Change can generate mixed responses. Eli Noam, Director of the "Columbia Institute for Tele-information" observed recently that:

"It is characteristic of individuals, institutions, industries and entire societies to misjudge the future. We do so by simultaneously exaggerating, belittling and fighting change. On the one hand, we tend to succumb to the various merchants of hype, overestimate the short-term spread of technology as to its salutary impact — "a helicopter in every garage" … (O)n the other hand, we tend to underestimate the deeper, long-term impact of fundamental technologies: the automobile and the radio were seen as convenient substitutes for the horseless carriage and the wireless telegraph rather than the agents of revolution in cityscape and mass media, in living patterns and politics. But when realization dawns that the mere convenience is also a sorcerer’s apprentice, attitudes change from benign wonder to hostile defensiveness" (1)

When seen in this light, it is easier to comprehend why there is still much uncertainty surrounding the "theory and practice" of telemedicine, and how a polarity of opinions has developed both as to telemedicine’s potential, the obstacles which impede that potential and the strategies which ought to be deployed to overcome those obstacles.

It is true that telemedicine (and indeed "e-health") offers much hope - but also much hype. The treatment opportunities facilitated by the technology are apparently limitless and it is tempting to portray telemedicine and its related technologies as harbingers of a "watershed" in the delivery of healthcare. It is also true that because telemedicine challenges and undermines long-held assumption about the roles and responsibilities of doctors and the ways in which medical practitioners communicate with their patients and with each other, it poses challenges that are numerous and complex and that extend to all aspects of the healthcare delivery system. As this Report has outlined, those challenges extend, but are not limited, to such areas as the nature and extent of the duty of care owed by and the standard of care required of telepractitioners and their employer-institutions; standards-setting issues associated with telemedicine quality and safety; the evidentiary repercussions of communicating in a new technological environment and privacy, confidentiality and security issues.

Some commentators have suggested that some or all these challenges are insurmountable. It is submitted that this is not the case. While telemedicine policy, regulatory and medico-legal analysis poses several unique challenges, those challenges must and should be addressed bearing in mind that the analysis and resolution of those issues must be undertaken as part of a broader information and communication technology strategy

Further, the analysis of telemedicine issues cannot be undertaken in a policy or legal vacuum. Many of the issues confronting telemedicine are also being addressed in a broader setting, be it the "health information infrastructure", the "national information infrastructure", "electronic commerce" or the "information economy". The analysis and resolution of telemedicine policy, regulatory and medico-legal challenges will and must respond to and reflect developments in these areas.

Telemedicine’s potential must be tempered by the current and anticipated limits of fiscal, cultural and clinical reality. Telemedicine technologies and the business and practice strategies that depend upon them must accommodate, adapt to and reflect the financial and functional constraints and the level and type of clinical need of the varying sites which they seek to service. The future role of telemedicine is yet to be determined and is difficult to predict: will it ultimately act as a supplement, complement to or substitute for traditional patterns of health services delivery — or will it act as all three? In an area where stakeholders have diverse interests, priorities and skills-bases and where the rate of change is accelerating rapidly and with unpredictable results, the only certainty is to "expect the unexpected".

While telemedicine can generate novel and revolutionary modes of practice, it does not necessarily follow that the legal and regulatory principles and mechanism that govern and affect the healthcare delivery system must undergo equally revolutionary change. Indeed, it is submitted that policy-makers and regulators should, wherever possible, avoid an undue rush to a legislative "quick fix", as in many instances the application of the combination of common sense, established principles, collaboration and coordination will successfully address the challenges posed by the new telemedical facts. Having said that, it is inevitable that many important questions will remain unanswered in the short to medium term. The capacity of telemedicine and related technologies to contribute to the achievement of strategic objectives will largely depend upon the goodwill of relevant stakeholders. Government, industry groups, peak bodies and practitioners and administrators at the "coal face" of care, all have an important role to play. All will be required to respond to the challenges of telemedicine by not only considering how telemedicine creates new challenges and new opportunities, but also how the new technology can "fit in", if at all, with practices and patterns of delivery that have developed through a combination of custom, legislative or regulatory mandate and various "unwritten rules". At hospital, network and practitioner level, there will be a need for closer collaboration and communication between all stakeholders and a greater focus on meaningful risk-identification and risk minimisation strategies. In this way telemedicine can be used by senior health managers to facilitate continuity of care, integration and the enhancement of skills to produce the best clinical outcome at the lowest possible cost and thereby contribute to efficient, coordinated service delivery.

Coordination will also be required from peak bodies, including government. To that end, this Report shares the recommendation made in several Australian reports which called for the formation of some form of "umbrella" body responsible for relevant telemedicine policy deliberations. The HOL Report called for the establishment of a "National Working Group on Telehealth and Health Informatics.(2) Similarly, the Centre for the Study of Clinical Practice, in its report Evaluating Telehealth Services in Victoria; A Generic Framework, suggested that the Department of Human Services should maintain a "State Telehealth Advisory Committee". (3) Because of its diversity and the uncertainties which currently surrounding its implementation, it is submitted that telemedicine policy is an area that is particularly suitable to leadership and coordination from such a peak body.

Endnotes to Chapter 9

(1) EM Noam "Will books become the dumb medium?" Educom Review, March/April 1998 page 18 and 19

(2) HOL Report p. 170.

(3) p. 124

Index