the work to make telemedicine work: a social and articulative view

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Social Science & Medicine 62 (2006) 2754–2767

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The work to make telemedicine work:A social and articulative view

Davide Nicolini

Warwick Business School, The University of Warwick, Coventry CV4 7AL, UK

Available online 15 December 2005

Abstract

This article contends that the take up of telemedicine results inevitably in the reconfiguration of the existing work

practices and socio-material relationships. This new way of working triggers a variety of shifts in coordination

mechanisms, work processes and power relationships in the health care sector. The paper, which is based on the findings of

a research project conducted in Northern Italy, addresses three critical issues of telemedicine: the conflict between the

scripts embodied in telemedicine technologies and the daily work practices of heath care professionals; the tendency of

telemedicine to produce a delegation of medical tasks to non-medical personnel (and to artifacts); and the tendency of

telemedicine to modify the existing geography within the health care environment. The paper contends that telemedicine

presupposes and entails some significant changes in work processes which affect both the material conditions of the

expertise which is supposed to be distributed, and the relationships between health care professionals and their practices.

r 2005 Elsevier Ltd. All rights reserved.

Keywords: Telelemedicine; Heath care practices; Information technology; Italy

Introduction

The great majority of existing research andpractitioners’ literature on telemedicine adopts aclinical, technical, and economic approach. Socialand organizational issues, albeit often mentioned,have been scarcely addressed (Chiasson & David-son, 2004). In this article I shall argue that in orderto understand some critical aspects of this new wayof practicing medicine, we need to attend closely tothe relationship between technology, work contextand the structuration of organizational activitiesfrom a social and organizational perspective.

Using this perspective, and building on the resultof a three years research, I will particularly contend

e front matter r 2005 Elsevier Ltd. All rights reserved

cscimed.2005.11.001

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that the take up of telemedicine results inevitably inthe reconfiguration of the existing work practices,triggering a variety of shifts in coordinationmechanisms and socio�material relationships.

The article is organized in the following way.I will start by introducing some of the fundamentaltenets and potential benefits of a social andarticulative view of telemedicine. I will thenintroduce the setting of a research conducted atfour telemedicine sites in Northern Italy upon whichthe present discussion is based (Gherardi & Strati,2004). The main characteristic of these sites was thatoperations had been in place for at least two years,that is, projects had progressed beyond (andsuccessfully passed) the experimental and pilotingstage. It takes in fact time organizational practicesto start shifting and for social issues to emerge.

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ARTICLE IN PRESSD. Nicolini / Social Science & Medicine 62 (2006) 2754–2767 2755

I shall then proceed to discuss three of these issues,namely the consequences of the conflict between thescripts embodied in telemedicine technologies andthe daily work practices of heath care professionals;the tendency of telemedicine to produce a delega-tion of medical tasks to non-medical personnel (andto artifacts); and the tendency of telemedicine tomodify the existing geography within the health careenvironment. I will conclude the article by observingthat the research dispels the widespread idea thattelemedicine simply constitutes a way of distributingat a distance existing services. On the contrary, thedata support the idea that telemedicine presupposesand entails some significant changes in workprocesses which affect both the material conditionof the expertise which is supposed to be distributed,and the relationships between health care profes-sionals and their practices.

A social and articulative view of telemedicine

Technological innovations in general, telemedi-cine being no exception, have always triggeredcontrasting reactions both in the general publicand among members of the scientific community.When a significant technological breakthroughappears in the public sphere, opinions tend topolarize between optimists, who emphasize thepotentialities of the new technology, and pessimists,who tend on the contrary to stress the difficultiesand the potential barriers to the adoption of the newinstrumentality.

We are so accustomed to framing our conversa-tion along this continuum that we seldom pause toobserve that these two positions, in spite of theirapparent diversity, share in fact some very basicassumptions. For example, they both assume thattechnology constitutes a fundamental, if not themost fundamental, cause of social and organiza-tional change. They also share the implicit idea thattechnologies are a given, a sort of ‘‘black box’’ thatmoves on a linear trajectory from invention todiffusion and adoption. For both these positions,then, we can study the impact and effects oftechnology on work, organization, and society in away that is not too different from how we would goabout studying the impact of a meteorite on theplanet’s surface.

In the last two decades these notions have beenstrongly questioned by a variety of scholars, whohave argued that such a view ignores the reciprocalinfluence between technology and its social and

historical context of emergence (see Jasanoff,Markle, Peterson, & Pinch, 1995; Sismondo, 2003for a review).

According to this view, it is always possible todemonstrate that specific historical and socialprocesses are implicated in both the design anduse of any technology. Technology, actors, andsociety need hence to be thought together as part ofheterogeneous network or ecology, instead ofseparate worlds (Bijker & Hughes, 1987; Gibson,1979; Law, 1986, 1992; Bijker & Law, 1992; Star,1995). This shift towards a social and historical wayof studying the relationship between technology andsociety (and, by extension, technology and organi-zation) has three important consequences.

First, this social perspective contends that tech-nologies are never ‘‘neutral’’. Technologies, in fact,carry with (and within) them the traces of theirhistory. Accordingly, all technologies embody theintentions, desires, and views of those who createdthem; by the same token, they reflect a particularway of understanding the world and formulatingand solving problems.

Second, technologies should not be thought of asa given; what we call technologies are in fact a(more or less) stable assemblage of a variety ofmaterial and human elements. The stability oftechnologies, and especially of complex technologieslike telemedicine, is in effect the result of some kindof effort or work. All technologies are hence, at leastpartially, subject to (practical) interpretation.

Third, technologies only assume a defined prac-tical meaning when they are put to use in a specificsocial and material, i.e., situated, context. Wecannot think of a ‘‘technology’’ without makingsome reference to some users and a historicaland material context of use populated by othertechnologies, actions, discourses, and interests.Technology is, by definition, always technology-in-use and should be studied as such (Timmermans &Berg, 2003).

The adoption of such a social, constructive, andprocessual view of technology (and telemedicine)generates in turn some new and very promisingresearch questions. Studying technology as technol-ogy-in use means in fact shifting the attention fromthe supposed effects of technology to the relation-ships and actions that attach meaning to the newtechnology and that stabilize its use within theextant work and organizational practices. Thisrequires, in turn, that we adopt an articulativestance (Gubrium, 1988) which focuses on ‘‘how

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1The EPR study was carried out by Attila Bruni. The data

discussed here are examined in detail in Gherardi and Strati

(2004) and Bruni (2005).

D. Nicolini / Social Science & Medicine 62 (2006) 2754–27672756

members of situations assemble a reasonable under-standing of the things and events that concern themand, thereby, realize them as objects of everydaylife’’ (p. 27). The overall result is a perspective ontechnology which augments our appreciation of thephenomenon by giving prominence to some aspectsthat other approaches leave largely unexplored.Three of them are worth mentioning here.

First, a social and articulative perspective ontechnology brings to the fore the (often hidden)work necessary to make the innovation usable. Tofocus on technology-in-use means, in fact, toobserve both the work carried out by users to makethe technology work, as well as the (often hidden)work performed by the technology in order torespond to the users’ needs and to align with otherexisting elements (Berg, 1997; Heath & Luff, 2000).

Second, this approach studies technology as anobject emerging within a densely interconnectedassemblage of actors, actions, and relationships.This directs our attention to whether such ‘‘ecol-ogy’’, which comprises users, other technologies,rules and regulations, institutions, and a variety ofother heterogeneous elements, constitutes a contextof use or whether the necessary mutual negotiationsand alignment between elements fail, and the contextbecomes in fact a context of non-use or rejection(Hanseth, Aanestad, & Berg, 2004; Law, 2002).

Finally and yet importantly, observing technologyin this way means focusing on how the localcondition of use participates with, and contributesto, larger institutional processes. Even when studiedlocally, telemedicine appears in fact to be anchoredto a variety of other practices and broader organiza-tional, legal, and economic conditions. By observingtelemedicine from this perspective, we can investi-gate to what extent this (new) way of doing medicineis aligned with the existing professional and institu-tional arrangements, and to what extent it deviatesfrom them generating new possibilities of change(Aas, 2001; May & Ellis, 2001; May et al., 2001;Mort, May, & Williams, 2003; Webster, 2002).

In the rest of the paper I shall apply thisperspective to the study of some major telemedicineinitiatives conducted in northern Italy. As it willemerge, the perspective adopted here is substantiallydifferent from the medical and technology-orientedway in which the topic is usually addressed in theextant literature (see Roine, Ohinmaa, & Hailey,2001; Taylor, 1998a, b for an extensive review). Theadoption of a social and articulative perspective ontelemedicine brings to the fore a number of critical

phenomena, some of which are likely to influencethe future take up of telemedicine. Three aspectswill be addressed in detail: (1) the consequences ofthe conflict between the scripts embodied intelemedicine technologies and the daily workpractices of health care professionals; (2) thetendency of telemedicine to produce a delegationof medical tasks to non medical personnel (and toartifacts); and (3) the tendency of telemedicine tomodify the existing geography within the health careenvironment in the direction of strengtheningexisting centers of power, both professional andeconomical.

Research setting and methods

The data discussed derive from a three yearsresearch project conducted in Northern Italy. Theoverall aim of the research was to deepen under-standing of the nature of the organizationalinnovation introduced under the generic label of‘‘telemedicine’’, the characteristics of the technolo-gies employed, and the effects on the existingmedical practices.

The study focused in particular on four tele-medicine initiatives: the evaluation of a teleradiol-ogy project; the observation and analysis of atelecardiology consultation service; and the investi-gation of two major services of telemonitoring andtelecaring (‘‘teletriage’’) for serious heart failurepatients; the introduction of an electronic patientrecord (EPR) in a hospital ward.

These sites were chosen for a number oftheoretical and practical reasons. First, I wantedto cover the most relevant tele medicalized special-ties. My previous research illustrated that telecar-diology and teleradiology are among the mostcommon initiatives of telemedicine (Nicolini, Bruni,& Fasol, 2003). The study of the EPR was includedbecause the system was supposed to support thevirtual interaction between family doctors and thecentral hospital.1 Second, all these sites wererecognized as national and international centers ofexcellence. Third, the cases covered different Italianregions (which have different organizational andfunding set ups) and included both private andpublic sector organizations. Last but not least, thesetelemedicine initiatives had been in place for at least


2 years, that is, projects had progressed beyond (andsuccessfully passed) the experimental and pilotingstage. This allowed me to observe the emergence oforganizational and professional issues that usuallydo not emerge when a project is in the experimenta-tion or piloting phase. All the case studies were of aqualitative nature. The data on the teleradiologyproject were mainly collected through seven focusgroup interviews with about 65 users of the service.The focus groups were taped and subsequentlytranscribed. The transcriptions were analyzed usingthe coding process and category building practicesof grounded theory (Bryman & Bell, 2003; Strauss& Corbin, 1990). The empirical evidence on thetelecardiology initiative was gathered through anumber of semi-structured interviews and shortperiods of participant observation over a period of24 months. Finally, data about the two telemonitor-ing services and the EPR projects derived fromextended periods of participant observation (threenon-consecutive months over a 2 years period andthree consecutive months, respectively), supplemen-ted by a number of ethnographic and semi-structured interviews. The four case studies wereanalyzed combining the theoretical process ofanalytic induction (Bloor, 1978; Miles & Huber-man, 1984) with some of the operational suggestionsput forward by Eisenhardt (1989). Accordingly, thecase studies were written-up separately and thencompared using reiterate cycles of cross-site searchfor shared features and differences, field datareview, and saturation of the categories.

While an extensive summary of the findings of theindividual case studies is available in Gherardi andStrati (2004), I focus here on four organizationaland social aspects emerging from the research: thecounter-intuitive effects produced by the encounterbetween the scripts embodied in the new technolo-gies and the existing work practices; the redistribu-tion of tasks and responsibilities implicit in many ofthe prevailing telemedicine discourses and therelated risk of marginalizing certain roles; andthe tendency of telemedical practices to redesignthe relationship between center and periphery in theorganization and delivery of health care processes.

When technolgical scripts and daily practices do not

match

One of the central ideas of the social andarticulative study of technology is that all technicalartifacts used in daily activity embody patterns of

use and interactional scripts which reflect (to someextent) the views and intentions of their designers.

According to Akrich (1992; see also Hanseth &Monteiro, 1997), when designers conceive technicalartifacts, they tend to define actors with specificduties, tastes, competencies, motives, aspirations,and preferences. A large part of the designers’ workis that of inscribing a vision of (or prediction about)the world in the technical content of the newobjects. During the design process, the designerswork out a scenario for how the system will be used.This scenario is inscribed into the system. Theinscription includes programs of action for theusers, and defines roles to be played by users and thesystem. In doing this, the designers also makeimplicit or explicit assumptions about what compe-tencies are required by the users as well as thesystem. However, the patterns of use inscribed inthe artifact by the designers only come to life in thecontext of the daily activity of the users. When putto work, the concrete anticipations and restrictionsof future patterns of use embodied in the techno-logical artifact interact in complex ways with theexisting work practices of the users. The result is aprocess of negotiation between the innovation andthe work activity. The outcome of such negotiationdetermines, on the one hand, how the innovationis used ‘‘in practice’’; at the same time, it producessome kind of change in the work practice, usuallyalong lines which reflect (to some extent) thedesires and intentions of the designers and theirsponsor. Most important, the outcome of thisencounter process is paramount for the successfultake up of the innovation. It is not unusual, in fact,that such negotiations fail, so to speak, and thetechnology is rejected, ostracized, or, more often,silently ignored.

Some counterintuitive effects of recording data

electronically

A first interesting instance was provided by someunexpected and counterintuitive effects that the useof EPRs brought to bear in the delivery of theservice it was supposed to support. One of theexpectations of the introduction of EPRs (and moregenerally of IT based systems for accessing medicaland diagnostic information) is that they willimprove the quality of the relationship betweenhealth care professionals and patients by affordingthe former fast and efficient access to a vast amountof data and expertise (Lau et al., 1999; Webster,

ARTICLE IN PRESSD. Nicolini / Social Science & Medicine 62 (2006) 2754–27672758

2002). This, however, is not always the case andthings are more complex and uncertain.

In one instance, several sessions in which doctorswere to formulate and communicate a diagnosisbased on the data retrieved through the EPR (testsresults, previous reports, etc.) were observed. Thedoctors were usually sitting across the desk from thepatients facing the screen, so that the patients couldonly see the back of it and did not have access towhat the doctors were seeing and doing. Most of thedoctors made much effort to conduct seamless,patient oriented interviews. However, they had tostop often to type in the EPR fields the informationgathered from the patients. These interruptions andthe period of silence that followed tended to raisethe level of patients’ anxiety. Patients who were left‘‘on hold’’, exhibited a variety of anxiety revealingbehaviors like biting their fingernails and whistling.In one of the doctor’s words: ‘‘[the problem] is thesilenceyduring the silence patients start to think allsort of thingsy’’ To some extent, then, the practiceof sympathetic interviewing put in place by thedoctor, who tried to use a soft tone, an invitingposture, and a conversational approach in order toput the patient at ease, ran against the scriptembodied in the EPR that required a more standard(and more detached) question and answer interac-tional order. The two conflicted to the detriment ofthe interaction quality.

I observed a similar effect in the case oftelemonitoring distant patients in one of thetelecardiology centers. In this case, I was able toobserve how monitoring calls were conductedbefore and after the introduction of an EPR.

Prior to the introduction of the tool, nurses rantheir calls by consulting a variety of documents,which they laid on the desk in front of them. Theywould then let their phone conversations with thepatients take a very informal course, collecting theinformation they needed as the patient would offerthem. By utilizing this conversational discursivegenre, they could thus establish warmer and moreamicable relationships with patients who theycontacted on a regular basis.

Even though the way in which the patientprovided the required information depended onthe individual conversations, the nurses were alwaysready to register the necessary information aboutpatients’ health, symptoms, and the therapy, simplyby writing on one of the documents in front ofthem. All that was required was moving a paper or anote book to the side of the desk and pulling

another one closer. All this changed, however, withthe introduction of the EPR. The EPR, in fact, hadbeen structured in a traditional hierarchical way andscreens were organized in a ‘‘logical’’ way accordingto an established sequential order. Such orderreflected the ‘‘ideal pattern’’ of a ‘‘well done’’ callwhich was, however, very formal and interview-likeand hence seldom followed by the nurses. The latter,on the contrary, preferred using a more looselystructured pattern that helped them in establishingmore informal and warm interactions. This meant,however, that once they started to use the EPR tokeep track of patient’s information while on thephone, nurses had to start ‘‘searching’’ for theappropriate screens in order to input data. Thiswould take some time and required that nurses drawtheir attention from the patient to attend to suchtasks. These very short interruptions of rhythm werehowever soon picked up by patients, who started toask whether anything was wrong. They had learnedthat pauses in the rhythm of the conversation oftenmeant that the nurses had found something wrongand that they were double checking or thinkingabout it.

In response to these emerging difficulties, somenurses reverted back to paper and pencil, anddecided to input data after the call. In other cases,they introduced new practical ways of keeping thepatients on hold without worrying them. Forexample, they started telling them aloud what theywere doing or, alternatively, they started usinginterjections like ‘‘excuse me a moment’’. Some ofthem used jokes to fill up time, e.g., by saying to thepatients ‘‘I am so slow with this computer’’,signaling thus the reason for the interruption andapologizing for it in the same sentence.

In both cases, using the EPR implied a shift in thepractices and required a certain amount of repairwork by the professionals and the patients (who hadto learn to wait). In the case of the nurses who optedfor reverting to pen and paper, this meant asignificant workload increase. It must be added thatin the first case one of the doctors stated that he hadlearned to capitalize on the silences, observing howpatients reacted to it, and using the data to conductlater parts of the conversation (e.g., he would askpatients who bit their fingernails information abouttheir hygiene). This latter comment suggests that,from a social perspective, the mismatch of scriptsand practices is not necessarily conducive tonegative consequences; the encounter betweentechnology and practices may harbor unexpected


positive outcomes as well. What is important tonote is that such effects are partially unpredictableand emerge only when the scripts embodied in theartifacts are translated into practice.

Misalignments between technological scripts and

practices

Misalignments between technological scripts anddaily practices were observed not only at the micro-interactional level but also at the level of the overallorganization of the service.

In the case of teleradiology (an emergency serviceproviding radiology services to peripheral hospitalsat night and during holidays), I observed the clashbetween the script embodied in the new technologyand the program sanctioned by the existing legalframework. The latter required, in fact, that allmedical reports were signed off by a doctor ‘‘onduty’’ in order to obtain legal value. Accordingly, adisclaimer was added to all the medical reportsproduced by the distance radiologists. The disclai-mer stated that the report had, in fact, no legalvalue. Given that the system was intended as a toolfor helping the periphery medical centers to decidewhether to send the patients to the regional hospital,this element neutralized a large part of its perceivedvalue, drastically reducing its level of use. At thesame time, for similar legal reasons, the reportproduced by the distant radiologists had to besystematically reviewed the following morning bythe in-house radiologist who had to sign it off. Theresult was, in this case too, the production of asubstantial amount of extra work which, accordingto my informants, significantly reduced the level ofuse of the system.

A final clear instance of the potentially negativeeffects of the clash between scripts and practicesemerged in my study of one of the telecardiologycenters. On the basis of the success of its operations,which were run on a 24/7 basis, the center started tooffer to the existing family doctor clientele thepossibility of accessing a variety of second opinionconsultations (from teledermatology to telepsycol-ogy). Because of budget constraints, however, theservice was initially designed to operate a-synchro-nically: doctors had to submit a request via email orphone and the expert in charge would contact themwith an answer during specific office hours. Such a‘‘script’’, however, conflicted with the family doctorpractice, which requires giving patients instantanswers in order to deal with their anxiety.

Although in theory (i.e., in a marketing surveycarried out prior to the launch of the service)doctors were extremely interested in the support thesecond opinion service could provide them with, inpractice the way in which this technology was set upconflicted with other relevant aspects of theirpractice. The result was the failure of the project,which was soon cancelled for lack of customers. Inthis case, the amount of work necessary toaccommodate the innovation and the daily practicesexceeded its perceived benefits; hence its failure.

As the previous examples illustrate, seen from asocial and articulative perspective, telemedicine (inall its forms) embodies a script which has beeninscribed within it by its designers. The utilization oftelemedicine should therefore be thought of as aprocess of negotiation between script and extantpractice. This process has three main characteristics:it is mainly unpredictable in theory, and it onlymaterializes in practice; it is never a foregone result;and it requires a certain amount of remedial workwhich affects the balance between the costs and thebenefits of the innovation. When the work necessaryto make telemedicine work (Berg, 1997) exceeds itsbenefits, the technology fails to find its place in theexisting social and material technology. I suggesttherefore that this neglected aspect needs to betaken into consideration for it constitutes one of thecritical factors towards the success of any techno-logical innovation, and it may be at the root of eventhe best planned or well intentioned telemedicineproject.

Redistributing and delegating tasks

The ecological view of technology (and telemedi-cine) introduced above supports the notion thatwhat we customarily call ‘‘work roles’’ are not fixedsocial positions determined by rules and prescrip-tions, so much as the result of the interaction andnegotiation of a variety of dimensions and aspectswhich all concur to determine how the task at handwill be interpreted in the particular situated work-place. From this perspective, negotiating boundariesand positioning oneself vis-a-vis other professionalknowledges and technologies, allocating responsi-bilities, and redefining mutual accountability allconstitute ordinary aspects of being at work.

The introduction of telemedicine should hence beconsidered an instance of the reshuffling of all theseelements, or, seen from a ‘‘power’’ perspective, anopportunity for different parties to re-negotiate


their respective boundaries and to extend theirinfluence. My study has found a recurrent pattern inthe way labor is re-distributed following theintroduction of telemedicine. Such redistributionassumes quite often the form of the delegation ofclinical tasks to non-medical personnel and arti-facts. According to my data, this pattern is strictlyrelated to the nature of the technology itself. Thishas of course some far reaching implications.

The work of delegating

The first and most obvious place where I observeda process of task re-distribution was the study of the‘‘tele triage’’ service, which was aimed at monitoringat a distance serious chronic heart failure patients.In this case, the redistribution was one of the mainaims of the initiative. The very notion of ‘‘triage’’ is,in fact, an emerging form of division of labor whichlegitimizes some tasks that nurses have carried outfor years on an informal basis. The practice oftriaging (legally) delegates to nurses tasks andprerogatives that were previously reserved only tomedical doctors. Triage, whether at the emergencydepartment or on the phone, constitutes a form ofredistribution of work that delegates some clinicaltasks to non-clinical personnel. In the case Iobserved, ‘‘telenurses’’ were expected to handleautonomously the majority of cases and to refer todoctors only in exceptional cases. In fact, they didthis extremely well: according to their data, nurseshandled autonomously more than 90% of contacts,interacted with doctors in about 5% of cases andonly in 2–3% of the cases they handed the casemanagement over to doctors (Scalvini et al., 2005).

The process was not, however, as seamless as thedata would suggest. This is because telemedicineintroduces a dimension of distance and remotenessnot only between health professionals and patients(an expectation which has received a lot ofattention), but also between health professionals.The latter is an aspect seldom considered in theliterature. In fact, modern specialized medicine,especially in hospitals and clinics, assumes the co-presence, proximity and mutual visibility not onlybetween staff and patients, but also between healthcare professionals.

Hospital wards, and especially intensive or sub-intensive units such as those dealing with thepathologies discussed here, thrive on forms ofdistributed cognition such as the one discussed byHutchins (1995a, b). Knowing is distributed be-

tween a complex array of people, artifacts andrepresentations—including the patient, in which‘‘there is a substantial sharing of knowledgebetween individuals with the task knowledge ofmore expert performers completely subsuming theknowledge of those who are less experienced(Hutchins, 1995a, p. 49). The knowledge ‘‘pos-sessed’’ by members of the medical team is bothhighly variable and redundant. Individuals workingtogether on a collaborative task engage in interac-tions that will allow them to pool the variousresources to accomplish their tasks. These interac-tions are only in part planned and ordered.Programmed and legitimized forms of interactionand coordination such as formal meetings andinformal gathering (taking a coffee together) coexistwith a further layer of important random encoun-ters (or failed encounters). In the wards people runand bump into each other all the time, interfere witheach other, or miss each other when they shouldmeet. The result of this (well known) planned chaosis not only effective team performance, but also highreliability. All medical (and non-medical) personnelhave ‘‘war stories’’ to tell about how they were just‘‘passing by’’ and noted some mistake made byanother colleague, and how their intervention savedthe day and prevented a catastrophic consequence.

This arrangement, however, also produces an-other notable effect, that is, it supports a sort of‘‘circulating accountability’’. Although in (most)western cultures accountability is strictly individual,in many team-work situations informal and tacitarrangements apply so that the distribution of tasksfollow the contours of experience and competenceinstead of the rigid profiles of bureaucratic account-ability. For example, in a ward, because of theintense regime of interaction, it is not unusual fornon-medical personnel to carry out medical duties.This, however, presupposes a regime of proximity inwhich there is always ‘‘a doctor’’ nearby so thataccountability trails can, in case of necessity, bebrought back to the person in charge. All thischanges, however, when distance is introduced inthe equation. The distance between health careprofessionals interferes, in fact, with both theseprocesses and thus requires some remedial strategiesto be put in place. Several were observed in my casestudies.

For what concerns the distribution of knowing,nurses were ‘‘trained’’ so that some of the knowl-edge and skills previously available within the teamcould be handled individually. The effort was thus


directed towards enabling the nurses to reproduce atan individual level as much as possible theredundancy collectively sustained in the ward. Theredistribution of work was therefore more than asimple task-decomposition and delegation exercise;the redistribution followed, in fact, a sophisticatedhologrammatic logic aimed at mimicking within themicrocosm of the individual work the resourcesused in the collective process of distributed knowingand remembering. In order to facilitate this process,the world of the nurse was populated by a variety ofnew artifacts (protocols, forms) that carried outsome of the knowing and remembering workpreviously distributed among several people. This,however, meant that the nurses had then to becomeproficient in handling their work through themediation of a variety of symbolic artifacts whichhad been previously (or at least formally) theexclusive concern of medical doctors. The distancecreated between colleagues led to the ‘‘up-skilling’’of the telenurses.

A variety of strategies were put in place to try tocompensate for the effects of distance on account-ability, given that the legal framework was designedto sustain the traditional collocated division oflabor. Most of these strategies can be understood asways of performing in the new conditions the effectaccording to which ‘‘a doctor is always in charge’’.

As critical observers of medical work have noted,practical regimes in western medical establishmentsare set up to support the institutionalized myth that‘‘it is the doctor who decides’’, although eachdecision depends upon prior substantive work andthe alignment of long and complex chains of people,information, tests, and machines to produce ques-tions such as ‘‘is this medicine the right one for thispatient in this very moment?’’ (see Berg, 1997 for anin depth discussion).

The first way of sustaining such a myth wasthrough the use of a variety of discursive practiceswhich have tended to downplay what nurses did.Even when they were clearly interpreting clinicaldata (such as electrocardiograms), nurses refrainedfrom using terms such as ‘‘diagnosis’’, which werereserved to doctors, even when physicians simplyendorsed what the nurses had told them, as in themajority of cases.

A second way of supporting this myth requirednurses to maintain, both symbolically and materially,accountability trails which would link their acts tosome previous, recognizable, and legitimate medicaldecision. One of the skills of the nurses was therefore

figuring out at what point it was necessary to reportto the doctor (which often meant working hard toobtain his or her attention) so that the trail would notbecome too thin. At that point, the nurse would fillthe doctor in with just enough details to allow him orher to make a decision which would act as a sort of‘‘recovery’’ point should something happened (‘‘re-member, I talked to you about it that dayy’’).

Third, the effect of ‘‘the doctor is always incharge’’ was achieved by enlisting a variety ofsymbolic artifacts such as flow charts and protocols,which, although very seldom used by the nurses,were often mentioned and visibly posted in theirroom. Protocols and flowcharts allowed nurses tofollow a particular course of action without havingto making formal decisions. To the extent that theycould attribute the decision to the protocol, theyestablished an accountability trail which leadsdirectly to the professional institution that hadissued it, i.e., a sort of institutional ‘‘super doctor’’with whom few would dare argue. In this case, oneof the new skills developed by nurses entailedknowing how much they could ‘‘push’’ the protocol.As one of them put it: ‘‘if we use the protocol andsomething happens, it is easier to get away withityhowever, this can be done within a limit: one hasto show being able to carry out her duties, otherwiseyou’re in trouble, with or without the protocol’’.

Last but not least, a material strategy put in placefor safeguarding the institutional arrangementaccording to which ‘‘doctors are always in charge’’,was avoiding putting too much (physical) distancebetween telepersonnel and physicians. Accordingly,the service was initially located within a room in thehospital ward. While the reason for this arrange-ment was initially attributed to cost and space, thisset up was maintained even after a major relocation.At closer inspection, then, the reason for thisproximity was mainly organizational: as long asnurses worked in or near the ward, it was easy forthem to demonstrably remain under the control of adoctor who, in turn, could then be made accoun-table for the decision taken (although, as we haveseen, this only happened in a minority of cases). Theissues introduced by distance were hence casemitigated by reducing it.

Telemedicine and the necessity of knowledgeable

intermediation

While a delegation of tasks was to be expectedwhen observing the teletriage project, similar


phenomena to those just described were observedalso in all my other case studies, albeit on a smallerscale.

The most relevant to our considerations was asecond telemonitoring center. In this case, anexplicit decision had been made to establish atelemonitoring service that was not based of anexplicit triage model. In fact, in this case, thecontact between patients and the center wasmediated by an electronic device that collected vitalsignals (weight, blood pressure, etc.) and lab testresults sent by patients. Patients were asked to carryout lab tests and send the results to the center bykeying in the data using their telephone handsetsfollowing recorded voice instructions. These datawere then compared by the program with apredetermined patient profile, and a warning wasissued in case of significant deviation implying therisk of destabilization.

Although the nurse was supposed to perform aplain secretarial role (printing out results anddelivering them to the doctor), observation revealedthat her task was much more complex and implied avariety of highly skilled, interpretive roles. Forexample, on more than one occasion I observed thatthe nurse, after being notified by the machine thatsome of the data were significantly outside the setinterval, did not communicate this information tothe doctor and did not call the patients to inquireany further, as one would have expected (somethingshe did at other times). When I investigated whatwas going on, I was explained that the data keyed inby the patient was ‘‘incompatible with life’’—that is,the data were greatly beyond not only the normalthreshold, but also a pathological variation. More-over, all other data were ok, therefore suggestingthat this was simply an inputting mistake. On theother hand, because the general agreement was thatnurses would call only if something was wrong, shewould limit contacts with patients as much aspossible in order not to alarm them. This veryconcerned attitude, however, presupposed a level ofprofessional skill and substantial medical knowl-edge that prefigured her work as a form of activeintermediation more than a simple transfer ofinformation. The active intermediary role requiredof the nurse by the technology became even moreevident in the case in which the nurse called backpatients to inquire about significant variationsreported by the software. What should have been(in theory) a straightforward question and answersession, turned out instead to be a subtle exercise

through which the nurse would use previouscontacts with the patients, relational and conversa-tional skills, and knowledge of the pathology and itsmain symptoms, to collect the necessary data. Inother words, she was operating in a way not verydifferent from what her colleagues were doing at theother center. Only then, therefore, would shetranslate this information in the format requiredby the doctor (written numerical indexes), eliminat-ing the contextual information she had to gather inorder to provide meaningful data. It was notunusual, however, for this contextual informationto be communicated informally to the doctor whenthe papers were handed to him so that he could‘‘follow up’’. In sum, far from performing a passivedata transfer task, the nurse acted as a veryproactive and knowledgeable operator who workedin order to fill the gaps produced by the remotenessof the patients. By skillfully anticipating theinterpretive needs of the doctor, she was in factactively, albeit silently, mediating between herselfand the distant patient, therefore performing avicarious role. If we compare the findings of thisstudy with those of other qualitative studies ofdistant medical work (e.g., Mort et al., 2003), itemerges that these elements are a constant aspect ofdistant medical work. I suggest that the reason forthis recurrent finding is that translating lay speech,(like that of a patient), into medical discourse, is ahighly skilled task that constitutes an alreadysignificant interpretive (if not outright diagnostic)activity. Accordingly, whenever it introduces inter-mediaries between the distant patients’ medicaldecision-makers, telemedicine produces a delegationof significant professional aspects of work. It is mycontention that this happens because of the natureof the task at hand; therefore, the redistribution ofwork brought to bear by telemedicine constitutes aform of delegation even when it is not openlyconceived as a form of triage.

In summary, the introduction of distant ways ofworking in medicine engenders the re-distribution oflabor in terms of a delegation of professional work.This process requires that telehealthcare practi-tioners carry out duties usually more complex andmore professionally connoted than they would havedone before. In this sense, the redistributionamounts to a form of delegation which is, however,still seldom acknowledged either legally or econom-ically (none of the personnel I encountered in mystudy received any form of compensation for thenew level of work they were asked to carry out).


This tendency is somewhat inherent not only in theeconomical rationale of many telemedicine initia-tives, which are predicated on providing the samelevel of services at lower costs, but also in the verynature of the task and technology.

Redesigning the relationships between center and

periphery

For many years the adoption of IT technologiesin healthcare has been purported as a way ofintroducing a more even distribution of services,therefore improving the access of remote commu-nities and patients (Brauer, 1992). This optimisticvision, however, is matched by a contrary viewwhich claims that telemedicine might in fact deepenthe existing inequalities. Cartwright (2000), forexample, argues that telemedicine can be used asan excuse to reduce investments in local services,dividing the world into those who have access to‘‘real doctors’’ and face-to-face care, and otherswho will have to be contented with electronicallymediated and sensorially anesthetized relationships.As this author puts it: ‘‘will physicians exhibit thesame degree of ‘care’ for those patients who receivedistant treatment?’’ (p. 257).

Both positions rightly underscore the fact that theintroduction of telemedicine is bound to trigger ashift in the geography of health care provision.Cartwright (2000), moreover, aptly emphasizes thatthis results in the increased centrality and power ofsome, and the corresponding marginalization ofothers. I argue, however, that the transformationof the health care geography brought to bear bytelemedicine is more complex and contradictorythan it is depicted in some polarized debates, andthat it involves not only patients but also health careprofessionals. Overall, my findings indicate that,contrary to the idea that IT systems propel thetransformation of post industrial society into a flatnetworked society (Castells, 1996), telemedicineproduces a centralizing tendency which goes exactlyin the opposite direction, reinforcing the role andinfluence of existing centers of power, be itprofessional or economic.

Sealing the relationship between the center and the

periphery

One of the frequently mentioned benefits oftelemedicine is the possibility for a variety of usersin remote areas to access highly specialized knowl-

edge. Users can be either health professionals (as inthe case of remote clinics or second opinion services)or patients. As illustrated by previous research, suchaccess is not always unproblematic. For example,Lehoux, Sicotte, Denis, Berg, and Lacroix (2002) andMort et al. (2003) documented the multifacetednature of the relationship between distant health careprofessionals and the so called ‘‘tele-expert’’. Accord-ing to my study, the same can be said for therelationship between specialized centers and patients.One phenomenon that seems particularly interestingis the tendency to establish direct and preferentialrelationships between patients and specialized centers.In time, such relationships seal out other actors,therefore potentially altering the existing geographyof relationships within the health care environment.Most notably, this happened in spite of the fact thattelemonitoring initiatives had been designed with theintention of actively involving the community careservices and the family doctors.

In Italy, since the late 1970s family doctors(general practitioners) have been considered thecornerstone of the national heath care system. Thelogic is that of making family doctors the obligatoryentry points to the public system, to promote apatient-centered system and prevent improper useof second level healthcare services. To date, a familydoctor prescription is necessary for accessing publichospitals and specialized services (apart fromemergency services), as well as for carrying out testsand obtaining free or subsidized medicines throughthe public systems.

As in many other Western countries, however, theItalian healthcare system is under constant pressuredue to a rapidly ageing population and a progres-sive reduction of resources. At the same time, as inother places, the relationships between community,general, and hospital healthcare professionals arefraught with difficulties; these are rooted not only ina variety of practical constraints, but also indiverging worldviews and logics of action. Suchdifficulties become even more serious in the case ofparticular conditions such as chronic heart failure, adisease which requires highly specialized and con-tinually updated skills and knowledge, and in whichpatients quite often become highly knowledgeableabout their own condition.

When in such conditions specialized centers usenew telemedical instrumentality to extend in timeand space their new and sophisticated strategy ofdisease management, there is a real risk that therelationship between patients and centers becomes a


‘‘closed environment’’, as one of the teledoctors inmy study put it. The center and the patient establisha fiduciary relationship that leads to a progressivebypass of other actors. This in turn leads to areconfiguration of the patterns of communication,decision making, and influence among healthprofessionals, with the (often distant) specializedcenter taking a central role in managing the patient(with all the ensuing legal, professional andeconomic implications).

My observations indicate that at least threefactors combine to determine this state of affairs.First, chronic patients, whose well being andsurvival depend on rapid access to medical atten-tion, quickly elect to rely on the center’s supportinstead of other health agencies. After all, thecenters I observed are highly specialized, nationallyknown and highly reputable, and their service ishighly reliable. Moreover, these centers, unlikefamily doctors, are readily accessible (in this case,access was guaranteed 24/7). They subsequentlyprovide quick and competent responses, two basicingredients which greatly reassure patients. Oncepatients start relying on the support of distantcenters, they reduce their contacts with their generalpractitioners. They tend to go to their familydoctors only to obtain the prescriptions and thetests ‘‘required by the center’’, and progressively relyfor everything else on the distance relationshipestablished with the center.

Second, unless family doctors have a specialinterest in deepening the understanding of thisspecific pathology, they are usually happy todelegate the management of these patients to atrustworthy specialized center. After all, these areoften very complicated patients, both clinically andemotionally. These patients (and/or their partners)are also often very competent, and hence verydemanding. In my research I heard stories ofpatients who proved to be more informed abouttheir own conditions than their doctors, thanks toboth the formal training and informal learningderived from their extended contact with specialists.

Finally, even though in theory it would fall to thespecialized center to involve the family doctoractively, preventing his/her exclusion from therelationship, practice is different. Involving a multi-plicity of actors in the process of care requires asignificant investment of time and human resources,two commodities most health care establishmentsrarely have an abundance of. Keeping the familydoctor (and other community care services) in the

loop would in fact demand overcoming bothpractical and entrenched cultural and professionaldifficulties. For example, when family doctors callthe hospital at all, they prefer to speak to otherdoctors. This would run contrary to the intermedia-tion and ‘‘triage’’ logic that justifies telemonitoringin the first place, as discussed above. In our cases,while nurses were always readily available, estab-lishing relationships with hospital cardiologists wasmuch more difficult, a factor that tended todiscourage general doctors to persevere.

At the same time, in my research I collected avariety of ‘‘war stories’’ that testify to the reluctanceof hospital personnel to contact family doctorswhom they sometimes fail to regard as their peers.Consider for example the following extract quotedverbatim from a conversation with a senior nurse:

yI recall one time when a very serious CHFpatient went home and was taken in charge byhis family doctor. The doctor prescribed him avariety of useless tests, but failed to check thelevel of anticoagulantyluckily we asked thepatient about it just hours before she wassupposed to undergo a minor dentist surgery.We found that the level was in fact extremelylowyhad she gone to the dentist it would havebeen big trouble.

Besides illustrating (and celebrating) the differ-ence in status of specialists vs. generalist doctors,the fragment also suggests that specialized centers’personnel consider the active involvement of familydoctors a burden or a sort of accessory effort that iseasily disregarded when the pressure of daily tasksbegins to bite.

The resulting ‘‘cutting out of community care’’, asthe phenomenon was described by another of myinformants, constitutes one of the still largelyunexplored hidden aspects of telemedicine. Thisphenomenon is worth considering because it para-doxically occurs only when the service is of a veryhigh quality and generates a high level of trust. Itsconsequences are, however, difficult to foresee. Theredesign of the relationships between center andperiphery may in fact have far reaching conse-quences of an organizational (what is the role offamily doctors in a system in which a patient candirectly access high level expertise?), financial (whowill pay for the service and how?), and legal nature(who is accountable if something goes wrong?)But there are other, more complex issues related tothe establishment of ‘‘closed environments’’ with


patients who are prone to extreme dependency, as inthe case of a patient who, claiming to trust only thespecialist at the center, decided to embark on a 600mile trip from his house to reach the specializedcenter, only to die on the way.

A telemedical capitalism?

There is another way in which telemedicine canalter the existing geography of the health careenvironment. In this case also the phenomenon islinked to some typical characteristics of this way ofdelivering care.

One of the recurrent findings in the case studies isthat ease of access is considered a critical require-ment of an effective telemedicine service. This waswell illustrated, for example, by the case of thesecond opinion initiative discussed above, whichfailed for its inability to fulfil the access expectations.Issues of immediacy of time emerged, however, in allmy case studies, as for instance in the teleradiologyservice. In this case, time emerged as a critical factor,because a slow or delayed response would havedefeated the very purpose of the service, which wasaimed at preventing improper hospitalization.

The proviso of fast, high level, and reliableresponses on a 24/7 basis constitutes however aconsiderable organizational challenge that requires,among others, some very substantial initial invest-ments (e.g., purchasing the technological infrastruc-ture), a sufficient and constant volume of ‘‘traffic’’to make viable the operation of an efficient callcenter, and access to enough health care expertise torespond in the necessary short time to all thequeries. Although there are several ways to fulfillthese and other requirements, it is clear that undersuch constraints telemedicine becomes a businessfor the limited number of players who have access tothis level of commitment. These players are likely tobe large public institutions or private companieswho have already the necessary financial, profes-sional and social capital to venture into an endeavorof such magnitude. It is not difficult to predict thatin the future there will be a limited number oftelemedicine centers that may, or may not, coincidewith the existing leading large health care establish-ments. Be that as it may, the result is thattelemedicine, far from materializing the vision, orthe ideology, of the flat network, is likely tostrengthen the existing power positions within thehealth care field on the basis of this unprecedentedform of digital divide.

Concluding remarks

In this paper I have used a social and articulativeapproach for interrogating telemedicine as anecology of human and non-human elements andexploring how it interacts, modifies, and interfereswith the existing work practices, organizing pro-cesses, and larger institutional arrangements.

The use of such perspective permitted us to enrichand integrate previous studies on the organizationalimplications of telemedicine. These observationscorroborate Aas’ (2001, 2004) findings according towhich telemedicine produces changes in workprocesses, determines shifts in coordination me-chanisms, and gives rise to learning phenomena.This study found out, not unlike previous ones, thatsuch shifts follow a recurrent pattern (Lehoux et al.,2002; Mort et al., 2003; Nifte, 2003). In particular,changes in work processes can often be understoodin terms of the encounter between the scriptsembodied in the new technologies and the existingwork practices. The data discussed here suggest thatwhen the resulting amount of (hidden) remediatorywork exceeds the perceived benefits of the technol-ogy, the latter is often abandoned or used only forcosmetic purposes. The study also indicates that theredistribution of tasks and responsibilities implicitin many of the prevailing telemedicine discoursesoften takes the form of a delegation of clinical tasksto non-medical personnel. This results in an increaseof the knowledge content of the work required ofthese non-medical personnel, albeit a seldomrecognized (and compensated) one. It also meansthat a variety of remedial strategies must be put inplace to align this new division of labor with theexisting legal and organizational framework. Final-ly, we see from the above discussion that the natureof telemedicine produces a shift and a redesign inthe relational geography between actors involved inthe health care process. As we have seen, there is arisk that this shift results in the exclusion, or by-pass, of community level health care services, andthe establishment of direct relationships betweencenter and periphery. At the same time, there is areal possibility that the economical and organiza-tional constraints of telemedicine redefine theinstitutional geography of the players within thehealth care sector in the direction of a strongcentralization and emphasize on the power differ-ential in the field.

On a more general methodological and concep-tual level, the discussion in the preceding sections


demonstrates that the prevailing discourse ontelemedicine, which is conceived as a unitaryconsumable object, suppresses the organizationalprocess and the sheer amount of work needed tocarry it out. This, in turn, reduces the possibility ofunderstanding, and intervening to support the takeup of this new form of medical instrumentality.Although a detailed discussion of the practicalimplication of my findings is beyond the scope ofthe present paper, it can be argued that the issuesevidenced here should inform both the design andthe evaluation of any telemedicine initiative. Forexample, the approach adopted here suggests thatsuccessful telemedicine systems should be designedin close collaboration with their actual usersaccording to a logic of ‘‘bricolage’’ and ‘‘cultiva-tion’’ of the technology (Dahlbom & Mathiassen,1993). In this sense, this approach to the study oftechnology is useful in three ways: the approachoffers the possibility of observing telemedicine froma novel perspective which considers it scarcelyfruitful to discuss the inherent benefits or risks oftelemedicine without focusing on its practical use. Italso suggests that we look at benefits and risks indifferent contexts and circumstances. Finally, theapproach taken here has the merit of bringing to thefore, and thus making susceptible to preventive thecapacity of telemedicine of interfering and conflict-ing with the set of existing work practices, with allthe consequent dynamics which this implies.

Acknowledgements

The research was conducted while the author wasat the Research Unit on Cognition, OrganizationLearning and Aesthetics of the Department ofSociology and Social Research of the Universityof Trento (Italy). Financial support was provided inpart by a grant from the Provincia Autonoma ofTrento (Italy), Progetto Scientifico No. 6 -2001. Iwish to thank K. M. Gilbert for her editorial work. Iam also grateful to the editor and the twoanonymous reviewers for their constructive com-ments on a previous version of this manuscript.

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the work to make telemedicine work: a social and articulative view

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