Updated: Sep 17, 97
SECTION 4: Interim Conclusions and Review of the Project

4.1 Scope of the Section

Within this context, this final section is presented as follows:

• Changing notions of 'state of the art': a comparative synthesis of the different 'world views' represented by the project brief; the literature review; the European R&D world, and the reality represented by the applications audit
• What was learned: inadequacies and misconceptions of the original TELMED approach and problems encountered
• Future progress: the revised TELMED conceptual and methodological framework, and implications for selection and implementation of case studies

4.2 Changing Notions of State of the Art: Comparative Positions Represented by the Initial Project Brief, Critical Review, and Applications Audit

4.2.1 Underlying assumptions of the project brief

Reviewing these conclusions in the light of the results of the Applications Audit, the evidence still paints a picture of uneven and limited implementation of telematics products and services within Europe and, ultimately, of a market that has yet to achieve a level of maturity and innovation diffusion commensurate with measurable impacts at the societal level. However, the evidence from the Applications Audit does highlight a need to review the conclusions of the early TELMED work in several important areas. These are outlined below.

4.2.2 Comparison of results of state of the art and applications audit

The availability of concrete data from some 277 applications drawn from a wide spectrum of domains, scenarios and geographical settings has enabled us to critically review the findings of our earlier, more speculative work, as set against a high level of empirically-based supporting evidence.

This critical review is summarised below in Table 5.

Table 5: Comparison of Findings from Critical Review and Applications Audit
Finding from state of the art review	Review following applications audit
1. Current provision
Mismatch between expectations and reality in terms of 'real' applications and interventions	Evidence of discrepancy between anticipated growth and diffusion, and unevenness of applications distribution on the ground - but the gap appears to be narrowing
Little evidence of the large-scale co-ordinated strategic development of telematics healthcare systems in Europe, outside the environment of EU RTD Programmes	Provision still primarily unintegrated, but evidence of strong intervention by national and regional co-ordinated programmes, particularly in infrastructure and basic network systems
Implementation fragmented, small scale and primarily driven by experimental and pilot projects underpinned by EU RTD	Still dominated by R&D and pilot projects, including EU funded but significant presence of established products and services, involving commercial partnerships
The bulk of working applications activity concentrated in EDI for healthcare; hospital administration systems, and electronic patient records and smart cards	Although these three applications environments together account for 40% of those identified by the audit, there is a broad spread across all types. Medical imaging systems, telediagnosis and community health applications are as significant
Uneven geographical spread, and evidence of sectoral differentiation, with EDI most extensively developed in northern Europe; telediagnosis and remote telecare more extensively developed in Southern European states & in isolated areas of Northern Europe; smart cards were concentrated in France and in Germany	Confirmed by audit. UK and France most extensive range of applications types; Scandinavia dominant in medical imaging (and teleradiology and pathology). EDI, hospital information and electronic patient record systems concentrated in Scandinavia; telediagnosis and tele-emergency services in remote and rural southern Europe. But differences in urban areas
Geographical and sectoral differentiation reflects political culture (e.g. in the UK, the introduction of 'national business goals' for the National Health Service)	Partly supported by the audit. Political agendas and investment availability strongly affects infrastructure provision. But pattern of distribution also reflects existing know-how and expertise and physical and demographic barriers
Education and training in the use telematics services for health running at a very low level of investment	Confirmed by the audit. Teletraining only really established in UK. Perceived as a major constraint to further growth of telematics for health
2. Impacts
Very little attention paid to measuring the socio-cultural effects of telematics in healthcare, and to organisational change.	Diffusion and penetration of established products and services concentrated at institutional level, providing 'bounded' systems (typically on a PC or closed server), rather than integrated, open networks at wider regional or national level. Therefore, impacts at societal level virtually impossible to test empirically. However, strong evidence of movement towards national infrastructure networks, regional networks- and a significant trans-European presence. These are currently mainly at the piloting stage.
Some evidence of changes in alliances, partnerships and socio-political structures in the provision of health care services	Supported by the audit. New private-public sector partnerships common in applications development and implementation.
Some evidence of a lack of investment in 'telehealth' (the adoption of telematics in primary and community health care) relative to areas such as hospital information systems, teleradiology and telepathology	Supported in part by the audit. The devolution of service provision from specialist to primary care networks still at a very embryonic stage. Most 'mature' sectors are in medical imaging and HIS.
Little evidence to be found relating to impacts at the institutional level. Some suggestion of displacement effects associated with the introduction, for example, of hospital information systems, reflected in a reduction in organisational support for care processes	Applications audit identified potentially informative data sources on organisational change and work practices. These will be further investigated in the case study analysis.
Constraints to future growth
Technical problems associated with infrastructure provision	Audit suggests more a problem of unevenness and lack of integration of basic infrastructure provision
Standardisation and interoperability problems	Audit identified some evidence in support. Connected to some extent with unevenness in development across Europe and 'North-South' divide.
Confidentiality and legal problems	Insufficient data. To be addressed in case studies.
Cross-cultural and transferability constraints	Insufficient data. To be addressed in case studies.
Financial constraints	Insufficient data. To be addressed in case studies.
Education and training	Strongly supported by the audit.
Organisational and institutional barriers.	Insufficient data. To be addressed in case studies.

4.3 Implications for Further Work

4.3.1 Lessons learned: inadequacies of the initial TELMED approach

Experiences of the two main sets of activities carried out so far - the critical review of state of the art and the applications audit - set against the main objectives specified in the project brief have highlighted a need for a number of re-adjustments both to the objectives and to the methodological approach adopted to address these objectives. The adjustments can be conveniently described in terms of problematics generated from a number of, sometimes opposing, 'world views' about telematics for healthcare.

As indicated earlier, the brief itself reflects assumptions about the maturity and cohesion of a domain that is accessible to impacts evaluation at the broadest societal level. This in turn reflects an underlying world view derived from experience of and immersion in what might be called the 'EU RTD Programme world'. This world is defined by an inherently structured, co-ordinated and integrated set of programme architectures intended to promote the realisation of anticipated scenarios for healthcare. Many of the characteristics of this world view appear to be shared by experts in the domain, and also in the literature, for example the consensus that health care telematics will help engineer a shift from specialist to primary care provision, and the consensus about the increasing integration of medical, social and other services in 'regional care scenarios'.

However, the structure and cohesiveness of EU RTD is not entirely mirrored empirically by the unevenness and immaturity of telematics implementation on the ground. As a result, the findings of the applications audit - with its identification of a relatively restricted and bounded set of mature applications sub-sectors focusing on medical imaging, hospital information systems and teleradiology - is likely to be perceived as a relatively 'conventional' or 'traditional' model when set within the EU RTD world.

At the same time, the classification typology used by the applications audit appears rather constraining and too inflexible to adequately express the emerging 'open systems' that are being developed through the internet, through regional integrated services and on the back of large scale infrastructure programmes.

4.3.2 Methodological approach to outstanding activities

• a selection strategy for case studies that, on the one hand includes examples of the 'established' or mature applications areas in medical imaging and teleradiology (in order to maximise data capture on impacts at the macro level) but also includes examples of more emergent applications environments based on open systems architectures

• the inclusion in the range of selection criteria used to shortlist case examples of typologies based on 'scenarios of use' (see above, Section 3.2.3), reflecting applications as flexible socio-technical practices, rather than static technological artefacts

• redirection of the 'object of evaluation' of the project to some extent to what is currently happening in EU RTD in telematics for healthcare, to reflect the unevenness and relative immaturity of the 'real world' domain, and to help refine interpretative assessments of future trends

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