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Introduction

Telemedicine is a broad term comprising a number of technologies, from digital X-rays to over-the-phone consultations, utilization of video conferencing and performance of remote surgery (1). In other words, it is simply the use of telecommunications technology for the delivery of medical care or services. It offers access to medical care via video calls, e-mails, access to medical information, and remote diagnosis including care for rural people in the near future. Advances in the field are to allow the vast majority of the planet to be within reach of medical care. This would change significantly the course of development of many nations. Telemedicine delivers freedom by making it easier for patients and individuals to access medical care. Rather than spending many hours or days traveling to a healthcare center, medical advice and consultation could be obtained more locally, freeing up time and increasing the ease of receiving care (2).

However, this emerging technology, as in the case of emerging technologies, has significant challenges to overcome before it can realize the potential it offers. Understanding the field as it grows poses one major obstacle. If the development of technologies including e-mail and cell phones is considered, it is evident that accurate information and understanding of the technologies in the developing country context in terms of the possibilities that it offers is lacking. For example, transnational corporations have a failure rate of 71% in adapting Western information and communication technologies (ICTs) to developing nations (3). This suggests a lack of adequate information or research for the implementation of emerging technologies in developing countries. For academics and professionals, it is a challenging task to identify relevant and high-quality research on an emerging technology in order to achieve progressive developmental changes. Information is scattered across many locations and significant gaps in the research exist. This holds true for telemedicine as well. It is difficult to find the latest information efficiently, leading to inefficient implementation of projects, repetitive research, and, ultimately, less development.

Existing challenges of the field

Emerging technologies offer great potential for development, as well as great challenges. While new technologies can increase access to basic human services, increase efficiency, and alleviate poverty, they also lack sufficient research and shared best practices to be applied as effectively as possible in the development context. This holds true for telemedicine. While telemedicine can potentially deliver access to healthcare services to a much larger population, these projects fail to meet their objectives over 63% of the time (4). One cause of these repeated failures stems from the difficulty of learning about the research that has been conducted. Multiple databases, with differing inclusion criteria present telemedicine research in fragmented segments (5,6). Within the research, terms are not uniform and even contradict one another at times. Especially within the realm of ICT technology, where advances occur rapidly, the telemedicine applications continue to change. This leads to confusion. It is also difficult to know where gaps in the research exist. The lack of a structured centralized repository with clear criteria makes understanding and utilization extremely difficult (7). With these barriers in place, it is essential that a clear view into the research and its outcomes be understood by those working or looking to enter into this critical field. At present, this is nearly impossible because it is unclear how one could easily access and review the available information. A fragmented look at the data increases the likelihood of repetition, misunderstanding, and inefficiency.

Current views in the clinical setting

Telemedicine technically enables the remote application of medical services. Distant countries and regions have started to form thicker connectivity via telemedicine. However, again, structural realities continue to favor the advantaged in this regard over the disadvantaged. The agreements forged for the sharing of medical services by region and internationally occur within the framework of the ‘healthcare system’ (8). The global healthcare system consists of institutions and medical networks that do not provide care to disenfranchised and fringe groups within society, the individuals that need it most. It is a cruel paradox that with the potential to benefit and to reach these individuals for the first time, the benefits of telemedicine have largely been utilized for those already well within the healthcare system. However, without a clear view into this trend for the layman trying to access research, it is unlikely anything may change. With telemedicine on the rise and an opportunity to increase its impact becoming more realistic, it also becomes more complicated and difficult to understand and organize telemedical information by the day. The challenge of bringing structure to a system that already has a significant presence is only likely to become challenging. Taxonomy in telemedicine offers a means for the standardizing of communication and structuring of the historic work carried out in this field (9).

The law poses one of the most significant barriers to the widespread distribution of telemedical benefits. No international framework exists for physicians to deliver telemedicine to jurisdictions and countries outside of their own, protecting privacy and confidentiality via data transfer, authenticating health professionals, and their handling liability (10). There are many bureaucratic barriers including ICT literacy, infrastructure, linguistic and cultural differences, that play a role in the development of telemedicine mainly due to a lack of any fundamental organization for resolving such issues. Furthermore, there is also a lack of certainty with regard to possible attempts being made on a wide scale to overcome these issues. Thus, access to information is imperative for better decision-making, in the use of telemedicine in developed as well as developing countries. Specifically, it is a prerequisite to good decision-making. Bashshur's taxonomy offers a potential tool for improving access to existing telemedicine research for academics and professionals in the field of telemedicine (11).

Emerging technologies in developing countries

While emerging technologies often have the potential to impact the lives of the poor positively, this potential is not often realized. The institutional support and infrastructure to make these technologies function well is often lacking in developing countries (12). Without an educated population, electricity, and political organization, implementing wide-scale change poses major challenges that speak to systemic issues. It is easy to mistake the technology as having failed, whereas it is just that it is not always appropriate for the developing nation context. An excellent example of the potential and differences of emerging technologies in developing countries is the spread of cell phones throughout Africa over the past 10 years. Cell phone penetration in Africa has increased by over 4,000% in the past 10 years (13). At the same time, electricity has not reached many of the places where cell phone service exists. This means that although many individuals own cell phones, they are used in different ways than in developed nations. They are typically kept off and only powered on when needed for a call. Additionally, calls are usually made for essential needs, not for casual conversation. Thus, subscribers pay much less per month than they do in developed nations, making it impossible to cover certain regions if one expects to make a profit.

It also tends to be the case that errors are made because of inadequate availability of information on emerging technologies. As the field emerges, information lags behind the current state of the technology (14). Examples of this include the proliferation of e-mail, text messaging, and Skype. Data on the value of these technologies was not obtained for a long period of time after their use was implemented. Individuals had to comprehend technology for themselves, based mostly on intuition. As such, it is difficult to make informed decisions and find best practices for using these technologies in new contexts. Inefficiencies and unmet potential occur as a result. The Internet is probably the best example of what was once an emerging technology with poorly understood implications. At present, it has been shown that a 10% increase in internet penetration increases GDP by 1.4% (15). Initially, however, few understood the implications of worldwide connectivity. Only until the internet reached high enough usage levels did the potential for it to improve and change our lives and effect development by improving the freedom of information did the internet's promise become clear.

Development and healthcare

Healthcare in developing countries poses significant challenges. It is the major focus of large non-profits, such as the Bill and Melinda Gates Foundation, and a consistent source of frustration for many governments (16,17). One major challenge in delivering successful care in the developing country context is the lack of data available on rural populations, making evidence-based public health decisions much more difficult (18). As a result, traditional practices and systems remain in place, even when new options become available. Decisions are relegated to little more than guesses.

At the same time, great strides are being made in the improvement of medical care. Child mortality rates and deaths from preventable diseases continue to decrease and major viruses have been eradicated. Some of this progress can be directly attributed to the emergence of new technologies and medical solutions reaching developing nations (19). Thus, technology has the power to improve healthcare in developing countries, but systemically applying it is difficult. It becomes a question of knowing what works and to scale the solutions effectively. As in the case of any emerging technology, the technology of healthcare needs to be adapted and understood within the context in which it is introduced. Finding a fit between a context's needs and the healthcare model delivered, appropriate healthcare, makes a real difference in life and death outcomes (20).

Globalization and telemedicine

The meaning of globalization and its association with medicine holds valuable information. Medical technology, particularly telemedicine, has called into question the meaning of ‘place’, bringing health services to populations that were previously too distant to receive it (21). Nevertheless, location plays a major role in the quality of care that individuals receive. There is a tension present in the global versus the local. Furthermore, medical technology seems to be restructuring social order to some degree. By extending healthcare to remote areas, these populations are classified and managed differently, in what resembles an actuarial model of understanding (22). This serves to create groupings of individuals that receive individualized healthcare and those that receive healthcare tailored to population management and disease control. At the very least, two groups are emerging with different health rights. There are obviously powerful forces at play. Multiple models of globalization can emerge, ‘unipolar globalization,’ based on exclusivity, and ‘multipolar isolationism,’ based on protectionist trade barriers and internal repression, being two undesirable possibilities (23). Constructing a less sociologically violent and inclusive model seems far more desirable. To establish this type of system, an understanding of how and why policy decisions are unfolding in their specific way is of vital importance.

It seems that there is support in the medical community for a more global system, generally. Over 90% of physicians surveyed by St. George University in Grenada said that a global accreditation authority may be beneficial (24). However, the physicians had much less unanimity with more detailed questions regarding the manner in which to structure such an authority, what standards to apply, or what its ultimate effect would be. There are several approaches to merging disconnected medical systems. Approaches include cross-border exceptions for consultants, mutual recognition, reciprocity, endorsement, limited licensure, national licensure, and registration. With each of these methods, there are the elements of inclusivity (who can participate?), agency (how can they participate?), and conditions of association (in what scope can they participate?) that are at the heart of what is being negotiated.

Conclusion

It can be concluded from the abovementioned studies that progress has been made in the field of telemedicine. However, much progress is pending to establish it as a gold standard technique.

References