The organising vision for telehealth and telecare: Discourse analysis

The organising vision for telehealth andtelecare: discourse analysis

Trisha Greenhalgh,1 Rob Procter,2 Joe Wherton,1 Paul Sugarhood,3 Sara Shaw1

ABSTRACTObjective: To (1) map how different stakeholdersunderstand telehealth and telecare technologies and(2) explore the implications for development andimplementation of telehealth and telecare services.

Design: Discourse analysis.

Sample: 68 publications representing diverseperspectives (academic, policy, service, commercialand lay) on telehealth and telecare plus field notesfrom 10 knowledge-sharing events.

Method: Following a familiarisation phase (browsingand informal interviews), we studied a systematicsample of texts in detail. Through repeated closereading, we identified assumptions, metaphors,storylines, scenarios, practices and rhetoricalpositions. We added successive findings to anemerging picture of the whole.

Main findings: Telehealth and telecare technologiesfeatured prominently in texts on chronic illness andageing. There was no coherent organising vision.Rather, four conflicting discourses were evident andengaged only minimally with one another’s arguments.Modernist discourse presented a futuristic utopianvision in which assistive technologies, implemented atscale, would enable society to meet its moralobligations to older people by creating a safe ‘smart’home environment where help was always at hand,while generating efficiency savings. Humanistdiscourse emphasised the uniqueness and moralworth of the individual and tailoring to personal andfamily context; it considered that technologies wereonly sometimes fit for purpose and could create aswell as solve problems. Political economy discourseenvisaged a techno-economic complex of powerfulvested interests driving commodification of healthcareand diversion of public funds into private business.Change management discourse recognised thecomplicatedness of large-scale technologyprogrammes and emphasised good projectmanagement and organisational processes.

Conclusion: Introduction of telehealth and telecare ishampered because different stakeholders holddifferent assumptions, values and world views, ‘talkpast’ each other and compete for recognition andresources. If investments in these technologies are tobear fruit, more effective inter-stakeholder dialoguemust occur to establish an organising vision that betteraccommodates competing discourses.

INTRODUCTIONAssisted living technologies comprise thesensors, devices and communication systemsthat, in combination, support delivery ofservices to a person in their own home. Theyinclude telehealth (remote medical care,treatment or monitoring) and telecare(remote social care services or monitoring),proposed as a solution to the inter-relatedtrends of ageing of the baby boom generation;rising rates of chronic illness and disability;

To cite: Greenhalgh T,Procter R, Wherton J, et al.The organising vision fortelehealth and telecare:discourse analysis.BMJ Open 2012;2:e001574.doi:10.1136/bmjopen-2012-001574

< Prepublication history andadditional appendix for thispaper are available online. Toview these files please visitthe journal online(http://dx.doi.org/10.1136/bmjopen-2012-001574).

Received 29 May 2012Accepted 18 June 2012

This final article is availablefor use under the terms ofthe Creative CommonsAttribution Non-Commercial2.0 Licence; seehttp://bmjopen.bmj.com

1Centre for Primary Care andPublic Health, Barts and theLondon School of Medicineand Dentistry, Queen MaryUniversity of London,London, UK2Manchester e-ResearchCentre, University ofManchester, Manchester, UK3Barts Health NHS Trust,London, UK

Correspondence toProfessor Dr TrishaGreenhalgh;[email protected]

ARTICLE SUMMARY

Article focus- Despite significant research and investment,

telehealth and telecare technologies are notwidely used and their value is contested.

- We used discourse analysis to study thecompeting arguments and practices of differentstakeholder groups.

- Our research questions were: (1) how dodifferent stakeholders understand telehealth andtelecare technologies? and (2) what are theimplications for development and implementa-tion of telehealth and telecare services?

Key messages- We identified four conflicting but overlapping

discoursesdmodernist (technology-focused,futuristic, utopian), humanist (person-centred,small-scale, grounded in present reality), politicaleconomy (critical, cautious) and change manage-ment (recognising complicatedness but notconflict)dwhich engaged only minimally withone another’s arguments.

- We suggest that stakeholders in telehealth andtelecare projects work towards establishing cross-sector learning communities in which differentpoints of departure, priorities and accountabilitiesare made explicit and acknowledged.

Strengths and limitations of this study- Detailed close reading of texts enabled us to

make sense of a complex and heterogeneousacademic, policy and lay literature.

- Discourse analysis is not well understood orvalued by the mainstream medical community.

Greenhalgh T, Procter R, Wherton J, et al. BMJ Open 2012;2:e001574. doi:10.1136/bmjopen-2012-001574 1

Open Access Research

shortfalls in health system capacity and budgets andshifting social roles and expectations.1 2 The term ‘tele-health’ (for which a more detailed definition might betechnology-supported medical or nursing tasks under-taken in a person’s home or other remote site, especiallysending biometric data from the patient to the healthcaresystem and/or sending advice, instructions or remindersfrom the healthcare system to the patient) should bedistinguished from ‘telemedicine’, which conventionallyrefers to technology-supported links between differentparts of the healthcare system (eg, between a generalpractice and a hospital), and is not covered in this paper.In the UK, telehealth technologies are usually linked withthe public or private healthcare system, whereas telecaretechnologies, mostly comprising alarms and sensorsintended to detect such things as falls, flooding andpeople who have become lost while wandering, aregenerally linked with social services. The terms ‘tele-health’ and ‘telecare’ are relatively new. Older texts usea wide range of terms, some of which would now beconsidered insensitive or politically incorrect (eg, ‘aids forthe handicapped’), and the broader term ‘gerontech-nology’ was introduced recently to refer to telehealth,telecare, mobility aids, lifts and other communicative andassistive technologies when used by (or offered to) olderpeople.3

Despite the espoused potential of telehealth and tele-care technologies to enable people to ‘age in place’ (ie,avoid or defer institutional care in later life and remainactive participants in society), benefits achieved to datehave been modest.4 This is partly because exploration ofthe personal, organisational, cultural, ethical and legalimplications of telehealth and telecare has laggedsignificantly behind technology development.5e9

Yet interest and investment from industry, governmentand research sponsors remain high. In the UK, forexample, the government-funded Technology StrategyBoard allocated £25 million to assisted living technologydevelopment, most of which was contingent on matchedindustry funding, between 2008 and 2011. Research anddevelopment increasingly involves large-scale, multi-partner inter-sectoral partnerships such as DALLAS(Delivering Assisted Living Lifestyles at Scale, a £23million partnership between the Technology StrategyBoard and government departments, launched in June2011) and the ‘3 million lives campaign’, an agreementbetween government and industry to create an enablinginfrastructure for assistive technologies in the UK publicsector (http://www.3millionlives.co.uk/).These UK examples, which are mirrored in many

other countries, illustrate the multiple stakeholdersinvolved in telehealth and telecare, including govern-ment, policymakers, the technology industry (whooperate as businesses), researchers (who bring preferredtheoretical and methodological approaches and stan-dards), health and social care professionals (who mayhave a view on what ‘good’ care consists of), andmanagers (who may operate within particular metrics of

efficiency), third-sector organisations (such as patientand carer support groups and charities), citizens (whomay have a view on how their taxes are spent) and thepeople who use telehealth and telecare technologies orchoose not to use them. The process of developing,disseminating, implementing and using telehealth andtelecare technologies requires coordination betweennumerous individuals and organisations, each of whommust commit to making a personal, professional orfinancial investment in the technologies and the workinvolved in their use.Programmes whose aim is to introduce a new tech-

nology must create a vision of what life will be like whenuptake has reached the hoped-for levels, generate posi-tive expectations and mobilise stakeholder efforts todevelop and disseminate it. As the pace of technologicalprogress in medicine quickens, ‘regimes of truth’ (whatpeople know or claim to know) may give way to ‘regimesof hope’ (in which lack of hard evidence that a tech-nology worksdor even existsdis reframed as evidencethat investment needs to increase).10

Technologies introduced into organisations are opento different interpretations. Different staff in organisa-tions frame technology differently, for example, engi-neers typically view technologies as tools for undertakingparticular tasks; managers view them as instruments forachieving business goals.11 Sense-makingdin whichmembers negotiate the meaning of the technology, howit should or might be used and what benefits andhazards it could bringdis crucial for successful imple-mentation.12 A related concept at societal level is that ofthe ‘organising vision’: ‘a focal community idea for theapplication of information technology . that embedsand utilises information technology in organisationalstructures and processes’ (p. 460).13 A flawed or incon-sistent organising vision may explain why technologiesthat show initial promise subsequently fail to enterwidespread use.In this study, undertaken as background to an empir-

ical research study on assisted living needs in, andtechnology design for, older people, we sought to mapthe stakeholders and identify the discourses thatcontributed to the organising vision for telehealth andtelecare technologies. Our research questions were: ‘howdo different stakeholders understand telehealth andtelecare technologies and what do they envision will beachieved with them?’ and ‘what are the implications ofthese different understandings for the development andimplementation of telehealth and telecare services?’

METHODSThe ATHENE (Assistive Technologies for Healthy Livingin Elders: Needs Assessment by Ethnography) study wasfunded by the Technology Strategy Board under itsAssisted Living Innovation Platform call. The steeringgroup included a lay chair and representation fromindustry, NHS, social care, technology users andacademics. Ethical approval was granted by Queen Mary

2 Greenhalgh T, Procter R, Wherton J, et al. BMJ Open 2012;2:e001574. doi:10.1136/bmjopen-2012-001574

The organising vision for telehealth and telecare: discourse analysis

University of London Research Ethics Committee(QMREC2011/38) in June 2011 and Bromley NHSResearch Ethics Committee (11/LO/0737) in July 2011.

Theoretical position: organising vision as discourseWe adopted Swanson and Ramiller’s notion of organ-ising vision, as comprising metaphors, buzzwords, imag-ined scenarios and related framings, and centringaround widely (though not necessarily universally)acknowledged problems and issues.13 The organisingvision serves three functions for those seeking to intro-duce and ‘roll out’ a new technology: (1) interpretation(a shared notion of what the technology is and how itcould be used); (2) legitimation (a shared rationale forwhy the technology should be adopted and used) and(3) mobilisation (activating and coordinating stake-holders to promote adoption and diffusion). An organ-ising vision must be informative (clear about what thetechnology is and what it might do), plausible (free ofexaggerated or misplaced claims about the expectedoutcomes of adoption), convey a sense of importance(about the value of the technology) and present thetechnology as distinctive (offering something new overexisting products and practices).14

While the organising vision for most commerciallyavailable technologies resides within a single industry(designers, suppliers, vendors and so on), the vision forhealthcare technologies must embrace a much widercommunity of stakeholders with differing values andperspectives, including industry, government, third-sectororganisations, health professions, patients and carers,researchers and research sponsors.15 16 Their variousspoken, written and enacted communications frame andpresent the arguments through which different stake-holders engage with one another (and/or the argumentsby which they dismiss one another and fail to engageeffectively). We considered such communications to bebroadly equivalent to one definition of discourses:‘ensemble[s] of ideas, concepts and categories throughwhich meaning is given to social and physicalphenomena, and [.] produced and reproducedthrough an identifiable set of practices’ (page 67).17

Discourse analysis is a well-established technique inqualitative research; its principles are explained in twointroductory articles.18 19 Discourse refers to bothspoken and written forms of communication. It isrevealed by studying both written documents and a widerset of ‘texts’ including oral speech, speech acts (perfor-mances), pictures, symbols and artefacts such as soft-ware. An idea or frame of reference may be conveyed bytexts through literary devices such as metaphor, imagery,symbols, graphs and through structuring devices such astabulation, listing, footnotes and so on. Discourse anal-ysis requires a judicious balance between teasing outthe broad overarching storylines within which ‘facts’are presented (‘macro-’ or ‘big D’ Discourses) andundertaking detailed micro-analysis of particular texts(‘micro-‘ or ‘little d’ discourses), while recognising thereciprocal relationship between these two levels.20

MethodsThe method is summarised in box 1. In this analysis, wewere interested mainly in the macro-level discourses thatcontribute to the organising vision. To identify these, wefollowed the basic principles of discourse analysis,19

supplemented by selected (macro-level) elements ofHajer’s argumentative discourse analysis.17 To gain famil-iarity with the topic area, we browsed a range of literatureand other sources (eg, websites), attended orientationevents and held five informal open-ended (helicopter)interviews with fellow academics, industry contacts andfront-line clinicians. We then sought a maximum varietysample of documentary sources (listed in onlineappendix) covering research, policy, industry, third sector,health and social care, knowledge brokers (includingmanagement consultants and think tanks), business andlay media and technology users. We asked our steeringgroup members and searched electronic databases(Medline, Social Science Citation Index and GoogleScholar for academic sources and government websitesfor policy sources) for ‘telehealth’, ‘telecare’, ‘assistedliving technologies’ and ‘assistive technologies’, thenpursued reference lists and hyperlinks. For health andsocial care organisations (including third sector), webegan with local organisations with whom we wereworking on the ATHENE project. For media sources, weprospectively captured relevant outputs from nationalnewspapers, television and the internet between August2011 and April 2012.From approximately 400 candidate documents (all of

which were published since 2000 and most since 2009), weselected our final sample of 68 (10 from 2002 to 2008 andthe rest post-2009) using the following prioritising criteria:

Box 1 Methodological approach, adapted from othersources17 19

Familiarisation phase1. Desk research. Reading a broad range of sourcesincluding academic papers, lay press, websites, industrypublications and so on to produce a ‘first reading’.2. Informal ‘helicopter interviews’ with five lead informantsselected to provide an authoritative overview of the topic.

Main phase3. Document analysis. Systematic analysis of a sample ofdocuments for structuring concepts, ideas, categorisations,metaphors and key storylines.4. Analysis of argumentative exchangesdin this study,conference presentations and audience responses.5. Interpretation: drawing the above together to produce anaccount of different discourses, the sites where these areproduced and shaped and extent of engagement andargumentation between them.

Consolidation phase6. Member checking. Preliminary interpretation is checkedfor resonance with a sample of informants includingrepresentatives of different stakeholder groups.



viewed as authoritative by others in the field (eg, widelycited, personally recommended or having official status);offered a summary and/or overview of the field includinga statement of the problem, proposed (technological orother) solution and how people were intended to use thetechnology(ies); serving at least one key purpose in theorganising vision (interpretation, legitimation or mobi-lisation); typical of other documents in this genre orrepresenting a significant alternative position and recent(post-2009 or, if published before then, still being used as‘current’). We were interested mainly in the prevailingorganising vision in this rapidly developing field, and tothat end, we prioritised material produced in the last3 years. But in order to couch current discourses appro-priately in historical context, we included strategy docu-ments published before that date and still being used as‘current’.Between September 2011 and April 2012, we attended

10 knowledge-sharing events (conferences, workshops),sampled for maximum variety in terms of size, lead sector(public or private), intended audience, goals and stage(launch event, mid-stage or post-project dissemination).We made field notes and collected documentation(eg, marketing materials, abstract books, proceedings),following the approach developed by Allen (who usedethnography at meetings and conferences to surface theunderlying assumptions, values and key arguments in aninterdisciplinary community of researchers).21

Data analysisTo analyse our documents and field notes, we first readand reread each to gain familiarity, flagging sectionsof text that interested or surprised us. We then rereadeach text looking for specific material includingimages, metaphors, scenarios, rhetorical devices (suchas associationddepicting two concepts as similar orrelateddand dissociationddepicting two concepts asdissimilar or mutually exclusive), underpinningassumptions (eg, about the safety or reliability of tech-nologies) and overarching storylines. We used spread-sheets to organise excerpts into overarching discoursesand (within these) particular themes and categories,drawing on interdisciplinary discussions betweenresearch team members whose backgrounds spannedmedicine, computer science, psychology, occupationaltherapy and sociology. In an interpretation and synthesisphase, we drew together findings from this analysis,adding those from successive texts to an emergingpicture of the whole using the constant comparativemethod.22 We presented a near-final draft of our analysisto 15 people representing all main stakeholder groupsand refined this in response to feedback.

RESULTSDescription of data set and overview of findingsOur final data set consisted of 78 texts (68 documentsand 10 sets of field notes). Documents comprised 22academic papers (11 empirical and/or theoretical,

11 reviews or commentaries), three guidelines or stan-dards, three local protocols, five European Union and12 UK policy documents, six lay and four businessmedia articles, five reports from independent consul-tancies or think tanks, three conference brochures,three industry brochures and two patient organisation‘factsheets’. Field notes covered 10 conferences andother knowledge-sharing events. Of our 78 texts, 58were from UK, 10 from elsewhere in Europe, nine fromNorth America and one from Australia.Analysis identified four overarching discourses

(summarised in table 1): modernist, humanist, politicaleconomy and change management. Modernistdiscourse, often written in the future tense, depictedhigh-technology innovations designed by experts asoffering reliable, cost-effective and ethically benignsolutions to complex clinical and social problems.Humanist discourse focused on individuals and depictedpresent-day technologies (chiefly alarms and monitoringdevices) as potentially disruptive (stigmatising andunwelcome in the home), distantiating (separatingpeople from their families and carers) and disempow-ering (surveillance as control), and as offering at besta partial solution to the age-related decline of thehuman body and mind. Political economy discoursedepicted telehealth/telecare as a lucrative businessmarket being manipulated by commercial vested inter-ests. Change management discourse depicted adoption,spread and sustainability of these technologies asdependent on good project management and organisa-tional processes. We describe these contrastingdiscourses in more detail below.

Modernist discourse: technology as solution, technologyuser as consumerThe problem for which telehealth and telecare tech-nologies were considered to be the solution wasexpressed thus by one academic review:

The over burdened health care system will face a world-wide wave of retirees who will live longer, cost more totreat, and demand new goods and services to help themstay healthy, active, and independent. (page 171)23

This extract illustrates several features of modernistdiscourse. The population of older adults was depictedin vague, collective and homogeneous terms (‘retirees’,‘elders’, ‘baby boomers’); expanding in an uncontrolledand threatening way (‘wave’, ‘tsunami’, ‘time-bomb’);and as resource-hungry, demanding and chronically sick(hence in need of preventive input, monitoring andtreatment). Their longevity was depicted as a problemrather than a positive marker of health or the success ofthe healthcare system. The healthcare system, corre-spondingly, was depicted as operating at near-maximumcapacity and in danger of collapse.Telehealth and telecare technologies were presented

as the rational and cost-effective solution to these prob-lems, as tidy, precise, ‘in control’, (near-) invisible,



Table

1Summary

ofdifferentdiscoursesin

telehealthandtelecare

Modernist

Humanist

Politicaleconomy

Changemanagement

Philosophicalposition

Instrumentalrationality

Phenomenology

Criticaltheory

Pragmatism

Whatis

consideredto

beofvalue?

Efficiency,cost-effectiveness,rational

solutions,technologicalprogress,

businesssuccess

Feelings,experiences,relationships,

reciprocities

Emancipation,reductionin

oppression/domination

Adoption,assim

ilation

into

business-as-usual,

sustainability

Usualunitofanalysis

Technology(product)

Person,technology-in-use

Interestgroup/conflict

situation

Servicemodel,

organisationalroutine

Methodologicalapproach

Experimental

Naturalistic

Historical

Naturalistic

Preferredresearchdesign

Randomisedcontrolledtrial

(hypothesis-driven,deductive),

emphasis

onsizeandscale

and

productionofgeneralisable

truths

Ethnography,in-depth

interview,

focusgroup(qualitative,inductive),

emphasis

onunderstandingthe

individual’s

perspective

Casestudy(qualitative,

inductive),emphasis

on

surfacingandchallenging

powerstruggles

Casestudy(qualitative

ormixed-m

ethod,

inductive),emphasis

onexplaining

barriers

tochange

Whatis

viewedas‘research

evidence’?

Effectsize,metrics(eg,mortality

rates,admission/readmission

rates),‘proofofconcept’

Authentic,plausible

accountoflived

experienceandthemeaningof

technologyfrom

users’perspective

Contextualisedaccountof

powerstruggles

Contextualisedaccount

ofchange(orlackof

change)

Assumedcharacteristicsof

technologies

Automated,‘smart’/‘intelligent’,

sophisticated(eg,robotic),ubiquitous,

seamlessly

connected,failure-free,

agentic(ie,doesthings)

Potentially

stigmatisingor

constraining,proneto

failure,

needinghumaninputto

work

effectively.Maybelow-tech

forexample,recycledeveryday

objects

Benefits

inflatedbymarketing

andcommodificationbyan

industrybiasedtowards

high-tech,‘innovative’products

Focusontechnology-in-

use.Hence,same

technologywillhave

differentutilityin

different

systemsandcontexts

Metaphorfortechnology

development

Developingandim

plementing

technologicalsolutions

User-centreddesignorredesign

Manipulationofthemarket

Creatingopportunitiesfor

system

redesign

Metaphorfortechnologyuse

Deployment,choice,empowerm

ent,

compensationforhumandeficits

Being-in-the-w

orld,technology

ready-to-hand

Commodification

Acceptance,adoption

Assumptionofwhatpeople

willusetelehealth/telecare

technologiesfor

‘Self-m

onitoring’d

sendingbiometric

data

tohealthprofessionals

Communicatingwithfriends/family,

maintainingautonomy,leisure

activity

Manypeople/serviceswillbuy

thesetechnologiesbutfew

willusethem

Supportingroutines

(personal,family,

healthcare

provider)

Metaphorforhow

technologiesare

takenup

Businessdrivers,regulatory

levers,

innovationvaluechain,silvermarket

Creative,adaptiveandperhaps

heroic

humaneffort

Marketdomination

Routinisation

Continued



freestanding, mobile, portable, autonomous and ethi-cally benign. Imaginary future scenarios of the ‘smarthome’ (spacious, clean, connected, safe, watched-overand free of technical or emotional trouble) and digitallyempowered older citizen (literate, skilled, technicallyand socially engaged and with high quality of life despitehaving illnesses in need of monitoring) were common(see, eg, the Smith family in a ‘roadmap’ prepared forthe European Commission24).‘Empowerment’ was equated in this discourse with

compliant use of telehealth technologies for self-monitoring and education. Through ‘persuasive tech-nologies’ (defined as ‘a computing system, device, orapplication intentionally designed to change a person’sattitude or behaviour in a predetermined way’23),medical intervention would be possible at an increas-ingly earlier stage in the chronic disease process,allowing the person (assumed to be a rational actor) theopportunity to ‘choose’ a healthier lifestyle.Technological and human infrastructures were

depicted, like the technologies themselves, as ubiqui-tous, error-free, ‘automatic’ and always available:

. electronic sensors or equipment that monitors vitalhealth signs remotely, e.g. in your own home or while onthe move. These readings are automatically transmittedto an appropriately trained person who can monitor thehealth vital signs and make decisions about potentialinterventions in real time, without the patient needing toattend a clinic (page 4)Headline findings, Whole Systems Demonstrator Trial25

Modernist discourse sometimes acknowledged mate-rial limitations of current technologies, including peri-odic breakdown, ‘clunky’ functionality andinteroperability and governance challenges, butdepicted a time in the near future when such limitationswould be overcome. Some texts offered future scenariosof automated ‘placeless’ data capture occurring withoutdisruption of people’s lives or lifestyles.Modernist discourse anticipated significant reductions

in costs as technologies generated various (unspecified)efficiency savings, typically using an eclectic selection ofreferences and conditional language (eg, ‘(a maximally-saturated assistive technology market) may yield up toaround $75 billion annually of savings, or about 5% ofthe projected $1.7 trillion spent on United Stateshealthcare’26).Telehealth and telecare technologies were depicted as

a business opportunity, fuelled by a lucrative ‘silverpound/dollar’. Moral worth was located in the techno-logical and business sphere, aligned with innovation,financial and technical efficiency and clinical effective-ness. Modernist discourse tended to equate ‘ageing well’with becoming adept in the use of technologies, whiledepicting human contact between professional carersand vulnerable older people as unnecessary, inefficientand wasteful of resources (technologies were seen as‘saving’ resources by reducing contact time). TechnologyT

able

1Continued

Modernist

Humanist

Politicaleconomy

Changemanagement

Assumedconsequencesof

(widespread)useof

telehealth/telecare

technologies

‘Demographic

timebomb’willbe

contained;healthcare

costs

willfall;

people

willbehealthierandhappier;

new

markets

forassistiveproducts

andserviceswillboosttheeconomy

Positive:cansupportindependent

living.Negative:mayreduce/

replacehumancontact,cause

stress,medicalisethelife-w

orld,

becomethe‘patient’when

theybreakdown

Public

fundsdivertedinto

private

business.Lossof

service-sectorjobsand

traditionalservices(eg,district

nurses).Institutionalisedageism

inscribedin

technology

Organisationaltasksand

processesmademore

efficient;stafftimefreed

upto

dootherwork;

healthoutcomesim

proved

Non-useoftelehealth/

telecare

technologies

explainedin

term

sof

Educationgap,motivationgap,

awarenessgap,incentivegap

Uniquenessandcomplexityof

individualcircumstances;meaning

oftechnology

Resistanceto

domination

Individual-,organisational-

andsector-levelbarriers

tochange



development was framed as a design-as-engineeringchallenge, undertaken by specialists in a setting removedfrom front-line healthcare or the lived experience ofillness.In modernist discourse, agency was sited in the tech-

nology itself (eg, ‘The devices gather health informa-tion’). Technology users were depicted as consumers oftechnological products, passively accepting of whatevertechnologies were provided, skilled (and/or willing todevelop skills) in how to use them, gaining enhancedhealth status and social experience (telepresence) fromthem and having only positive emotions towards them:

Ms EW, 64, a retired technologist who keeps a laptop onher dining room table near a crocheted doily anda scented candle, often uses the [video chat] service todrink her morning coffee with one of several friends wholive in the same town.New York Times feature article27

Delays or barriers in the adoption of telehealth ortelecare were explained in terms of a deficiency in thetechnology user, who was described as ‘resisting’ or‘unengaged’; the solution to this was framed in terms ofuser education or modification to the technology.Negative emotions and interpersonal conflict wereeither not addressed or presented with a potentialtechnological fix.A number of elements of modernist discourse helped

to construct telehealth and telecare technologies andtheir use in the home as legitimate (reasonable, ethicaland examples of good professional practice, good citi-zenship and so on). These included medicalisation(ageing is a disease or predisease to be ‘monitored’ and‘treated’), rationalisation (technologies represent prog-ress towards a more ordered and rational society), risk(the autonomous, unmonitored older person is ‘at risk’and ‘unsafe’), deficiency (older people lack somethingthat technology can replace), rational choice (peoplecan be persuaded or ‘nudged’ to use technology fortheir own good) and empowerment (technology isliberating and provides comfort, quality, convenienceand value for money).A significant component of modernist discourse was

mobilisation. For example, the Technology StrategyBoard and the European Union both talked of a ‘4-pointplan for mobilisation’, which comprised: (1) raiseawareness, (2) create the ‘right’ conditions (eg, removebarriers to free trade), (3) accelerate investment in andtake-up of proven solutions and (4) prepare for thefuture through further research. Technology develop-ment was depicted as necessarily progressive, occurringin phases (‘prototype’, ‘beta’, ‘launch’, ‘1st/2nd/3rdgeneration’), each phase producing a more sophisti-cated, more fit-for-purpose and more efficient (but nomore expensive) product.28 This progression wasdepicted as occurring at speed and accelerating; stake-holders were exhorted to board the train before it leftthe station or risk getting left behind.

Modernist discourse was particularly apparent atknowledge-sharing events, at which it was enacted as wellas written. The focus in most of these events was onshowcasing advanced technological ‘solutions’ (eg,robotic products) that were not yet on the market butwere presented as ready to be deployed, typicallyaccompanied by speech acts such as the award of a prizefor the most promising innovation. The argumentativework of modernist discourse was achieved at these eventspartly by the mutually reinforcing activities of stake-holders from different sectors as industry representativesdemonstrated their products, academics offeredresearch findings, policymakers launched new docu-ments or themes and journalists asked questions.Since the problem that telehealth and telecare tech-

nologies were intended to solve was considered to beextensive, urgent and rapidly worsening, the solutionwas depicted, correspondingly, in terms of partnershipsbetween multiple institutional stakeholders (see Intro-duction section), supported by frequent knowledge-sharing events and ‘digital economy hubs’. Thepreferred research design was the large-scale experiment(to show ‘what works’), as exemplified by the £31 milliongovernment-funded randomised Whole System Demon-strator trial.25 National policies and business strategies inthe UK were nested in a wider European vision andinfrastructure for knowledge and economic growth.28

Substantial upfront allocations of resources to buildinter-sectoral links and facilitate research and develop-ment were justified via a discourse of investment,payback and economies of scale, but potential conflictsof interest between these stakeholders went largelyunexamined. The social change predicted by modernistdiscourse was dramatic, far reaching and technologydriven: new technologies would not merely enhancecurrent approaches to supporting people in theirhomes; they would fundamentally alter them.

Humanist discourse: technology user as activemoral agentSome texts in our data set, notably academic papers bysocial scientists29e33 and patient organisation advicedocuments34 35 revealed a very different discourse whichcontrasted with modernist discourse in five key ways.First, it centred not on technologies but on the livedexperience of illness, ageing and disability; the spacesand places where people lived; the care relationshipsand accountabilities (formal or informal) whichsupported them and the positive human qualities oftechnology users. In particular, older people, whetherphysically disabled or cognitively impaired, werepresented as active, resourceful and moral agents whostruggled to live meaningful lives, fulfil social obligations(such as not troubling their professional carers orrelatives too much) and look after the technologiesgiven or lent to them. They were presented as thesubjects rather than the objects of technology design andto that end, research studies typically had participatory



and qualitative designs and studied a small sample ofparticipants in depth.Second, humanist discourse focused not on an

imagined high-technology future but on current low-technology realitydespecially on the (fairly limited)range of alarms and monitoring devices available at thetime of our study. While technologies were not neces-sarily depicted negatively (eg, one study showed howpeople with dementia used mobile phones when outwalking,29 and voluntary sector advice often emphasisedbenefits of technologies34 35), these were seen asoffering, at best, partial solutions to the complex chal-lenges of chronic illness, ageing, rejection and variousforms of exclusion and isolation. Health and social carestaff and users represented in research studies in oursample, typically saw assistive technologies as prone tofailure, with limited interoperability, not always fit forpurpose, creating as well as solving problems, distractingcarers from the human needs of the technology user andbecoming the ‘patient’ as users or carers took onresponsibility for maintaining and repairing them.Third, humanist discourse emphasised symbolic

meaning. Qualitative studies that explored participants’reluctance to use alarms and tags found that somepeople viewed them as intrusive, disempowering, stig-matising, isolating and exposing them to surveillance byrelatives and/or the state.29 Metaphors included medi-calisation of the lifeworld and technology as intruder.These texts emphasised that different parts of the homehad different social and cultural meaning. The livingroom, for instance, typically served as a site of socialinteraction, leisure and public display (of flowers,photographs, trophies and so on); the bedroom wasa site of privacy and intimacy. Technologies placed inthese spaces acquired altered significance and in turnaltered the significance of the spaces. The behaviour ofparticipants who refused to install, turn on or use tele-health or telecare technologies could sometimes beunderstood in terms of protecting the boundarybetween the home and the clinic.30

Fourth, humanist discourse reframed technologydesign as a personal and interactive activity, in which theintended user was an equal partner and expert in theirown needs and preferences. One group of researchers,for example, described a person with early dementiawho still enjoyed jogging but sometimes could not findhis way home; designers worked with ‘The Runner’ tounderstand and incorporate his values and priorities; theresult was a lightweight satellite positioning device ina Velcro-fastened striped armband that conveyeda ‘sporty’ rather than ‘tagged’ identity.31

Finally, humanist discourse emphasised the delicateand situated balance between benefit (eg, protection)and harm (eg, stigma, intrusion, distantiation).Inscribed in technology, deliberately or inadvertently,are the values, norms, world-views and assumptions of itsdesigners and sponsors, which may include age, gender,class, cultural and other stereotypes. It is a strange form

of ‘empowerment’, for example, that requires an indi-vidual to stay at home, undertake bodily rituals severaltimes a day and enter data into a machine for distantprocessing. Video technology could increase social isola-tion by enabling professional carers and relatives tomonitor them at a distance, avoiding getting close tohuman mess (smells, emotional needs, suffering, inter-personal conflict, body fluids). As the Royal College ofNursing put it, ‘Healthcare and nursing practice hastraditionally demanded face-to-face contact betweenpatients and professionals. The ethics of remote assess-ments and treatment have yet to be fully explored’.36

Political economy discourse: the technologicaleindustrialcomplexPolitical economy discourse was articulated mainlythough not exclusively by critical academics. It sought toidentify and challenge the techno-economic regimescreated and perpetuated by vested interests aroundassisted living technologies.37 Matheson, for example,draws explicit parallels between the pharmaceutical andmedical device industries.38 He argues that scientific andtechnological innovation is far from a politically neutralexercise in building a knowledge base. Rather, researchand marketing activities combine to produce ‘productcanons’ (master narratives depicting a large growingneed and a drug or technology that will meet it) thatintegrate scientific truth claims and commercial posi-tioning, thereby generating knowledge with implicitcommercial functionality.Texts in political economy discourse challenged the

‘efficiency narrative’ (ie, the assumption that technology,however expensive, will increase efficiency and hencebring return on investment and progressive cost-savings)put forward by techno-economic regimes. Theypredicted that the introduction of telehealth and tele-care technologies would be a conflict-ridden processoccurring at a slow pace since negotiations would beheavily constrained competing vested interests andstructures such as organisational boundaries, budgets,professional accountabilities and legal jurisdictions:

The current climate of strong desire to control healthcarecosts, to introduce fundamental reform of NHS commis-sioning and to support technological solutions togetherwith powerful commercial interests from equipmentsuppliers and uncertainties about efficacy could well resultin expensive and inappropriate implementations beinginitiated. [.] It would be extremely unfortunate ifinvestment in telemedicine is made and schemes devel-oped at the expense of more low-tech interventions thatare proven to be effective (in particular, PulmonaryRehabilitation programmes). (page 18)39

A key argument presented within political economydiscourse was that the symbolic meanings we give tech-nologies are shaped and constrained by institutionalforces and by our awareness (or lack of awareness) ofalternatives. Policymakers seduced by the rationalist



appeal of technology may conflate the management ofillness (ie, everything a person needs to do in order tolive well with a condition) with the much narrower set oftasks linked to the management of disease (collection ofa more limited data set of biometric data such as bloodpressure, weight or peak expiratory flow rate). Fewintended users achieve the insight and confidence torecognise and challenge this framing.Finally, political economy discourse proposed that the

techno-economic complex linked to telehealth andtelecare technologies reflects a shift away from tradi-tional social values in which healthcare is a public good,and society’s duty to the vulnerable is defined in terms ofhuman contact and the logic of care, towards neoliberalvalues in which healthcare is a commodity and society’sduty to the vulnerable is defined in terms of monitoringand instrumental rationality (decision-making). Poverty,poor health and social exclusion have complex deter-minants which are little if anything to do with the so-called ‘digital divide’ and which do not have a simpletechnological or behavioural fix. Far from beinga benign transformative force that will producea healthier, more equal and more cohesive society oncethe information-poor have been given training andbehaviour modification advice, ‘assistive’ technologiesare an invidious form of social control, potentiallyincreasing inequalities by transferring responsibility andworkload from the system onto the patient and family.Political economy texts ask, on behalf of the intendeduser, ‘Whose interests does this technology serve?’.33

Change management discourseSome texts depicted the introduction of telehealth andtelecare technologies in terms of change management.40e44

For example, a monograph by the Kings Fund, an inde-pendent think tank which was a partner in the WholeSystems Demonstrator trial, hints at forthcoming trouble astechnologies that have been shown to ‘work’ in generouslyfunded randomised controlled trials encounter real-worldissues such as staff motivation and skill base; professionalroles and relationships; organisational routines andinter-organisational care pathways and the need fora substantial recurrent budget for purchasing and main-taining technologies.40

Such notes of caution have tended to come fromsenior individuals who were actively involved in imple-menting telehealth and/or telecare technologies andwho had initially positioned themselves within thedominant modernist discourse, but who subsequentlysought to explain low uptake, patient or staff resistanceor unexpected consequences (eg, hidden costs). Thistypically required a re-engagement with the ‘mess’,which technologies had originally been expected toresolve, as this academic paper illustrates:

the failure of e-health systems to become routinely usedwithin the health services is not necessarily a conse-quence of design or technological flaws. [.] Manyfactors could be at play: disruption to services,

a mismatch between functionalities of the system andwork practices, or resistance or even rejection by end-users for reasons including: concerns regarding patient/practitioner relationship, the need to redefine structures,roles and hierarchies, perceived threat to status withinthe organisation, fear of a lesser role, becoming redun-dant, etc. (page 301)45

Commentators in this discourse continued to viewtelehealth and telecare technologies as potentially bene-ficial, transformative and cost saving. But in an explicitdeparture from the technological determinism ofmodernist discourse, they sought to emphasise thattransformation would require a great deal of additionalwork and to reframe technology as opportunity for ratherthan driver of organisational change.Two research studies in our sample used May’s

normalisation process theory to frame a series of ques-tions to guide data collection and analysis in a telehealthimplementation project: (1) ‘what is the (new) work thathas to be done?’; (2) ‘who does the work?’; (3) ‘how doesthe work get done?’ and (4) ‘how is the work understood(accounted for)?.45 46 Most studies in this literature,however, lacked an explicit theory of change.While many texts used the term ‘complexity’, organic

metaphors that reflected a complex adaptive systemperspective (‘co-design’, ‘evolution’, ‘dynamic system’,‘interdependence’) were rare. More commonly, the termwas used to depict complicatedness, that is, multiplestakeholders and components for which the key chal-lenge was essentially operational: planning, projectmanagement, clarity of roles and responsibilities and soon. One management consultancy, in a monographentitled ‘Healthcare without walls’, for example, offereda step-by-step approach to developing telehealth services.In one example from an NHS Trust (page 33), theysuggest step 1: Identify needs; step 2: Establish buy-in;step 3: Consider which technologies are needed; step 4:consider workforce requirements such as training andchange management; step 5: Design evaluation; step 6:plan implementation; step 7: write business case andstep 8: Share best practice.41

This example illustrates a key difference betweenpolitical economy and change management discourses.Whereas the former viewed inter-organisational andinter-sectoral conflict as inherent and linked to historicaland social forces, the latter anticipated that at some stagein the future (if the correct steps were followed,relationships built, groundwork done, knock-on effectsmitigated and so on), they would be resolved.Indeed, change management discourse engaged onlysuperficially with the issue of conflict betweenstakeholdersdpresenting it either as a straightforwardproject management challenge or as a ‘difficulty’ thatwas raised but not analysed further.

How discourses mapped to stakeholders and interactedWhile the different stakeholder groups were not entirelyhomogeneous, it was broadly the case that the four



discourses described above reflected the position of oneor more key stakeholders. Modernist discourse largelyreflected that of policymakers, the technology industryand researchers from biomedical and health informaticsdisciplines. In the UK, these three groups frequentlycame together in government-funded knowledge-sharing events and ‘digital economy hubs’. Humanistdiscourse tended to reflect the perspective of socialscientists and related academic disciplines (eg, nursing);these stakeholders were represented at the large knowl-edge-sharing events but their work was less prominentand less highly valued (eg, research in the humanisttradition did not feature in keynote presentations or winprizes for ‘best innovation’). Political economy discoursewas aligned with the position of critical academics andsceptical clinicians and again was a minority voice exceptat ‘fringe’ meetings. Change management discourse wasarticulated mainly by those at the front line of imple-mentation (in particular, management consultanciesand think tanks).The four discourses were readily discernible and

distinguishable from one another. However, few indi-vidual texts restricted themselves to a single discourse.Rather, most texts reflected one (most commonly,modernist) discourse but, to a greater or lesser extent,acknowledged elements of the other three. With fewexceptions, however, different discourses tended to ‘talkpast one another’ in documents (eg, with the minordiscourse appearing only in a footnote or a separatesubsection) rather than informing and challenging oneanother in effective interdisciplinary dialogue. Similarly,conferences held to showcase high-technology researchoften included one or two sessions on ‘the user experi-ence’, ‘change management’ or ‘cost-effectiveness’, butthe main presentations were futuristic, technologyfocused and strikingly divorced from considerations ofreal-world implementation. In the academic world,modernist discourse dominated health informatics andcomputer science journals and conferences, whilehumanist and political economy discourses were sited inthe social sciences, with little cross-fertilisation betweenthese.

DISCUSSIONSummary of findingsThis study, based on argumentative discourse analysis ofa diverse sample of 78 texts, has revealed four conflictingbut overlapping discoursesdmodernist (technology-focused, futuristic, utopian), humanist (person-centred,small-scale, grounded in present reality), politicaleconomy (critical, cautious) and change management(recognising complicatedness but not conflict)dinrelation to telehealth and telecare technologies. As table1 shows, these discourses differed in their underlyingphilosophical assumptions, values, perspective on tech-nology, preferred research design, assumed mechanismby which technologies would be taken up and imple-mented and assumed consequences of this uptake.

Strengths and limitations of this studyTo our knowledge, this study is the first to have applieda discourse lens to telehealth and telecare technologies.Discourse analysis is a broad church, and in this study, wechose to focus almost exclusively on macroleveldiscourses. A detailed close reading of texts enabled us tomake sense of a complex and heterogeneous academic,policy and lay literature; consider why particular tech-nology projects or research studies were set up as theywere and tease out what Hajer called the ‘ensemble[s] ofideas, concepts and categories through which meaning isgiven to social and physical phenomena’.17 In theethnographic component, we have also begun to showhow the arguments associated with these discourses are‘produced and reproduced through an identifiable set ofpractices’.17 The main limitation of the study is, perhaps,that the discourse approach is necessarily subjective(indeed, it ‘challenges a traditional, rationalist view of anobjectively discoverable social world, instead acknowl-edging that social worlds are subjectively understood andexperienced’19) and hence is likely to have limitedcredibility within the dominant modernist discourse.Our interpretive inductive methodology, whose claim torigour lies in close reading of texts, reflexivity anddiscussion among team members, is likely to be ques-tioned by those who value experimental study designsand ‘objective’ tools and techniques.

Implications for practice, policy and further research‘Telehealth’ and ‘telecare’ are umbrella terms coveringnumerous product types from low-tech alarms to high-tech biosensor equipment; hence, it would be simplisticto consider their adoption as a single case. With thatcaveat, the current gap between policy enthusiasm fortelemonitoring and its more limited uptake and impactin practice might be considered as a ‘trough of disillu-sionment’.46 In order to go beyond this, we suggest thatthe stakeholders whose contrasting (and sometimesconflicting) concepts and perspectives were revealed inthis study need to engage more effectively with oneanother.Previous literature on organising vision has begun

from the assumption that the introduction of a newtechnology requires a single, coherent organising visionand that this vision will link and mobilise a relativelynarrow range of stakeholdersdchiefly the industrieswho produce and distribute the new technology and theindividuals and organisations who purchase and use it.13

Effectively, a market must be created. As we and othershave shown previously in relation to electronic patientrecords, the stakeholder groups involved in healthcaretechnologies are not simple ‘buyers’ and ‘sellers’.15 16

Rather, they have various commercial, political, profes-sional and institutional allegiances; they place differentvalue and moral worth on the use (and non-use) ofhealth-related technologies. The professional values ofclinical quality, patient safety and privacy may conflictwith the business values of efficiency and return oninvestment.



Because of these complexities, the notion of ‘the’organising vision for healthcare technologies is over-simplistic. The different interest groups described in thispaper are likely to continue to exist in an uncomfortabletruce with one another, competing for dominance asthey gain more or less public appeal, professional cred-ibility, political power, resource and so on. Our findingssuggest the hypothesis that the gap between the enthu-siasm of policymakers and technologists for telehealthand telecare and their more limited uptake in practicemay be at least partially explained by this contestedorganising vision. While consensus is not a realistic oreven desirable goal, surfacing such things as assumptionsand values, and inviting debate on their significancethrough intersectoral and interdisciplinary dialogue willhelp achieve what systems thinkers have called ‘accom-modation’ (acknowledgement of, and adaptationtowards, other perspectives and practices).47

We suggest that stakeholders in telehealth and telecareprojects and programmes work towards establishingcross-sector learning communities in which differentpoints of departure, priorities and accountabilities aremade explicit and acknowledged. Our ongoing ATHENEproject aims to help build one such learning communityand so make progress towards a broadly coherentorganising vision in which these technologies may, whereappropriate, become embedded and sustainable.

Acknowledgements We thank the members of the ATHENE steering group,the telehealth/telecare stakeholders and technology users who helped withorientation interviews and/or who provided feedback on our interpretationsand to Jill Rusell, Clive Seale, Mark Hawker and two peer reviewers forhelpful comments on earlier drafts of this paper.

Contributors TG conceptualised the study, led the data analysis and wrote thepaper with input from all other authors. RP, JW and PS conducted interviews,made field notes and contributed to data analysis. SS provided theoretical andmethodological expertise. All authors checked the final version of themanuscript.

Funding This study was funded by the Technology Strategy Board (seemethods section).

Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement The texts used for this analysis are listed in the onlineappendix. Most are publicly available documents. Deidentified empirical datawill be available from the authors once the ATHENE study is complete.

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