Telemedicine for low resource settings: Exploring the generative mechanisms
Introduction
Seventy-five percent of health care facilities (infrastructure and manpower) in India are concentrated in urban areas, which accounts for only 27% of the population. The lack of manpower is mainly at the specialists' level with about half of the posts for surgeons, gynecologists, pediatricians and physicians lying vacant in rural areas (Bhandari and Dutta, 2007). Information Communication and Technology for Health (ICT4H) interventions, such as telemedicine, acting as a conduit of information, offer promise to bridge the knowledge gap between the “haves” and the “have-nots”, between the urban and rural areas (Miscione, 2007). Telemedicine has been defined as a distant delivery of health related services through transfer of audio, video and graphical information via telecommunication networks, including consultative and diagnostic services along with enablement of planning, coordination, collaboration and education (Singh et al., 2009). However, despite the promise, adoption of ICT4H initiatives such as telemedicine, has been slow, uneven and limited in scope (Chandwani and Dwivedi, 2015, Sims, 2016), especially in low-resource settings such as India (Miscione, 2007). In this paper, we conceptualize a low-resource setting as one that is characterized by infrastructural constraints, both, in terms of access to healthcare services and the technical infrastructure (Miscione, 2007).
To achieve the potential of telemedicine in a low-resource setting, there is a need for researchers to develop a comprehensive and deep understanding of how the telemedicine process works in such contexts- including an understanding of processes, contingencies, structures and causal mechanisms. This deep knowledge would be highly valuable for managers and professionals involved in design and implementation of telemedicine. Our research focuses on the mechanisms that contingently underlie successful telemedicine in low-resource settings such as India. Specifically, by examining the doctor-patient interactions over a successful1 telemedicine initiative in India, we attempt to understand “What are the mechanisms underlying successful telemedicine design and implementation, especially in low-resource settings.”
One of the important reasons for slow and uneven adoption of telemedicine, is the lack of fit between the technology design and the human dimensions of the technology usage (Avison and Young, 2007, Miscione, 2007). The literature on impact of telemedicine has largely focused on the technological aspects of telemedicine (Mair and Whitten, 2000, Nelson et al., 2010). As highlighted by Whitten, Sypher, and Patterson (2000), ‘we know a good deal about bandwidths and resolutions, but little about the human dimensions that make practice possible’ (p. 112). Telemedicine can result in marked changes in technical and interpersonal context within which communication takes place (Miller, 2011: 55). Indeed, successful diffusion of telemedicine programs is dependent upon the capacity of the actors to communicate effectively in this new medium (Miller, 2011); accordingly, we examine both social and technological dimensions- interactions amongst various actors and the interactions of actors with technology. As the purpose of the research is to explicate underlying mechanisms for successful telemedicine, we propose critical realism (CR) as a lens for the study, given its emphasis on generative mechanisms (Archer et al., 1998, Bhaskar, 1998, Bhaskar, 2013, Sayer, 1992).
Generative mechanisms are defined as “causal structures that generate observable events” (Henfridsson and Bygstad, 2013). The idea of generative mechanisms draws from Bhaskar's philosophy of critical realism where these are understood as originative arrangements that make possible the visible situations that emerge (Bhaskar, 1998). Aligning with the theoretical lens and the philosophical underpinning of critical realism, we take an interpretive approach and adopt qualitative methods for the study. Qualitative methods are opportune in making sense or meaning of the observable events to delineate underlying generative mechanisms (McGrath, 2013).
Our research contributes to the literature in multiple ways. First, we identify three generative mechanisms that determine successful telemedicine interventions and how these mechanisms contingently lead to the outcomes specifically in the low-resource settings. The focus on generative mechanisms driven by critical realism advances current knowledge about why some telemedicine interventions evolve successfully while others do not sustain (Sims, 2016). Further, the paper demonstrates the efficacy of critical realism as an important perspective for making substantive contributions to the ICT4H literature.
The rest of the paper is structured as follows. In the following section we dwell on the theoretical framework of critical realism and generative mechanisms. Then we explicate the research context and the methodology. Next we present the findings of the study. In the discussion section we analyze the findings and tie them to the theory. We further outline the contributions to theory and practice. We conclude by highlighting the key insights from the study and outlining the directions for future research.
Section snippets
Theoretical framework- critical realism and generative mechanisms
Much of the extant IS literature is either situated in an (a) interpretivist paradigm, focusing on the rich understanding of meaning-making of the socio-technical milieu by the actors or in (b) positivist paradigm, focusing on the directly observable phenomena in the empirical domain. The CR perspective on the other hand positions itself as an alternative paradigm (Wynn and Williams, 2012), leveraging elements from both perspectives. CR combines a realist ontology with an interpretive
Research method
As we have assumed a CR paradigm to investigate the phenomenon of interest, we have adopted a methodology consistent with the CR perspective. We examine both the actors' interpretations and the structures and mechanisms that interact to produce the outcomes in question. The steps for CR-based research entail describing the context, identifying mechanisms, and explicating the interactions between mechanisms and context (Ackroyd, 2010).
While Bhaskar did not propose any particular research
Findings
In this section, we describe the findings of the study. These findings enabled us to identify and detail in the structures and to understand their relevance, given the contextual nuances. Thus the findings and their interpretations enabled linking the structure to events. We explicate the findings under four dominant themes identified in the analysis: Coordination work, expert patient, formation of informal social support groups, and enhancement of skills of the physicians in peripheral nodes.
Discussion
In this section we link the structure to events by identifying and explicating the generative mechanisms and validate the proposed mechanisms on the basis of theoretical and logical arguments. These mechanisms enabled the telemedicine initiative to overcome the major challenges occurring in a low-resource setting. The healthcare system in India, as described above, is highly skewed towards urban areas and the remote rural areas lack access to healthcare, especially specialists' services. While,
Conclusion
While most of the ICT4H interventions that are implemented fail to sustain, there are certain initiatives that are successful. A comprehensive understanding of the causal structures and mechanisms that underlie successful telemedicine would be highly valuable for academicians as well as practitioners. In this study, adopting a critical realist perspective, we examined a specific telemedicine intervention to identify and explicate generative mechanisms that underlie successful telemedicine in
Acknowledgement
This research is based upon work supported by the Strengthening Information Society Research Capacity Alliance (SIRCA II: Grant No. 17).
Rajesh Chandwani is an Assistant Professor at the Indian Institute of Management in the Human Resource Management Area. His research interest areas are scaling up of healthcare services for the underprivileged and the use of IT for enhancing healthcare services.
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Rajesh Chandwani is an Assistant Professor at the Indian Institute of Management in the Human Resource Management Area. His research interest areas are scaling up of healthcare services for the underprivileged and the use of IT for enhancing healthcare services.
Rahul De' is Hewlett-Packard Chair Professor in the Decision Sciences & Information Systems Area in Indian Institute of Management Bangalore.
Yogesh K. Dwivedi is a Professor of Digital and Social Media and Director of research at School of Management Swansea University, UK.