One of the more significant developments over the past decades has been the emergence and widespread deployment of information and communication technologies (ICT) [1
]. The 'digital revolution' has transformed our everyday lives and has had a pervasive influence on work and organizations. ICT has captured the attention of health care providers as well as health policy makers, who are encouraging these technologies primarily because of their potential to address issues such as inequalities in access to health care and the need to reduce costs, while delivering at least equivalent, if not better, standards of health care than traditional alternatives [4
Telemedicine is the use of information technology to support delivery of health care from a distance [6
]. Despite the general impact of new technologies in society and the political will to promote telemedicine in public health care, telemedicine has primarily been used on a small scale in clinical activity. As a field of practice, telemedicine is mainly characterized by trials, demonstrations, or experimental services that do not endure beyond the life of specific research and development projects. Only a few telemedical applications have been implemented on a wide scale and sustained [9
It is commonly suggested that the main reason for the low routine clinical use of telemedical applications is the insufficient evidence of its efficacy, in terms of both clinical and organizational impact on the health care sector. Without evidence of any effect, professional and political support for telemedicine cannot be sustained [12
]. However, the outcome of clinical trials does not communicate the whole story about what is needed to make telemedical applications work [15
]. Conditions operating during the projects, which could have been important for the outcome of the trial, are seldom mentioned or questioned; neither is the correlation between positive outcomes of clinical trials and routine use. In addition, it is often unclear in the literature whether the telemedical application being discussed has been introduced into routine operation, and whether any such routine operation in fact is an extension of the research and development project or represents a new introduction of the application in a completely different part of the health service.
An understanding of why telemedicine is seldom used in clinical practice is important to clinical and policy proponents of these technologies, who see telemedical applications offering solutions to some key problems in improving access to health care and equitably distributing specialist clinical expertise [12
]. Previous telemedicine research provides little insight into why there is so little routine use of telemedicine in clinical practice. In recent years, however, studies on 'organizational issues' have emerged [7
]. Some of the reports refer to the study of science and technology in a social context, or STS theory [17
], and the term 'social negotiation' [17
] has been used to describe a key aspect of the difficulties of routine clinical use. The basic assumption in STS theory is that scientific knowledge and technologies do not evolve in a vacuum. Rather, they should be seen as parts of the social world, being shaped by it, and simultaneously shaping it. The term 'social negotiation' indicates that while technological issues such as inadequate design or poor performance will reduce the system's chances of being implemented successfully [19
], use or non-use is determined by the social context in which the technology is implemented. This is because a more or less explicit controversy will always arise when a new technology is implemented. The controversy may involve the problems that the technology is intended to solve, as well as the ways in which they are to be solved. The various participants may also have different perceptions of what the organizational challenges are, what the solution should look like, and whether an implementation is viewed as a success or a failure.
From the perspective of those who question the assumption that insufficient evidence of telemedicine is the reason for low clinical use, it is clear that new technologies alone do not create change. Rather, it is the interplay between technical and social factors that produces particular outcomes [17
]. That is, organizational difficulties lie in the deep interrelation of technical and social aspects of designing and implementing technologies. Conversely, success entails handling these complex, heterogeneous factors, which are expressed in controversies and solved through social negotiation.
The purpose of our study is to contribute to this emerging literature on telemedicine and organisational issues by doing an in-depth analysis of the characteristics of telemedical applications that have been implemented into routine clinical practice. Our method is a review of the literature on telemedicine with success. Our principal research questions are: 1) What are the characteristics of telemedical applications that have successfully been implemented in routine clinical practice? 2) In what way are these characteristics associated with the emerging literature on telemedicine and organisational issues, particularly with respect to STS theory and the concept of 'social negotiation'.
On the basis of our findings, we aim to suggest how proponents of telemedicine should proceed when planning to implement telemedicine in clinical practice, and to indicate areas for further research.