. For example, Lehoux et al. (17) found that the use
of telemedicine did not fit into clinicians’ communication
routines of consultation and referral. We suggest that a more
fruitful direction for the evaluation of telemedicine is to fo-
cus on the patient pathway. The patient pathway includes all

INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 22:1, 2006 137

Coughlan et al.

the clinical routines (or processes) into which telemedicine
is placed, so that it can be assessed on how it sustains or
supports variation in clinical practice.

SIMULATING THE PATIENT PATHWAY

Patient pathways are tools that assist in providing general
guidelines of care for dealing with individuals and groups
of patients suffering from a wide variety of diseases. How-
ever, the majority of studies focused on traditional patient
pathways (23). The introduction of telemedicine, however,
offers a new pathway to care, although the impacts of it
are even less well understood. To this end, simulation is
put forward as a method of modeling pathways that cap-
ture the timeline of care from the start to the journey’s
end.

Discrete-Event Simulation Technique

Discrete-event simulation (DES) offers many features to cope
with understanding the complex nature of health care sys-
tems, of which the patient pathway is a clear example. There
are three critical steps to the technique that are advanta-
geous for representing pathways, which can be described
as follows: (i) Understanding the system or process to be
modeled—this is in terms of its main entities (e.g., patients),
events (e.g., clinic visits), and decisions (e.g., referral of
patient for consultation) and must be achieved for the sub-
sequent model building to have a good representative basis;
(ii) Changing the parameters of the model (e.g., time and
cost)—this step can suggest (based on mathematical distri-
butions) the optimum capacity of the system in the present
and for the future given different scenarios; and (iii) Under-
standing the inter-relationships between different entities,
events, and decisions in the system—this step can identify
the interdependencies of variables and the effect of changing
one has upon another.

The simulation’s significant feature is its capability of
performing “what if. . . ” type analyses through the manip-
ulation of variables to understand the inter-relationships
within the model and, hence, the real system. This iterative
nature to the modeling process brings about the identification
of the optimum system setup. Although simulation is not
intended to replace current designs of evaluation studies,
acceptance of any new approach to studying health care
problems needs to be justified on the professed benefits of
the proposed solution option.

Benefits of Simulating the Patient Pathway

Whereas simulation has the potential to overcome many of
the problematic issues in telemedicine evaluation (as shown
in Table 1), the true value of the approach rarely has been
realized, given the narrow focus to which it has been applied
previously, typically hospital scheduling problems (11). This
quantitative view of simulation modeling—as a way of calcu-

lating outcomes—has often failed to produce results that can
be readily implemented in real-life applications. Moreover,
the telemedicine literature, in particular, reveals a paucity
of studies that have undertaken any simulation, except for
perhaps two notable examples (6;18). The impetus, there-
fore, clearly exists for a debate on the conceptual issues of
research in telemedicine, given the problems with current
evaluation techniques (4). Robinson (24) has called for a de-
bate on simulation study as a mode of practice in various
domains. We contend that this debate is necessary within
health care and propose that a starting point for this discus-
sion is on evaluating telemedicine from a simulation of the
patient pathway.

Patient pathways do not physically exist; therefore,
methods of computerizing pathways have demonstrated
some degree of success (7). The understanding that is gained
through simulation is of a greater value than the pure numer-
ical values produced. We propose, therefore, that simulation
be viewed as a tool not to calculate outcomes but to appre-
ciate them. This difference is subtle yet powerful. In this
manner, the use of simulation will crucially serve to elicit
the intangibles, such as insight into the way the system actu-
ally operates, understanding the variables that can affect the
system, and informing decisions concerning the system and
their possible consequences.

The benefits of simulating patient pathways are in-
creased when qualitative investigations (e.g., interviews, ob-
servations, and so on) are directed at critical points along the
pathway so as to supplement the models and understand more
holistically the relationship between the interpersonal (e.g.,
patient satisfaction) and technical aspects of telemedicine (9).
For example, to return to the three key measures discussed
earlier, in diagnostic accuracy, a control patient group can be
simulated to compare the outcomes of consultations with a
clinical trial group. This approach has been shown previously
to provide an educational benefit for informing clinical deci-
sion making (14). Furthermore, cost-effectiveness measures
can also be extended to produce cost per quality measures
of outcome in terms of the quality adjusted life years for
specific health care interventions (10). This can have an im-
portant personal benefit, particularly for the patient in terms
of establishing the relationship between their illness and the
likelihood of health care saving their life. Moreover, incorpo-
rating patient satisfaction measures is possible by converting
patient responses into an appropriate numerical scale and ap-
plying these figures to the model. This strategy can have a
behavioral benefit in being able to determine fluctuations in
patient satisfaction and pinpointing problem areas.

Telemedicine Patient Pathway:
An Illustration

To illustrate the potential of simulating patient pathways,
leg ulcer sufferers were selected as case examples, given
the access to patients who have followed a traditional

138 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 22:1, 2006

Evaluating telemedicine

start

Patient visits GP

Decide on
tests to be
performed

More tests
required

Referral
required?

Refer to
consultant

no

yes

Visit consultant

Blood test at clinic
Doppler test at

clinic
Photographs at

clinic
yes

Repeat visits to
GP

no Ulcer healed?

no

stop

yes

Traditional

Telelink
consultation

telelink

Tests

Process continues beyond
this point

Telelink or
traditional?

Figure 1. Leg ulcer patient pathway.

and telemedicine patient pathway. Figure 1 is a graphic
representation of part of a leg ulcer patient pathway. Informa-
tion to structure the pathway and its critical variables is col-
lected from patient records and interviews with doctors and
nurses. Figure 1 serves to illustrate all the health care events
along this section of the pathway, for instance a tele-link

consultation and the relationships between them. Figure 2
illustrates how identical patients can be treated through two
systems, both traditional and telemedicine (the timescale for
which is provided for illustrative purposes only).

Variables at strategic decision points along the path-
way control the flow of patients. These variables alter based

INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 22:1, 2006 139

Coughlan et al.

Week No.
0

1

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

Present to
GP

Referral to
consultant

Telelink to
consultant

Pre-surgery
tests

Present to
GP

Tests at
clinic

Referral to
consultant

surgery

surgery

In-person
visit to cons.

Pre-surgery
tests

Tests at
clinic

PRESENT TO GP
1. Patient volume – the number of patients arriving at the surgery are
established in order to determine the capacity that the system
currently deals with and how this affects the system.

2. Patient attributes – age, severity of condition, and general health
were key issues used in clinical decision-making. These were all
rated on a scale of 1-3 (with 1 being the youngest/least severe and
3 being the oldest/most severe).

TESTS AT CLINIC (and PRE-SURGERY TESTS)
1. Costs of tests – this variable is dependent on patient attributes
(i.e., the more severe cases will need more tests). It is also
dependent on time as if the period in between testing at the clinic
and pre-surgery is short then only one set of tests will be needed,
otherwise they may have to be repeated.

2. Costs of dressings – this variable is dependent on time, as
dressings have to be changed twice a week, during the course of
treatment.

3. Time – every event has a time delay, which may vary depending
on patient attributes, whether telemedicine is involved, or the
number of tests conducted.

Figure 2. Comparison of a traditional and telemedicine leg ulcer patient pathway.

on data parameters (patient volume), patient attributes (age,
severity of condition, and general health), and time, which
were deemed important for the treatment of leg ulcers
from interviews with clinical staff. These variables can be
further manipulated to determine different levels of effect
when changing sections of the process (i.e., introducing
telemedicine).

DISCUSSION AND CONCLUSIONS

This study has discussed simulation modeling—solely as a
mode of practice—for the evaluation of telemedicine in the
context of the patient pathway, as illustrated by Figures 1
and 2. Future work will need to computerize the pathway
into a dynamic running simulation model by comparing the

140 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 22:1, 2006

Evaluating telemedicine

predicted flow of patients with the actual flow along the
traditional and telemedicine pathway. This approach will
allow the capture of the long-term and organizational im-
pacts of telemedicine implementation. An integral part of the
discussion on the potential use of simulation has been the
focus on the patient pathway. This focus has provided a com-
pelling example of the importance of evaluating telemedicine
in the context of the health care processes into which it is
placed. A spotlight on pathways vivifies the collective bene-
fits of simulation that have been put forward by highlighting
how telemedicine can be evaluated in relation to the entities,
events, and decisions involved in the delivery of care that
it impacts upon. On the surface, telemedicine might appear
to offer a fast-track system for patients, which can reduce
the costs of dressing for leg ulcer patients, for example (as
shown in Figure 2). However, Phipps (22) provides a caveat
to this in stating that it is important that we understand how
optimizing one section of a process (e.g., introducing a tele-
link) can affect another section further along in the system
and potentially induce a bottleneck (e.g., at the surgery stage)
given that this section of the process will not have changed.
It is suggested that a new challenge for telemedicine eval-
uation studies is to compile a more comprehensive view of
the technology, in looking across multiple aspects of health-
care processes to provide a much-needed commentary on the
outcomes of health care and its delivery. To this end, pa-
tient pathway simulation has been introduced as a potential
evaluation tool for telemedicine to continually monitor clini-
cal practice, the effects of telemedicine, and changing health
outcomes.

CONTACT INFORMATION

Jane Coughlan, PhD ([email protected]),
Research Fellow, Julie Eatock, PhD ([email protected]
ac.uk), Research Fellow; Tillal Eldabi, PhD ([email protected]
brunel.ac.uk), Lecturer, Information Systems and Comput-
ing, School of Information Systems, Computing and Math-
ematics, Brunel University, Kingston Lane, Uxbridge, Mid-
dlesex UB8 3PH, UK

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