Tele-Medicine: Building Knowledge-Based Tele-Health Capability in New Zealand

ABSTRACT

This topic reviews the strategic planning of health information systems in New Zealand. This step is deemed necessary to identify the main accelerators and/or impediments that influence technology adoption and diffusion in health organisations in New Zealand. This research introduces the tele-medicine technology as one possible solution to provide continuous, quality, and immediate medical care to rural patients and to encourage networking among the different hospitals in New Zealand. This research suggests that in order to realise tele-medicine benefits in health care delivery in New Zealand, certain issues need to be addressed such as implementing comprehensive cost-benefit analysis and identifying the benefits sought from adopting the tele-medicine technology. The New Zealand context is unique and this perspective with respect to tele-medicine adoption and success is addressed in this research.

INTRODUCTION

Information systems (NZHIS, 1995a; NZHIS, 1995b; NZHIS, 1996; Neame, 1995; Austin, Trim & Sobczak, 1995; Conrad & Shorttel, 1996), information technology (IT) (Bomba, Cooper & Miller, 1995) and technology (Little & Carland, 1991) have been emphasised as strategic tools for enhancing health care delivery and for improving performance, leading to optimised services and efficiencies. However, the New Zealand studies (NZHIS, 1995a; NZHIS, 1995b; NZHIS, 1996; Neame, 1995) indicate that the sector is “relatively devolved,” with purchasing contracts being the main mechanisms to drive sector-wide change at the provider level. Much of the information needed is unavailable in the form needed or at the time that it is needed most. This in part is related to gaps in the conceptual understanding of service delivery, which is in this sector is a very complex business, spanning what has been an extensive range of relatively autonomous functional areas. But it is also due to a lack of reliable information about outcomes, effectiveness and actual costs on which improvements can be based. Because of this lack of empirical data, the tools for dealing with this complexity, and understanding what happens and why, are deficient (NZHIS, 1996). Various organisational issues and the lack of coordination at the national level were also identified. Expertise in health information management and systems is limited. Currently few health and disability sector personnel have the knowledge and skills to understand the issues or to make informed judgements about the validity of the advice they obtain.

New Zealand is not alone in this situation and different countries are facing similar difficulties although the severity of this situation varies from one country to another (Austin, 1992; Bakos & Tracy, 1986; Shortell, Morrison & Friedman, 1990; Topping & Hernandez, 1991; Conrad & Shortell, 1996). This literature points to different organisational, technological, and environmental impediments in adopting and in making use of IS/IT in organisations (Austin, 1992; Austin, Trimm & Sobczak, 1995; Ward, Griffiths & Whit-more, 1990). The 23 Health and Hospital Services (HHSs)1 that exist all over New Zealand are no longer in competition with each other or paid in principal according to the number of people they care for. The competition from the few private hospitals has no effect on them. Ever-lacking government funds (Neame, 1995) are faced with further reduction on the medical portfolio by reducing or eliminating less priority and less life threatening services for the sake of introducing important new ones. The various gaps that exist between the various stakeholders and the lack of a leader (e.g., the government) to coordinate between the different HHSs result in having 23 different information systems that eventually do not interact with one another.

Diminishing funds from the government and cost control mechanisms have led to the need for alternative and more cost-effective means of providing care (Edelstein, 1999; Neame, 1995). In many cases, this has become necessary for survival (Edelstein, 1999) in order to sustain the increased competition among health care providers. The business of health care has become so competitive in different countries that many small rural hospitals are trying to align themselves with larger tertiary care centres in a community health-information network, a tele-medicine network, or some other type of partnership in order to survive and to retain their local patients (Huston & Huston, 2000). Within these challenges, tele-medicine emerge as one possible solution to New Zealand health providers in reaching out to rural patients (Charles, 2000; Harris, Donaldson & Campbell, 2001), to areas where patient volumes for certain services are limited (Edelstein, 1999), to conduct administrative and clinical meetings, and to conduct different training courses to patients (smoke treatment centres), doctors, nurses, and other medical staffs (Perednia & Allen, 1995; Wayman, 1994).

Tele-medicine means medicine from a distance where distant and dispersed patients are brought closer to their medical providers through the means of telecommunication technologies (Charles, 2000; OTA, 1995; Noring, 2000; Perednia & Allen, 1995; Wayman, 1994). Noring (2000) provided an interesting comparison between the former definition for tele-medicine and tele-health. This researcher defined the term tele -health as expanding the capacity of tele-medicine to provide the full continuum of care, from health promotion and disease prevention through curative treatment and terminal care. This term also implies including non-physician-based health care providers.

Tele-medicine covers a wide spectrum of benefits through the use of video conferencing (VC) technology in areas such as consultations, diagnostics, therapeutic, transfer of patient-related records, case management, training, and meetings. Researchers envision tele-medicine to be an important building block in the strategic plan of many health care organizations (Charles, 2000). In a rural setting, tele-medicine could help New Zealand health providers in supplying quality, fast, and economical medical services to rural patients and hence save doctors and patients valuable time wasted in commuting long distances. Specialists could utilise this extra time in seeing more patients at the main hospital.

Thus, this research is interested in introducing the tele-medicine technology as one of the strategic building blocks of Health and Disability Information Systems (HDISs) integration across the different health care providers in New Zealand. This research is interested in achieving the following objectives:

1. Highlight the status of tele-medicine in New Zealand.

2. Highlight the importance of tele-medicine to health care providers in New Zealand and elsewhere. Identifying the accelerators and/or the impediments that influence tele-medicine success could assist health care providers in New Zealand and elsewhere in planning their adoption and use of tele-medicine. This research utilises the technological innovation literature as a guiding theoretical framework in highlighting these factors.

Before expanding on the potential benefits of tele-medicine to health care providers, the following section examines the status of tele-medicine in New Zealand.

TELE-MEDICINE IN NEW ZEALAND

One of the early initiatives that emerged in 1993 within Northland HHS was transmitting radiology images between two hospitals using leased telephone lines. Tele-medicine has been investigated by most of the health providers in New Zealand. The entire crown-owned hospitals in New Zealand are managed by regional organisations known as Health and Hospital Services (HHS)2. Some HHS regions have one hospital and others have more than one. In the North Island, Waitemata Health has three video teleconferencing systems. Two of those systems are used in psychiatry and the third one is used in administrative and training purposes (ADMN). Health Waikato has two VC systems. Two of these systems are used in dermatology and the third one is used in ADMN. Northland Health Ltd (Whangarei) has two VC systems and another two PC-based VC. These systems are used in psychiatry and ADMN. Starship Children’s Hospital (part of Auckland Healthcare Services) is in the process of establishing a national tele-paediatric network across the 23 HHSs and already started with a pilot project. Middlemore Hospital (South Auckland Health) has one group VC system for ADMN. Auckland University School of Medicine has one group VC system for training purposes and for conducting regular clinical meetings with other CHEs in New Zealand. Lakeland Health, LTD has two group video-teleconferencing systems for ADMN purposes.

In the South Island, Coast Health Care, LTD has three VC systems used in paediatrics, psychiatry, and ADMN.—HYPERLINK “canterburyhlth. html”—Canterbury Health, Ltd (Christchurch) has one video-conferencing system for paediatrics and for ADMN purposes. Healthlink South, LTD (Christchurch) has two group systems for psychiatry and ADMN. -HYPERLINK “hlth-sthcant.html”—Health South Canterbury, Ltd (Timaru), Healthcare Otago, LTD, -HYPERLINK “nelsonmarlboro.html”—Nelson-Marlborough Health Services, LTD, and Southern Health, LTD each have one group system. Otago University in Dunedin is using it for training in their school of medicine. It is interesting to know that there is a level of cooperation among CHEs in the South Island in the areas of psychiatry and paediatrics.

A stock-take of the VC technology in these hospitals reveals that medical schools in New Zealand were among the early adopters and users of the technology. Out of the 23 HHSs in New Zealand, only 12 have actively adopted tele-medicine. The adopted systems ranged between one and four tele-medicine systems with the majority of HHSs adopting one system only. Those HHSs that adopted one tele-medicine system use it mostly for general purposes such as managerial meetings, case discussions and occasionally for clinical training. Such initiatives were described as being initial and experimental. Where an HHS owned more than one tele-medicine system, it was oriented for clinical purposes such as psychiatry, paediatric, and dermatology areas. Hence, an attempt is being made to adopt tele-medicine to provide prompt, inexpensive, and quality medical care to geographically dispersed patients, which was otherwise not possible.

TELE-MEDICINE: A BACKGROUND

The first tele-medicine initiative employing interactive television sessions for medical purposes emerged in 1959 by using a microwave link for tele-psychiatry consultations between the Nebraska Psychiatric Institute in Omaha and the state mental hospital 112 miles away (Perednia & Allen, 1995). In the late 1980s tele-medicine was being used routinely to deliver general health services to remote regions of Norway (Noring, 2000). In the US, interest in tele-medicine was initially focused on use in the military, in space programs, on offshore oil rigs, in prisons, and in rural areas (Noring, 2000). It seems the opportunities provided by tele-medicine inspired many innovative ideas. For example, BMI British Midland has become the first airline to install tele-medical technology on planes making long-haul flights to the US Virgin Atlantic has also purchased the system and will start installing it in long-haul aircraft this year. The device monitors blood pressure via a wrist cuff, pulse rate, temperature via an ear probe, electrocardiogram, blood oxygen and carbon dioxide levels. Using a modem, this data is sent to physicians who can advise the crew on what action to take (Anonymous, 2002).

Since tele-medicine’s inception in the 1950s, Perednia and Allen (1995) reported limited growth and pointed to the fact that only few tele-medicine projects were instituted in the 1970s and 1980s at several sites in North America and Australia. They confirmed that none of the programs begun before 1986 has survived. Although data is limited, the early reviews and evaluations of these programs suggest that the equipment was reasonably effective at transmitting the information needed for most clinical uses and that users were for the most part satisfied. However, when external sources of funding were withdrawn, the programs disappeared, indicating that the single most important cause of their failure was the inability to justify these programs on a cost-benefit basis. Other issues, such as limited physician acceptance, played a less significant role in their downfall (Perednia & Allen, 1995).

The views about tele-medicine effectiveness in the medical area vary from one adopter to another. Depending on one’s viewpoint, tele-medicine can be seen as a valuable tool for providing immediate specialty care services to rural areas, a more efficient use of existing medical resources, a way to attract patients living outside a hospital’s normal service area, a way of bringing international health care dollars. On the other hand, others could see it as a serious misallocation of increasingly scarce health care dollars (Perednia & Allen, 1995). This challenge needs to be resolved by highlighting the importance of the tele-medicine technology in a rural setting specifically.

In review of the literature it was observed that despite the rapid growth and high visibility of tele-medicine projects in health care (Grigsby & Allen, 1997), few patients are actually being seen through tele-medicine for medical purposes. In almost every tele-medicine project, tele-consultation accounts for less than 25% of the use of the system (Perednia & Allen, 1995). The majority of the online time is used for medical education and administration (Wayman, 1994; Perednia & Allen, 1995; Hassol, 1996). The low level of usage can be explained in part by the federal government’s position on reimbursement for tele-medicine consultations (Hassol, 1996). However, this author did not find any association between reimbursement and tele-medicine utilisation in this research. Other issues need to be resolved first before the different benefits oftele-medicine can be realised. These unresolved important issues revolve around how successful tele-medicine can be in providing quality health care at an affordable cost and whether it is possible to develop a sustainable business model that could maintain profitability over time. This depends on (Perednia & Allen, 1995): (1) clinical expectations, (2) matching technology to medical needs, (3) economic factors like reimbursement, (4) legal (e.g., restrictions of medical practices across state lines (licensure) and issues of liabilities), and social (e.g., changing physician behaviours and traditional practices and workflow) issues (Anderson, 1997), and (5) organisational factors. These issues are discussed in the following sections.

TELE-MEDICINE ADOPTION: A THEORETICAL FRAMEWORK

Larsen (1998) states that information systems innovations are considered key enablers for business innovativeness. On the other hand, he asserted that the increased rate of failure among IS projects within organisations calls for an increased understanding about IS innovations (Moore & Benbasat, 1991). Innovation can be defined as an idea, practice or product that is perceived as new by the potential adopters even if it had existed earlier elsewhere (Rogers, 1995). The recent success and emergence of tele-medicine using the video conferencing (VC) technology in the early 1990s is an innovative approach of its adoption for medical purposes. In search for models that would explain technologies adopted by organizations, Rogers’ (Rogers, 1983, 1995) model appeared to be the most widely accepted model by researchers in identifying critical characteristics for innovations (Moore & Benbasat, 1991, 1996; Premkumar & Roberts, 1999; Thong, 1999). Rogers classical adoption model is made up of the following factors: relative advantage, complexity, compatibility, observability, and trialability (Table 1). The results of using tele-medicine (observability) are quite observable to the different hospitals and have been highly publicised by the literature (Al-Qirim, 2002; Grigsby & Allen, 1997). Cost has been outlined as an important determinant of adoption by Rogers (1995) and other researchers (Bacon, 1992; Elliot, 1996; Tornatzky & Klein, 1982) (Figure 1).

In the following, the different factors that influence tele-medicine success are reviewed in the light of the technological innovation literature. Further identification of these factors that facilitate and/or hinder adoption and diffusion of tele-medicine could help HHSs and policymakers in New Zealand and elsewhere in adopting tele-medicine and in overcoming different barriers that could hinder its adoption.

Table 1. Innovation characteristics

Innovation Characteristics

1. Relative advantage: the degree to which using technology is perceived as being better than using its precursor of practices.

2. Complexity: the degree to which technology is perceived as being easy to use.

3. Compatibility: the degree to which using technology is perceived as being consistent with the existing values, and past experiences of the potential adopter

4. Trialability: the degree to which technology may be experimented with on a limited basis before adoption

5. Observability: the degree to which the results of using technology are observable to others.

6. Cost: the degree to which technology i s perceived as cost effective.

Relative Advantage

Table 2 identifies some of the stakeholders involved in tele-medicine adoption and depicts their perception about tele-medicine advantages in comparison with their earlier practices (Al-Qirim, 2002; Perednia & Allen, 1995; Wayman, 1994).

1. issues concerning patient’s privacy;

2. specialists may reject extending their knowledge to rural doctors (profession protection) (Gammon, 1994);

3. some physicians prefer ambulatory services as a way to break a way from the hospital’s stressful environment; and

4. some busy doctors tend to see tele-medicine as an extra burden (Gammon, 1994).

The most extensive use of tele-medicine has been to support continuing education over VC. Many more doctors and nurses are now able to attend conferences or classes because the direct (travel) and indirect (out-of-office) costs are decreased (Wayman, 1994). This raises concerns about the main objective(s) of tele-medicine and how it is perceived in the minds of the adopters. Is it a teaching utility or a patient care utility? Although the former leads eventually to better care and stable physicians at rural areas, the latter is envisioned to be the ultimate goal.

Cost Effectiveness

There will be no advantage in adopting tele-medicine if the investment is not justifiable in terms of its acceptable financial returns. On the other hand, healthcare providers in general, including New Zealand, emphasise the importance of providing quality care and preserving human’s well-being. Thus, making the cost element one factor in the adoption decision of tele-medicine, but not the most important one. On the other hand, hospitals have limited resources and hence, it is feared that hospitals would assess the tele-medicine technology as a non-priority medical technology (Al-Qirim, 2002), which emphasises the need to strike a balance between its financial feasibility and its advantages. Let us not forget that tele-medicine is an ideal technology in a rural setting, which makes the cost element insignificant to a certain degree for various reasons. Rural areas typically experience a severe shortage in specialist staff. This is due to vast rural areas to service, poor payment levels for this specialty, significant difficulty in recruitment and retention, and the professional isolation specialists experience in rural areas are some of the reasons (Al-Qirim, 2002; Charles, 2000; Harris et al., 2001).

Table 2. Tele-medicine advantage

The potential importance of tele-medicine in impacting the health and the welfare of rural communities is tremendous. The estimates of the percentage of tele-medicine patient candidates who can be retained by the rural hospital vary between 50% and 80% (Wayman, 19945). This patient retention not only has a direct, positive effect on the rural hospital and rural physician, but also on the area economy. The average dollar in a rural community circulates seven times; each patient trip to receive speciality consultation encounters costs in gas, lodging, and food, not to mention lost wages for the patient and assisting family/friends (Wayman, 1994). Early intervention has often proved to be less expensive in the long run, so access to specialty care via tele-medicine can ultimately result in decreased healthcare costs to rural areas (Huston & Huston, 2000).

Despite the ongoing evaluations of tele-medicine feasibility in healthcare and the different attempts to measure the costs and benefits of using the tele-medicine technology, there are still not enough data to provide accurate estimates of tele-medicine costs (Huston & Huston, 2000). Another important point to indicate here is that sometimes and according to the internal policy of certain hospitals the financial benefits are hidden or intangibles and difficult to calculate. Direct costs such as the cost of equipment, training, maintenance and ongoing support, upgrades, and ongoing telecommunications are quite obvious and indeed resemble the major costs involved in any tele-medicine project. In a recent research study in the US it was suggested that reimbursement and the cost of telecommunications were identified as the most important barriers of tele-medicine adoption (Grigsby & Allen, 1997).

Perednia and Allen (1995) indicate that current literature tackling tele-medicine has failed in addressing its cost-effectiveness on the basis of its use: as a diagnostic tool and/or as a therapeutic tool and/or case management tool. This further complicates the cost/benefit formula. The concern would be whether tele-medicine is used in the correct place initially and whether it is being used effectively in any of the above three areas. It is essential in the process of adopting certain tele-medicine technology to choose the right one that matches the hospital needs. Using tele-medicine to transmit video when the case necessitates that (i.e., psychiatry, physical and occupational therapy, orthopedics, some neurology applications, etc.), text when appropriate (i.e., lab reports, patient histories and physicals, dietary evaluations, insurance information, medication histories, etc.) using email, still images (i.e., X-rays, pathology slides, lab specimen slides, CTs, MRIs, lung scans and ultra sounds) using scanners or still digital camera or fax machines, and audio (i.e., electronic stethoscope) using telephone or email. It is of utmost importance to remember that most diseases do not move and hence, there is no need for real time and full motion VC equipment (Perednia & Allen, 1995; Wayman, 1994).

Resources available for medical care are limited and the use of expensive tele-medicine technologies will reduce the total number of tele-medicine sites that can be installed regionally or nationally. While use of the latest and most powerful equipment may seem logical, the early adoption of two-way, full-motion video may be unrealistic for many rural and under-served areas (Perednia & Allen, 1995). This is due to logistical reasons concerning the quality of telecommunication lines provided to rural areas (Charles, 2000).

Evidence suggests that other forms of cost control initiatives in the US such as the establishment of health maintenance organisations (HMO) and managed care have a significant effect in the adoption of more technologies and systems than others (Baker & Wheeler, 1998). In the US, most cost-effective applications are those that are paid for by insurers, such as the use of tele-medicine for radiology, prisoner healthcare3, psychiatry, and home healthcare. Other applications enhance access to care but are not cost effective because third-party payers (e.g., HMO) do not pay for related costs for professional fees or the implementation of the technology (Charles, 2000; Huston & Huston, 2000). However, this situation does not apply to New Zealand because healthcare providers are paid ultimately by the government to provide healthcare services to patients in the regions they serve.

There are different ways to reduce the huge expenses in setting and running the tele-medicine sites and recent research suggests that some hospitals tend to promote other services through their tele-medicine network (i.e., like renting the facility to private entities and offices in rural areas to connect to their central offices) or encourage other health providers within and outside the hospital to join them and share the facility (Al-Qirim, 2002; Perednia & Allen, 1995).

Compatibility

Perhaps the greatest dilemma associated with all these changes is how to ensure that innovations in the process of delivering care are not achieved at the expense of sacrificing widely accepted values of what constitutes the humanity of care (Noring, 2000).

Tornatzky and Klein (1982) in their meta-analysis found compatibility features to be an important determinant of adoption. Rogers’ (1995) compatibility characteristic is highly stressed here because past research in healthcare (Austin, 1992; Austin, Trimm & Sobczak, 1995) considered the problem relating to physicians accepting IS for clinical purposes. The use of computers and cameras suggests a shift away from the one-on-one personal interaction now viewed as essential and desirable in healthcare delivery (Table 2). Issues such as “Surgeon syndrome” which is conservatism towards all other technologies than one’s own was highlighted as an impediment to the adoption of tele-medicine (Gammon, 1994). Some view it as an alternative to lack of care or treatment altogether; others view it as a dramatic quality and efficiency improvement to current levels of care (Wayman, 1994). On the other hand, these significant changes to the physician’s and patient’s treatment environment (i.e., one-to-one through the VC Vs. one-on-one and in person) are expected to create resistance for the tele-medicine technology (Al-Qirim, 2002). For example, recent research found that in an extreme case, one of the clinical staff in the rural area almost fainted when she saw herself in the television screen of the VC equipment (Al-Qirim, 2002). It is important that the changes introduced by tele-medicine be compatible with the hospital’s value, practice, and experience to ensure its successful adoption. Issues such as gradual introduction and motivation are highly envisaged here.

The concern is that physicians are reluctant to accept the technology. Gammon (1994) suggested that doctors in general and specialists, specifically, would be the single most influential group affecting the diffusion process of tele-medicine. Gammon (1994) distinguished between two groups of physicians: expertise delivering physicians and expertise receiving physicians. The first group consists primarily of specialists at central hospitals who either, have ambulated (conducted outside treatment visits or operations) visits and enjoyed supplementary income4 or have contributed significantly to hospital income by treating guest patients from neighboring municipalities. By carrying out distant consultations, they experience a reduction in income both for themselves and for their hospital. Furthermore, some physicians have shown a negative attitude toward allowing receiving (primarily rural) hospitals to participate (via VC) in medical meetings, while they are positive towards participating in similar meetings when they themselves are recipients. Physicians working in environments characterised by overload and stress will most likely perceive implementation of tele-medicine as an additional burden. This, coupled with tele-medicine’s replacement of ambulatory, as well as a possible fall in income will muster their resistance to tele-medicine, if not absolute sabotage towards the implementation of tele-medicine (Gammon, 1994). Development of reasonable incentives as well as measures for integrating tele-medicine into the working environment will be an important step.

Security and legal issues are some of the impediments to the success of tele-medicine in New Zealand (Table 2). The security of patient’s data and VC encounters are important issues and need to be addressed. Legal issues relating to operating a tele-medicine network including corporate practice of medicine, patient confidentiality and privacy, malpractice, informed consent, licensure and credentialing, intellectual property, funder’s (Medicare and Medicaid) payment, fraud and abuse, medical device regulation, and antitrust (price fixing) (Edelstein, 1999) are some of the major issues, which could bring any tele-medicine project to a complete halt. However, countries such as the US are well ahead in addressing these issues (Edelstein, 1999). Edelstein (1999) reports that in one session of the American Congress, 22 pieces of legislation relating to tele-medicine were introduced. Four tele-medicine-related bills have been introduced in the 106th Congress.

Complexity

Complexity in the case of tele-medicine could be divided into two parts: Firstly, complexity relating to technical limitations in the VC equipment and bandwidth. Buying the wrong or ill-specified technology such as not presenting clear picture and voice or the different components in the VC equipment are not fully compatible with each other may result in frustrating the users. Selecting the right communication technology and bandwidth such as ISDN, ADSL, and Bridges is essential in order to have clear images and voice, file download/upload, and a valid and reliable connection, respectively. It should be noted here that installing the VC equipment needs a special room with specialised lighting and acoustic system. Secondly, user’s complexity is related to the ease-of-use and to the simplicity of the VC equipment. Providing appropriate training courses earlier on could assist in removing lots of the misperceptions about the complexity of the equipment. This part should not be confused with the compatibility characteristic above, such as convincing the specialists moving from their offices or clinicians to the VC theatre. It could be argued here that the perceived complexity of the VC equipment could lead to incompatible perceptions amongst clinicians. Recent research examining the acceptance of the tele-medicine technology amongst physicians suggests that perceived usefulness was found to be a significant determinant of attitude and intention to adopting tele-medicine. However, the perceived ease of use was not significant (Hu, Chau, Sheng & Tam, 1999).

Trialability

Another important point here is the issue of trying and experimenting with the tele-medicine system before adopting it. Tele-medicine involves a considerable investment in buying the equipment and the training to know how to use it. Most importantly, it should be integrated into the hospital environment in general and in the clinical area specifically to witness its effectiveness. According to the reported challenges above, trying the system in the intended real setting could provide initial and vital signs, which could assist decision-makers in making accurate decisions concerning adopting or rejecting the technology. This makes the limited trialing of the system not sufficient to yield useful results. The issue here is whether the different HHSs are willing to make this involving step or whether the suppliers will accept lending their equipment for a considerable time to HHS to trial their system — and hence remains unanswered.

DISCUSSION AND CONCLUSIONS

If tele-health services are properly introduced and based on evidence of effectiveness, “… telehealth has the capacity to improve the quality of healthcare, provide equity of access to healthcare services, and reduce the cost of delivering healthcare” (Noring, 2000).

This research introduced the importance of adopting the tele-medicine technology by healthcare providers in New Zealand specifically. Tele-medicine represents a great opportunity for healthcare providers in New Zealand to network and to provide integrated healthcare and administrative services to rural areas specifically. This could provide important surrogates to the different gaps existing in the HDIS of the different HHSs in New Zealand. The lack of coordination and cooperation between the different HHSs in New Zealand needs to be resolved in order for this integration to succeed.

This research relied on the technological innovation literature to guide the development of the different factors that could accelerate or impede tele-medicine adoption. These factors are important to the strategic adoption and use of tele-medicine by the different HHSs in New Zealand and elsewhere. Tele-medicine introduces various clinical and administrative advantages as highlighted in this research and these advantages could be focused in delivering quality care and services to rural patients and physicians. However, as a precursor to adoption, it is important to identify the particular advantages sought from tele-medicine, taking into consideration the adoption context and the actual needs of the different HHSs. In a worst-case scenario, tele-medicine enables specialists in the main hospital give second opinions or allow for efficient follow-up and case management. If the costs involved in adopting and running the tele-medicine project were not planned well, the whole project could be brought to a complete standstill. Considering issues such as running costs and hidden costs needs to be identified earlier on. Issues pertaining to the complexity of the technology and to its compatibility with the physician’s working environment needs to be addressed with more emphasis put on the latter as it could prove detrimental to the whole success of the tele-medicine project. Therefore, providing a framework where physicians are encouraged to accept and use the technology in providing healthcare services to patients and to other rural physicians is highly stressed here.

New Zealand’s small area and population (3.82 million) (NZStat, 2001) could lessen the impact of many of the big challenges that hinder tele-medicine adoption in countries such as the US. Issues like licensure and reimbursement are major impediments in the US but not in New Zealand. There is one legal system in New Zealand and hence, interstate legalities and boundaries are large issues in the US but not in New Zealand. New Zealand has a sophisticated telecommunication (networks, mobile) infrastructure, which could serve the large-scale diffusion of tele-medicine across the different HHSs. This research demonstrated that tele-medicine provides various advantages and its potential in reducing costs at different levels has been established. It is important to further assess the strategic importance of tele-medicine within the different HHSs and at the national level in New Zealand. This task is quite achievable and requires the involvement of the different stakeholders highlighted in this research. Creating a national strategic plan aiming at identifying opportunities with respect to speciality-care, rural coverage and medical needs, and other administrative objectives could assist in driving the health sector forward and in providing fast and quality care to rural patients in the first place and to all New Zealanders eventually. Creating this integrated tele-medicine network amongst the different HHSs could prove viable to healthcare delivery in New Zealand.