1. The Multiple Contexts of Borders that Impact Telemedicine as a Healthcare Delivery Solution Pamela Whitten College of Communication Arts & Sciences Michigan State University

2. Universal Health Challenges Aging populations Public Health Threats (e.g., chronic health problems) Qualified Specialists Access to Services Spiraling Health Costs

3. Telemedicine/Telehealth Use of communication technologies to deliver health services –Synchronous –Asynchronous

4. How Do We Attempt to Predict and Explain…. Various theoretical models that describe the development, deployment, and adoption of new technologies abound –Diffusion of Innovations - uses staged model to demonstrate how innovations are spread across social networks –Actor Network Theory – offshoot of social constructionism that has been widely used in understanding formation and emergence of technologies in social and political contexts –Technology Acceptance Model – information systems theory that states that perceived usefulness and ease of use will determine how and when someone will use a new technology –Unified Theory of Acceptance and Use of Technology (UTAUT)– explains how multiple facets of implementation (organizational and individual issues) impact successful implementation

5. Normally, telemedicine researchers study… –Cost Outcomes –Health Outcomes –Changes in Access –Perception/Satisfaction –Relationships with Health Providers –Health Delivery Process –Policy Impacts

6. However… Use of technology erases the ability to define health solely within the confines of a geographical border Begs for the re-defining of borders

7. Political Borders Territorial lines between different groups with the power to make the rules that govern a population –Telemedicine in the Service of Peace (Shanit et al., 2002) Middle East Ophthalmology Network in Israel, Jordan, Morocco, Palestinian Authority and Tunisia

8. Cultural Borders Differences in values and beliefs about the role of groups, individuals, communication styles and other unwritten rules and behaviors that govern day-to-day life –Telehospice (Prince Edward Island vs Michigan) –Email Telemedicine in the Middle East (Patterson et al., 2007) Why higher rate of referrals from Middle East versus rest of world (Iraq local community views maternal death as an avoidable and suspicious disaster)

9. Geographical Borders Physical characteristics that differentiate one area from another, including topographical features such as mountainous terrain or demographics like population density –Michigan’s Upper Peninsula (Whitten et al., 2003; 2005) –Teleradiology in Columbia (Rendon et al., 2005) Forest and jungle regions of the Pacific Coast Mountainous regions in Department of Cauca –Project Tristan (Tristan de Cunha – middle of South Atlantic with population of 269)

10. Technological Borders Differences in the ability to provide, utilize and share technology efficiently and broadly within and between populations –Telemedicine in remote Cambodia (Heinzelmann, 2005) Village of 4000 in region with no mobile or conventional telephone…Internet through a school with donated satellite time

11. Economic Borders Differences in resources between populations, including financial, natural and human capital –Linking Africans (Ethiopia) to Indian Cardiac Expertise (Malone, 2008) Subsidize services and training and then hand over to African providers –Mobile phones for HIV treatment in South Africa (Kahn, 2004) Helps health workers monitor HIV patients cheaply

12. Ethical Borders Defined by the limits of behavior understood as acceptable and often pro- social. Home health/remote monitoring in Indiana (Whitten et al., in press) –Ethical Issues related to home-based telemedicine (Bauer, 2001) Does telemed further medicalize home environment? Does telemedicine further privatize life and increase control over daily life Does telemed more equitably distribute healthcare resources? How does telemed impact informed consent as responsibilities shift?

13. Next steps… Integrate/Update/Redefine traditional research priorities in telemedicine