Abstract
Much attention is paid to the technical aspects of telemedicine in the development of new applications, but the enthusiasm about what is technically possible very often leads to the user acceptance of such products being neglected. The number of successful and sustainable telemedicine applications would be much higher if developers concentrated more on matters related to the cognitive-emotional situation of the users involved in telemedicine. The users include the care and cure providers, as well as the care and cure receivers. Based on an informal literature search and discussions with telemedicine implementation staff, nine factors have been identified which are essential for the user acceptance of telemedicine applications. All of them are connected more to the cognitive-emotional than to the cognitive-rational side of information processing. This suggests that in the future the cognitive-emotional side will need more attention. This in turn implies that the nine points mentioned above have to find their way into requirements engineering, development processes and product life cycles.
Introduction
User acceptance of telemedicine applications is an important factor in the development of telemedicine generally and a determinant of the success of individual telemedicine applications in particular. On the whole, users of telemedicine applications report quite positive reactions, although as Whitten and Love have pointed out, there are some weaknesses in the methodologies that have been used to study user satisfaction. 1
One question is whether the positive reactions of users to telemedicine will remain the same as time passes. Broens et al. 2 refer to other research 3,4 by stating that after the initial enthusiasm other factors may appear which affect the users' motivation. They call this the consideration phase in which the product is thought over. This decrease in enthusiasm has also been reported by Schmidt et al. 5 For telemedicine with its rapidly developing technology it is quite easy to imagine that the positive attitude has its roots more in the enthusiasm for the existence of a new application than in the design itself.
A dedicated human factors development approach 6 can provide valuable support to overcome this problem. A number of principles have already been developed 7 , but it is still not clear which elements in particular will contribute to the long lasting user acceptance of an application. In order to develop guidelines which I could apply in my daily practice I conducted an informal literature search. However, this did not yield the desired results. While talking to people involved in the implementation of telemedicine, I noticed that certain items were not fully covered, were left blank or did not receive the attention they deserved. I made a list of those findings in the hope of coming closer to the desired guidelines. This list comprises the nine items described below.
Aim and usefulness
The added value of a telemedicine application must be crystal clear. Applications have often been based on brilliant inspirations which have never found their way into large-scale implementation because their benefit was not clearly exposed. Just like in an advertisement, the user must immediately understand the product's right to exist. Users must sense intuitively what the pay off will be for them if they start using the application. Rogers defined this as the ‘relative advantage’ that a product must contain. 8 Chau and Hu 9 identified that ‘perceived usefulness appeared to be the most significant factor affecting doctors’ acceptance of telemedicine technology'. They stated that perceived usefulness is even more important than ease of use.
This all implies that it is necessary to give users an incentive which makes them want to work with the telemedicine application. This incentive has to be a clear advantage in use compared with the way of working that the users are accustomed to.
Respect
The doctor and patient must feel that they are being taken seriously. Nobody likes to be patronised. And nobody wants to get the feeling while using a telemedicine application that he or she is considered unable to communicate with the system in a normal way. Therefore an interaction at an appropriate level that accepts the user the way that he or she is, is absolutely essential. Both the professional values of the doctor and the intrinsic values of the patient must be respected. This matter was also addressed by Haas, 10 who warned that patients and health-care providers might be bound too closely to telemedicine procedures imposed on them, which gave them no space for individual inclinations or whereabouts.
Control
Doctors and patients must not feel that they are losing control over their actions. People feel safe if they think they can control a situation. That is exactly why it is so difficult for patients to cope with a serious disease, as with the disease we lose control over ourselves. In this respect it is even worse if we as a patient are confronted with an application which seems to take away our control of the situation, for example by limiting our choices or taking unexpected decisions for us.
Also on the professional side, loss of control is threatening while working with a telemedicine application. Bulik 11 reported that health-care providers feel less in control of their time and the way that they perform history-taking when utilizing telemedicine. If it is not clear for the doctors that the application is subordinate to their professionalism, then the question might arise who is in charge of the situation: man or machine?
Retaining the care provider's status
Care providers must learn that only their roles change, not their status. Every human is attached to what they have achieved, certainly in their profession. Think for example of certain rights and liberties connected to a job. We identify ourselves to a large extent by the things that we can and that we are allowed to do. Very often it is not the content of the role we occupy, but the status we borrow from the role that is important. Introducing a telemedicine application may change the role of the doctor and lead to different expectations in roles and hierarchies, as demonstrated by Finch et al. 12
User profile
An optimum process takes into account the profile of the telemedicine users, i.e. their expectations, skills and restrictions.
Each user group – very often even each individual user – has their own ‘fingerprint’. That is, they have their own signature concerning their expectations, skills and restrictions.
Expectations: Even before starting to work with an application the users already have a certain idea about how the system will work and which information they will be able to find in the application. This may be a product of former interaction with another tool, but can also derive from additional information supplied to the user. In short, the users have formed a certain picture about how to retrieve information from the system and they attempt to apply this to the new system. Chau and Hu
9
, referring to Anderson
13
and Anderson and Aydin
14
, stated that doctors are quite reserved if they have to use technology which interferes with the routines they are accustomed to. Skills: Skills are the properties that the users need to interact with the application. What kinds of knowledge have the users already gathered which enables them to deal with the application?
2
What levels of education and background knowledge do the users have? How extensive is their knowledge concerning the subject being dealt with in the telemedicine application? Are they experts in this or another similar area, or do they have no experience at all? Restrictions: With respect to restrictions, situations are meant which impede the interaction with the application and for this reason have to be taken into account in the early beginning of the design of such a system. Possible points of interest are for example a visual handicap or the circumstances among which the users are working with the application: perhaps they have little time to interact with the system or they feel watched because they can be seen by others while working with the application. Brennan and Barker
15
call this ‘impairment’.
Emotional condition of the patient
The telemedicine application must provide enough space for the emotional condition of the patients, such as their need for safety, feelings of shame, fear or uncertainty.
Emotion is very important in the medical sector. The delicacy and nature of the supplied information can bring the patient to a particularly emotional state. People in such an exceptionally emotional situation react differently to information than people in an ‘ordinary’ situation: they select and interpret information differently and give priority to other information than they would do under normal circumstances. The quantity of information which can be dealt with properly in an exceptionally emotional situation is less than under normal conditions and information overload can easily arise. By creating an atmosphere of safety and confidence, and taking the emotion of the patient into account, telemedicine can fulfil an important role. That telemedicine can play an important part in dealing with emotions was shown by Schultz. 16 He showed that patients who use a cardiac (ECG) telemonitoring system reported that with the system they were more able to cope with the fear accompanying their disease.
Levelling of communication
Communication between several levels (for example different levels of training, experience or function) and positions (doctor - patient) must be facilitated by the telemedicine application.
Telemedicine applications enable communication between different participants. These participants can be distinguished by their knowledge about the communication subject or by the reason they are involved in the communication. This can lead to differences in the use of language or understanding. 17 A well-devised application must be able to bridge this gap. In this connection Haas 10 favoured a common terminology which enables different users to understand the topic of the communication.
Traceability
The possible effect of the traceability of the information contained in a telemedicine application must be considered in the design phase.
Telemedicine applications invite another approach concerning communication. Whereas a conversation with a general practitioner does not leave the consulting room and the notes made by the doctor are only intended for their own administration, information entered into a telemedicine application, however, may become available to third parties. The informational self-determination is at risk, as Schmidt and Koch 18 have stated. This may lead to a situation where the people who provide input into the application later on have to justify their input. That demands clarity and verifiability of the notes made: clarity with regard to the unambiguous nature of the information and verifiability concerning the correctness of the information. To prevent that, physicians avoid making notes which serve purely as aids to personal memory but which might be interpreted differently by other users of the telemedicine application. This also helps to reduce the possibility that useful notes will be replaced by useless information.
Information selection
Special attention must be paid to deliberate information selection. Telemedicine applications unlock large quantities of information. By the combination of several media, for example video and language, information can be revealed that was not accessible before. This may lead to information which might be important but does not belong to the actual objective of the telemedicine session. A video camera in the apartment of an elderly person for example can ensure that in case of emergency a rapid and accurate estimate of the situation can be made. In addition, the visualisation of a room can also contain information on the life and behaviour of its inhabitant. The question is what must happen with this information and whether a careful selection of the information to be displayed can be made prior to placing the telemedicine installation. In any case the situation must be avoided that patients feel that they are being watched by ‘big brother’, as Brennan and Barker 15 put it.
The cognitive-emotional approach
Looking at the list above, it is evident that all the items are connected more to the cognitive-emotional than to the cognitive-rational side of information processing. This suggests that in the future the cognitive-emotional side will need more attention.
The number of successful telemedicine applications could be much higher if developers would concentrate more on user acceptance in the exploratory phase preceding the start of a project, during the development process, the implementation and the follow up phase. The present article shows that in this respect it is likely to be profitable to focus on the cognitive-emotional aspects of user acceptance. This implies that the nine points mentioned above have to find their way into requirements engineering, development processes and product life cycles. A first step in this direction would be to identify measurable indicators which represent the cognitive-emotional items in order to make it easier to connect the theoretical framework with applications under development.
The nine points described in this article will help the user to cope with and appreciate telemedicine applications and to successfully face the changes accompanying the introduction of telemedicine applications by following and anticipating the way the user thinks and acts. This way a medium initially planned as a pure technical application will be experienced as useful, will inspire confidence and will therefore enjoy the acceptance of both care and cure.