International Journal of Technology Assessment in Health Care,

International Journal of Technology Assessment in Health Care,
22:1 (2006), 136–142.
Copyright c© 2006 Cambridge University Press. Printed in the
U.S.A.
Evaluating telemedicine: A focus
on patient pathways
Jane Coughlan, Julie Eatock, Tillal Eldabi
Brunel University
Evaluations of telemedicine have sought to assess various
measures of effectiveness
(e.g., diagnostic accuracy), efficiency (e.g., cost), and
engagement (e.g., patient
satisfaction) to determine its success. Few studies, however,
have looked at evaluating the
organizational impact of telemedicine, which involves
technology and process changes
that affect the way that it is used and accepted by patients and
clinicians alike. This study
reviews and discusses the conceptual issues in telemedicine
research and proposes a
fresh approach for evaluating telemedicine. First, we advance a
patient pathway
perspective, as most of the existing studies view telemedicine as
a support to a singular
rather than multiple aspects of a health care process. Second, to
conceptualize patient
pathways and understand how telemedicine impacts upon them,
we propose simulation
as a tool to enhance understanding of the traditional and

telemedicine patient pathway.
Keywords: Clinical pathways, Computer simulation, Evaluation,
Telemedicine, Patients
The telemedicine evaluation literature has grown substan-
tially from the advancement of a specific framework for
assessing telemedicine by the Institute of Medicine (IOM)
(16). This early report identified five dimensions important
to evaluating telemedicine: quality, access, cost, patient per -
ceptions, and clinician perceptions. However, a more recent
report by The Lewin Group (27) both confirmed and extended
these evaluation dimensions. It considered the properties of
these dimensions, in terms of measures and their impacts, but
also the methodology issues involved in evaluation. This di -
rectly responded to some disquiet expressed in the literature
over rigor and consistency that limited the generalizability of
some studies’ findings. In light of these concerns, we discuss
two possible improvements for telemedicine evaluation.
First, we argue that the focus of the evaluation itself
should be widened to look at telemedicine in the context
of the patient pathway (also known in the literature as the
clinical pathway) to understand its place along the patient’s
journey through the health service. Second, we put forward
simulation as a tool for evaluating telemedicine through its
representation of the patient pathway. Simulation will be
discussed as a viable methodology for addressing some of the
weaknesses documented in telemedicine evaluation, through
a review of the measures and methodologies used in the
assessment of telemedicine. The discussion of the potential
benefits of simulating patient pathways is supported by an
illustration—using leg ulcer sufferers as a case example—to
contribute to an understanding of care delivery by traditional
and telemedicine processes.

TELEMEDICINE EVALUATION ISSUES
Measures
Reviews of telemedicine evaluation are limited (1;12;25;27),
but those that do exist provide important overviews as to the
status of evaluations in terms of the measures and method-
ology used to assess telemedicine. Most evaluations have
sought to assess various quantitative measures of effective-
ness (e.g., diagnostic accuracy), efficiency (e.g., cost), and
engagement (e.g., patient satisfaction) to determine its suc-
cess. However, these studies have tended to focus on single
clinical contexts, specialties, and measures. To highlight the
problematic issues around the measures currently assessed
in telemedicine evaluation, we will briefly focus on three key
evaluation measures: (i) Diagnostic accuracy—this measure
has tended to overly dominate many studies’ outcomes (1);
(ii) Cost (and its associated variables, e.g., benefit, utility,
and so on)—many studies have equated a cost-saving as a
benefit, but with no reference to how it affects clinical out-
comes (28); and (iii) Patient satisfaction—this measure is the
136
Evaluating telemedicine
Table 1. Key Evaluation Methodology Issues for Telemedicine
Methodological Approach
Evaluation methodology issue Current telemedicine evaluations
Simulation

Technological maturity
Progress of technology through its
lifecycle and the stage of evaluation
Often carried out as single case studies
of performance at too early or late a
stage and can often produce unduly
positive or negative findings (26)
Evaluates telemedicine along the
continuum of maturity from immature
prototypes to fully matured working
systems
Focus of evaluation
Scope of the evaluation from the
technology itself to its broader
context
The focus is predominantly placed on
the specifics of the technology itself,
as opposed to its organizational
impact (2).
Offers a more holistic approach, in
analysing the processes of care into
which telemedicine is situated, along
with key evaluation measures
Perspective of evaluation
Standpoint from which the benefits
of the technology are realized
A single perspective analysis is most

common, often to the point of
exclusion of the impact from an
alternative perspective (21)
Provides a multi-perspective analysis,
(depending on the model’s variables),
e.g., to reflect a patient/clinician view
Comparator
Definition of a suitable control group
with which to gauge the effect of the
technology’s intervention
Patients who are treated with and
without telemedicine and then
compared, are often not of a similar
level (8)
Allows a consistent way of performing
like-with-like comparisons as data from
a single set of patients can be run in both
the traditional and telemedicine models
Randomization
Assigning of participants to
experimental and control groups on a
random basis
This process is difficult to achieve as the
sample group in a study are generally
quite small, in some published cases
as few as ten patients (20)

Avoids randomization issues because a
single set of patients can be run in both
the traditional and telemedicine models
Time horizon
Duration of data collection in a study The focus has been on
short-term pilot
projects, with a lack of follow-up (5)
Predicts future outcomes, applying the
analysis to gauge the long-term effects of
telemedicine implementation
most common evaluation undertaken, tends to produce con-
sistently positive results, but can often be misleading, as
patient satisfaction measures often fail to go beyond first
impressions (19).
A major reason for some of the limitations cited in the
research is that few high-quality studies exist (15). Despite
the usefulness of the clinical and economic data that have
been produced, the methodological paucity in the research
has somewhat undermined the value of the assessments un-
dertaken. This finding has resulted in calls for patients and
practitioners alike to remain skeptical over the professed
benefits of telemedicine compared with traditional face-to-
face patient care (12). In an attempt to manage some of the
methodological issues in telemedicine evaluation, simulation
is proposed as a potentially useful tool for producing more
robust findings.
Methodology
As a methodological approach, simulation revolves around
creating computer models of social structures and processes.

These models are subject to “simulation” that is experimen-
tation through the manipulation of variables (e.g., time and
cost) to understand the behavior of the model and evaluate
the extent to which it provides an accurate account of the
behavior of the observed system (13). In health care, simu-
lation has achieved some success as a problem-solving tool
(3). Moreover, as well as being able to incorporate the afore -
mentioned evaluation measures, it will be posited that simu-
lation modeling offers a systematic approach for addressing
key evaluation methodology issues that have been usefully
summarized by the seminal Lewin Group report (27). These
issues have been identified as technological maturity, focus
of evaluation, perspective of evaluation, comparator, random-
ization, and time horizon. Table 1 defines each of these issues
in turn, along with an example of how they are addressed in
current telemedicine evaluation studies and how simulation
can offer a potential solution to these challenging issues.
From Table 1, it can be seen that current telemedicine
evaluations largely fail to address the broader organizational,
clinical, and social processes that new technology impacts
upon. Some evidence that exists suggests that this is a crit-
ical issue and that the focus of the evaluation may be too
narrow. For example, Lehoux et al. (17) found that the use
of telemedicine did not fit into clinicians’ communication
routines of consultation and referral. We suggest that a more
fruitful direction for the evaluation of telemedicine is to fo-
cus on the patient pathway. The patient pathway includes all
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH
CARE 22:1, 2006 137
Coughlan et al.

the clinical routines (or processes) into which telemedicine
is placed, so that it can be assessed on how it sustains or
supports variation in clinical practice.
SIMULATING THE PATIENT PATHWAY
Patient pathways are tools that assist in providing general
guidelines of care for dealing with individuals and groups
of patients suffering from a wide variety of diseases. How -
ever, the majority of studies focused on traditional patient
pathways (23). The introduction of telemedicine, however,
offers a new pathway to care, although the impacts of it
are even less well understood. To this end, simulation is
put forward as a method of modeling pathways that cap-
ture the timeline of care from the start to the journey’s
end.
Discrete-Event Simulation Technique
Discrete-event simulation (DES) offers many features to cope
with understanding the complex nature of health care sys-
tems, of which the patient pathway is a clear example. There
are three critical steps to the technique that are advanta-
geous for representing pathways, which can be described
as follows: (i) Understanding the system or process to be
modeled—this is in terms of its main entities (e.g., patients),
events (e.g., clinic visits), and decisions (e.g., referral of
patient for consultation) and must be achieved for the sub-
sequent model building to have a good representative basis;
(ii) Changing the parameters of the model (e.g., time and
cost)—this step can suggest (based on mathematical distri-
butions) the optimum capacity of the system in the present
and for the future given different scenarios; and (iii) Under -
standing the inter-relationships between different entities,
events, and decisions in the system—this step can identify

the interdependencies of variables and the effect of changing
one has upon another.
The simulation’s significant feature is its capability of
performing “what if. . . ” type analyses through the manip-
ulation of variables to understand the inter-relationships
within the model and, hence, the real system. This iterative
nature to the modeling process brings about the identification
of the optimum system setup. Although simulation is not
intended to replace current designs of evaluation studies,
acceptance of any new approach to studying health care
problems needs to be justified on the professed benefits of
the proposed solution option.
Benefits of Simulating the Patient Pathway
Whereas simulation has the potential to overcome many of
the problematic issues in telemedicine evaluation (as shown
in Table 1), the true value of the approach rarely has been
realized, given the narrow focus to which it has been applied
previously, typically hospital scheduling problems (11). This
quantitative view of simulation modeling—as a way of calcu-
lating outcomes—has often failed to produce results that can
be readily implemented in real-life applications. Moreover,
the telemedicine literature, in particular, reveals a paucity
of studies that have undertaken any simulation, except for
perhaps two notable examples (6;18). The impetus, there-
fore, clearly exists for a debate on the conceptual issues of
research in telemedicine, given the problems with current
evaluation techniques (4). Robinson (24) has called for a de-
bate on simulation study as a mode of practice in various
domains. We contend that this debate is necessary within
health care and propose that a starting point for this discus -
sion is on evaluating telemedicine from a simulation of the
patient pathway.

Patient pathways do not physically exist; therefore,
methods of computerizing pathways have demonstrated
some degree of success (7). The understanding that is gained
through simulation is of a greater value than the pure numer-
ical values produced. We propose, therefore, that simulation
be viewed as a tool not to calculate outcomes but to appre-
ciate them. This difference is subtle yet powerful. In this
manner, the use of simulation will crucially serve to elicit
the intangibles, such as insight into the way the system actu-
ally operates, understanding the variables that can affect the
system, and informing decisions concerning the system and
their possible consequences.
The benefits of simulating patient pathways are in-
creased when qualitative investigations (e.g., interviews, ob-
servations, and so on) are directed at critical points along the
pathway so as to supplement the models and understand more
holistically the relationship between the interpersonal (e.g.,
patient satisfaction) and technical aspects of telemedicine (9).
For example, to return to the three key measures discussed
earlier, in diagnostic accuracy, a control patient group can be
simulated to compare the outcomes of consultations with a
clinical trial group. This approach has been shown previously
to provide an educational benefit for informing clinical deci -
sion making (14). Furthermore, cost-effectiveness measures
can also be extended to produce cost per quality measures
of outcome in terms of the quality adjusted life years for
specific health care interventions (10). This can have an im-
portant personal benefit, particularly for the patient in terms
of establishing the relationship between their illness and the
likelihood of health care saving their life. Moreover, incorpo-
rating patient satisfaction measures is possible by converting
patient responses into an appropriate numerical scale and ap-
plying these figures to the model. This strategy can have a
behavioral benefit in being able to determine fluctuations in

patient satisfaction and pinpointing problem areas.
Telemedicine Patient Pathway:
An Illustration
To illustrate the potential of simulating patient pathways,
leg ulcer sufferers were selected as case examples, given
the access to patients who have followed a traditional
138 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH
CARE 22:1, 2006
start
Patient visits GP
Decide on
tests to be
performed
More tests
required
Referral
required?
Refer to
consultant
no
yes

Visit consultant
Blood test at clinic
Doppler test at
clinic
Photographs at
clinic
yes
Repeat visits to
GP
no Ulcer healed?
no
stop
yes
Traditional
Telelink
consultation
telelink
Tests
Process continues beyond
this point
Telelink or

traditional?
Figure 1. Leg ulcer patient pathway.
and telemedicine patient pathway. Figure 1 is a graphic
representation of part of a leg ulcer patient pathway. Informa-
tion to structure the pathway and its critical variables is col -
lected from patient records and interviews with doctors and
nurses. Figure 1 serves to illustrate all the health care events
along this section of the pathway, for instance a tele-link
consultation and the relationships between them. Figure 2
illustrates how identical patients can be treated through two
systems, both traditional and telemedicine (the timescale for
which is provided for illustrative purposes only).
Variables at strategic decision points along the path-
way control the flow of patients. These variables alter based
CARE 22:1, 2006 139
Coughlan et al.
Week No.
0
1
12
13
14

15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Present to
GP
Referral to
consultant
Telelink to
consultant
Pre-surgery
tests
Present to
GP
Tests at
clinic
Referral to
consultant
surgery
surgery
In-person
visit to cons.
Pre-surgery
tests
Tests at
clinic
PRESENT TO GP

1. Patient volume – the number of patients arriving at the
surgery are
established in order to determine the capacity that the
system
currently deals with and how this affects the system.
2. Patient attributes – age, severity of condition, and general
health
were key issues used in clinical decision-making. These
were all
rated on a scale of 1-3 (with 1 being the youngest/least
severe and
3 being the oldest/most severe).
TESTS AT CLINIC (and PRE-SURGERY TESTS)
1. Costs of tests – this variable is dependent on patient
attributes
(i.e., the more severe cases will need more tests). It is also
dependent on time as if the period in between testing at the
clinic
and pre-surgery is short then only one set of tests will be
needed,
otherwise they may have to be repeated.
2. Costs of dressings – this variable is dependent on time, as
dressings have to be changed twice a week, during the
course of
treatment.
3. Time – every event has a time delay, which may vary
depending
on patient attributes, whether telemedicine is involved, or
the
number of tests conducted.
Figure 2. Comparison of a traditional and telemedicine leg ulcer

patient pathway.
on data parameters (patient volume), patient attributes (age,
severity of condition, and general health), and time, which
were deemed important for the treatment of leg ulcers
from interviews with clinical staff. These variables can be
further manipulated to determine different levels of effect
when changing sections of the process (i.e., introducing
telemedicine).
DISCUSSION AND CONCLUSIONS
This study has discussed simulation modeling—solely as a
mode of practice—for the evaluation of telemedicine in the
context of the patient pathway, as illustrated by Figures 1
and 2. Future work will need to computerize the pathway
into a dynamic running simulation model by comparing the
CARE 22:1, 2006
predicted flow of patients with the actual flow along the
traditional and telemedicine pathway. This approach will
allow the capture of the long-term and organizational im-
pacts of telemedicine implementation. An integral part of the
discussion on the potential use of simulation has been the
focus on the patient pathway. This focus has provided a com-
pelling example of the importance of evaluating telemedicine
in the context of the health care processes into which it is
placed. A spotlight on pathways vivifies the collective bene-
fits of simulation that have been put forward by highlighting
how telemedicine can be evaluated in relation to the entities,

events, and decisions involved in the delivery of care that
it impacts upon. On the surface, telemedicine might appear
to offer a fast-track system for patients, which can reduce
the costs of dressing for leg ulcer patients, for example (as
shown in Figure 2). However, Phipps (22) provides a caveat
to this in stating that it is important that we understand how
optimizing one section of a process (e.g., introducing a tele-
link) can affect another section further along in the system
and potentially induce a bottleneck (e.g., at the surgery stage)
given that this section of the process will not have changed.
It is suggested that a new challenge for telemedicine eval -
uation studies is to compile a more comprehensive view of
the technology, in looking across multiple aspects of health-
care processes to provide a much-needed commentary on the
outcomes of health care and its delivery. To this end, pa-
tient pathway simulation has been introduced as a potential
evaluation tool for telemedicine to continually monitor clini -
cal practice, the effects of telemedicine, and changing health
outcomes.
CONTACT INFORMATION
Jane Coughlan, PhD ([email protected]),
Research Fellow, Julie Eatock, PhD ([email protected]
ac.uk), Research Fellow; Tillal Eldabi, PhD ([email protected]
brunel.ac.uk), Lecturer, Information Systems and Comput-
ing, School of Information Systems, Computing and Math-
ematics, Brunel University, Kingston Lane, Uxbridge, Mid-
dlesex UB8 3PH, UK
REFERENCES
1. Aoki N, Dunn K, Johnson-Throop KA, Turley JP. Outcomes
and methods in telemedicine evaluation. Telemed J E Health.
2003;9:393-401.

2. Bangert D, Doktor R, Warren J. Evaluating the organizational
impact of telemedicine for project akamai. In: Proceedings of
the 32nd Hawaii International Conference on System Sciences
(HICSS’99); 1999. CD-ROM Version.
3. Barnes CD, Quiason JL, Benson C, McGuiness D. Success
stories in simulation in health care. In: Proceedings of the 1997
Winter Simulation Conference; 1997:1280-1285.
4. Bashshur RL, Reardon TG, Shannon GW. Telemedicine: A
new health care delivery system. Annu Rev Public Health.
2000;21:613-637.
5. Bishop JE, O’Reilly RL, Maddox K, Hutchinson LJ. Client
satisfaction in a feasibility study comparing face-to-face in-
terviews with telepsychiatry. J Telemed Telecare. 2002;8:217-
221.
6. Cameron AE, Bashshur RL, Halbritter K, Johnson EM,
Cameron JW. Simulation methodology for estimating financial
effects of telemedicine in West Virginia. Telemed J.
1998;4:125-
144.
7. Chu S, Cesnik B. Improving clinical pathway design: Lessons
learned from a computerised prototype. Int J Med Inf.
1998;51:1-11.
8. Craig JJ, McConville JP, Patterson VH, Wootton R. Neuro-
logical examination is possible using telemedicine. J Telemed
Telecare. 1999;5:177-181.
9. Eldabi T, Irani Z, Paul RJ, Love PED. Quantitative and quali -
tative decision-making methods in simulation modelling. Man-
agement Decis. 2002;40:64-73.

10. Eldabi TA, Paul RJ, Taylor SJE. Simulating economic
factors in
adjuvant breast cancer treatment. J Oper Res Soc. 2000;51:465-
475.
11. Fone D, Hollinghurst S, Temple M, et al. Systematic review
of the use and value of computer simulation modelling in pop-
ulation health and health care delivery. J Public Health Med.
2003;25:325-335.
12. Hailey D, Roine R, Ohinmaa A. Systematic review of
evidence
for the benefits of telemedicine. J Telemed Telecare. 2002;8:1-
30.
13. Hanneman R, Patrick S. On the uses of computer-assisted
simulation modeling in the social sciences. Sociological Re-
search Online. Available at: http://www.socresonline.org.uk/
2/2/5.html. Accessed December 13, 2005.
14. Hayes WS, Tohme WG, Komo D, et al. A telemedicine con-
sultative service for the evaluation of patients with urolithiasis.
Urology. 1998;51:39-43.
15. Hersh WR, Helfand M, Wallace J, et al. Clinical outcomes
re-
sulting from telemedicine interventions: A systematic review.
BMC Medical Informatics and Decision Making. Available
at: http://www.biomedcentral.com/1472-6947/1/5. Accessed
December 13, 2005.
16. Institute of Medicine. Telemedicine: A guide to assessing
telecommunications in health care. Washington, DC: National
Academy Press; 1996.
17. Lehoux P, Sicotte C, Denis J-L, Berg M, Lacroix A. The

theory of use behind telemedicine: How compatible with
physicians’ clinical routines? Soc Sci Med. 2002;54:889-
904.
18. Loane M, Wootton R. A simulation model for analysing
patient activity in dermatology. J Telemed Telecare. 2001;7
(Suppl 1):23-25.
19. Mair F, Whitten P. Systematic review of studies of patient
satisfaction with telemedicine. Br Med J. 2000;320:1517-
1520.
20. Miyasaka K, Suzuki Y, Sakai H, Kondo Y. Interactive
communication in high-technology home care: Videophones
for pediatric ventilatory care. Pediatrics. Available at: http://
pediatrics.aappublications.org/cgi/reprint/99/1/e1. Accessed
December 13, 2005.
21. Nordal EJ, Moseng D, Kvammen B, Lochen M-L. A
compara-
tive study of teleconsultations versus face-to-face consultations.
J Telemed Telecare. 2001;7:257-265.
CARE 22:1, 2006 141
Coughlan et al.
22. Phipps B. Hitting the bottleneck. Health Management Maga-
zine. 1999:1-3.
23. Renholm M, Leino-Kilpi H, Suominen T. Critical pathways:
A
systematic review. J Nurs Adm. 2002;32:196-202.

24. Robinson S. Modes of simulation practice: Approaches to
business and military simulation. Simulat Pract Theory.
2002;10:513-523.
25. Roine R, Ohinmaa A, Hailey D. Assessing telemedicine:
A systematic review of the literature. Can Med Assoc J.
2001;165:765-771.
26. Sicotte C, Lehoux P. Teleconsultation: Rejected and
emerging
uses. Methods Inf Med. 2003;4:451-457.
27. The Lewin Group. Assessment of approaches to evaluating
telemedicine, final report to the office of the Assistant
Secretary
for Planning and Evaluation. Department of Health and Hu-
man Services, Contract Number HHS-10-97-0012, December,
2000.
28. Whitten PS, Mair F, Haycox A, et al. Systematic review of
cost
effectiveness studies of telemedicine interventions. Br Med J .
2002;324:1434-1437.
CARE 22:1, 2006
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.

From Rookie to Reality Case Analysis and Rationale Template
Part 1: Case Analysis
1. Brief summary of the case:
2. Identify the issues to be resolved:
3. Stakeholders involved in the issues:
4. One or two existing laws or court rulings that relate to the
issues:
5. District policies that relate to the issues:
6. Possible solutions to the issues:
7. The solution you chose to resolve the issues:
8. Action steps (2-5) for implementing your solution, including
a timeline for each step:
9. Potential moral and legal consequences of the solution:
Part 2: Rationale

© 2019. Grand Canyon University. All Rights Reserved.
Page 1 of 2
Support the case analysis with a 500-750 word rationale
explaining the decision you made and
how the decision:
safeguards the
values of democracy,
equity, and diversity.
needs inform all aspect s of
schooling.
expectations.
Cite the case and any other source documents as appropriate.
Virtual medical geographies:
conceptualizing telemedicine and
regionalization1
Malcolm P. Cutchin
Department of Occupational Therapy, University of Texas
Medical Branch,
Galveston, TX 77555, USA
Abstract: Telemedicine is an innovation that is changing the
geography of medical care
provision. Regionalization of care is one important type of
geographical change resulting from

the implementation of telemedicine technology. This paper
introduces a range of issues bound
up with telemedicine and medical care regionalization and
offers a geographical conceptualiza-
tion of those issues through a synthesis of ideas from several
literatures. It begins by providing
a background for regionalization and telemedicine. The paper
continues by examining the
formation of ‘virtual’ regions and the problem of their internal
integration and integration with
‘material’ regions of care. A penultimate section argues for the
use of regional economic
geography and territoriality as contexts for understanding the
continued growth and
development of telemedicine networks. As part of an overall
critical challenge to the pro-
telemedicine bias in the medical care literature, the paper ends
by suggesting the development
of a normative ethics by medical geographers.
Key words: telemedicine, regionalization, technology, virtual
regions, networks, integration,
regional economic geography, territoriality, ethics.
I Introduction
During the last decade, telemedicine has emerged as a
consequential innovation within
the medical care system. Telemedicine is expected to evolve
into ‘a wide-spread and
permanent fixture of the medical care landscape’ (Grigsby,
1997: 318). Although
telemedicine may be defined as ‘the use of electronic
information and communications
technologies to provide and support health care when distance
separates the partici-

pants’ (Field, 1996), the most central form of telemedicine is
the interactive video-
consultation between a distant specialist and the local primary
care provider and
Progress in Human Geography 26,1 (2002) pp. 19–39
© Arnold 2002 10.1191/0309132502ph352ra
20 Virtual medical geographies: conceptualizing telemedicine
and regionalization
patient. The implementation of this technology is
geographically restructuring medical
care systems. Telemedicine’s impacts on the geography of
medical care include the
reshaping of space-time and access to specialized care, the
reformation of place and
medical care communities, the redirection of medical care
regionalization, and the glob-
alization of care systems. Nonetheless, with only a few recent
exceptions (Shannon,
1997; 2000; Mayer, 2000; Löytönen, 2000; Strömgren, 2000),
geographers have paid little
attention to the implications for medical care, both positive and
negative, arising from
telemedicine. Moreover, telemedicine research in general has all
but ignored the
character of ‘virtual’ medical care regions and their integration
with traditional care
regions (Bashshur et al., 2000). This paper will focus on
telemedicine and the regional-
ization of care with particular attention given to the USA.
Regionalization and telemed-

icine exist in a reflexive relationship to one another. The paper
conceptualizes regional-
ization and telemedicine and their reflexive relationship through
a synthesis of ideas
from several literatures.
While the paper’s primary focus is placed upon the medical care
dimensions of
telemedicine and regionalization, it is important to provide
some background for the
larger geographical contexts within which regional telemedicine
systems and their
most important associated issues are situated – contexts that
cannot be addressed in full
here. Therefore, a brief discussion of those contexts should be
useful to set the stage for
both the arguments to follow and additional routes of further
geographical inquiry into
telemedicine. Among the geographic contexts in which to place
telemedicine, I will
briefly describe the rural, economic and ethical.
The restructuring of medical care in the USA via telemedicine
is occurring most
frequently in a rural context. This restructuring process is
qualitatively different than
that analyzed by Kearns and Joseph (1997) in New Zealand, but
the outcomes in rural
communities may share many characteristics. It should be
acknowledged that the
concept of rurality remains complex and problematic, but it still
has value if recognized
as an entity arising from the social representations of space
created by academic and lay
discourses (Halfacree, 1993). The specific rural context , then,
shifts with the nature of

the local discourse and is thus able to account for the
tremendous diversity in rural
settings and space. Indeed, despite the fact that in the aggregate
American rural
populations remain poorer and less educated than urban ones,
the range of rural
experience is broad (Economic Research Service, 1995). In
addition, rural areas in the
USA and Europe are undergoing significant economic change
and restructuring (Beyers
and Nelson, 2000; Marsden et al., 1990; Murdoch and Marsden,
1996) with differing
outcomes. Overall, however, American rural populations
experience more serious and
severe health problems than urban populations (Gesler et al.,
1992; Ricketts, 1999), and
much of that experience is exacerbated by poverty and the
material circumstances that
accompany it (Schneider and Greenberg, 1992). Moreover,
American rural populations
face inequalities in access to care when compared to their urban
counterparts (Schur
and Franco, 1999; Ricketts, 2000). It is in this medical and
wider rural context that
telemedicine plays a role in reshaping the space of care.
As just suggested, the question of telemedicine rests not only in
a rural geographic
context but in an economic-geographic one as well. The role of
important technological
advancements and their economic applications has been
recognized as central in
development of the global economy and world-system (Hugill,
1993; Knox and Agnew,
1998). Indeed, technological systems, not unlike those used in
telemedicine, have been

the primary engine of global economic change, although it is
important to view them
as enabling rather than deterministic (Dicken, 1998). As I will
argue, telemedicine
should be considered as an important part of the package of
technologies and related
processes that shape emerging economic geographies. Such
information technologies
serve to help firms – and I would include medical care firms –
exploit geography better
(Charles, 1996). Furthermore, technology has been recognized
as essential to regional
economic change (Malecki, 1997) and to the creative
destruction and re-emergence of
regional economies (Florida, 1996).
Not independent from these contexts but distinct from them is
the ethical context of
telemedicine. There are numerous questions that arise from two
relevant themes
recently articulated by Proctor (1998): what is the place of
ethics in geography, and what
is the place of geography in ethics? Whereas significant works
by geographers are
emerging to address those questions (e.g., Proctor and Smith,
1999; Smith, 2000), the
relevant question for this paper is: how do we begin to think
about telemedicine and
regionalization as ethical-geographic issues? Crampton (1999)
provides some direction
by addressing the ethical dimensions of the internet, and two
points are worth noting.
First, he suggests that technologies such as GIS or the internet

give rise to competing
logics – totalizing and democratizing. Second, the utilization of
new technologies
creates new practices and outcomes – ‘a geography of
virtualization’ – that leads us to
ethical questions about connectivity and access. Some of the
arguments below speak to
these ethical questions, if only implicitly. In sum, telemedicine
resides within the con-
text of a geographical ethics similar to its technological
brethren GIS and the internet.
This paper is organized into three sections (II, III and IV) with
two subsections each.
Section II offers a more general conceptual basis for
understanding regionalization and
telemedicine. The first subsection provides an overview of the
question of regionaliza-
tion of medical care and its numerous meanings and underlying
ideologies. The various
circumstances of regionalization are the backdrop for
conceptualizing how telemedi-
cine is affecting, and more importantl y, is likely to affect in the
future, medical care
regionalization, and with it, the medical care system at larger
and smaller geographic
scales. The second subsection reviews several recent
geographical perspectives on new
communication and information technologies as an additional
context for conceptual-
izing telemedicine and its virtuality.
Section III emphasizes the ways in which telemedicine creates
both regions of care
and new problems associated with them. The first subsection
explains how telemedi-

cine creates new geographies of care through the formation of
virtual regions. In this
subsection, I discuss the ‘internal’ integration of virtual care
regions and their prob-
lematical aspects. The second subsection covers the problem of
‘external’ integration
between the virtual and material networks. Although proponents
of telemedicine
understand some of the hurdles to integration, geographers can
extend and deepen
their understanding as well as add insight into other aspects of
integration. An
overview at the end of that subsection provides a range of
integration prospects and
problems.
Section IV concentrates upon the regional economic context for
the current and future
implementation of telemedicine. The increasing role of
telemedicine in hospital and
medical care networks in the USA also suggests the questions:
why telemedicine and
why now? Beyond the more deterministic arguments for the
implementation of
telemedicine technologies, medical care organizations may be
viewed as firms in a
Malcolm P. Cutchin 21
and regionalization
regional economic geography of care provision. In essence,
there are many ways that

telemedicine may generate power for a medical care
organization in a regional setting.
The first subsection will briefly develop how telemedicine can
be viewed critically as an
enabling agent in strong economic competition among regional
medical care agents.
The second subsection suggests territoriality as a central
dynamic in telemedicine
systems and their economic geography. Telemedicine networks
offer medical care orga-
nizations a way to define, expand and defend territorial control.
Thus the regional
power of a large telemedicine hub becomes more than
economic; it becomes political.
This subsection thus sketches how territoriality may add yet
another important
dimension to geographical analyses of telemedicine.
The conclusions (section V) reiterate the key arguments and
suggest linkages
between regionalization and other geographic aspects of
telemedicine. Telemedicine
regions are only one piece of a complex geographical puzzle
created by the technolog-
ical practice. Moreover, the paper concludes that geographers
should not only concep-
tualize and theorize the new dynamics created by telemedicine
but also develop
normative arguments for the possible outcomes of these new
systems of care.
Philosophical bases that can support the technology-society-
geography nexus will aid
us in conceptualizing and critiquing telemedicine. Perhaps more
importantly, such
bases will assist us in arguing for and designing an ethical and
just form of telemedi-

cine – one that upholds shared values of medical care delivery
including accessibility
and equality of care.
II Conceptual bases of medical care regionalization and
telemedicine
1 Regionalization of medical care: a multifaceted concept
The regionalization of medical care is not a new idea.
Regionalization2 has been
implemented in many countries, and the meaning and utility of
regionalization has
been discussed in the USA since the 1920s (Hassinger, 1982).
The first generation of
telemedicine that developed in the 1970s failed because of
financial, technical and
behavioral constraints (Bashshur, 1995). The rapid re-
emergence of telemedicine
networks in the USA during the 1990s presents a new set of
questions regarding both
regionalization and telemedicine. Although the academic
literature does not cover the
relationship between telemedicine and regionalization to any
significant degree, the
interplay between the two processes present conceptual and
applied challenges to
medical geographers and health service researchers.
Non-geographers have contributed the bulk of ideas regarding
regionalization in
medical care, and therefore have dominated the way we might
think about the problem
in the USA. Beginning with the British Dawson Report of 1920,
various US government
studies and programs relied upon some concepts of

regionalization to suggest improve-
ments in the delivery of care to underserved groups. These
planning efforts have been
extended by more critical assessments of the potential of
regionalization. Eli Ginzburg
holds a prominent position among those who have contributed
to our understanding
of the problems and prospects of regionalizatio n. Ginzburg
(1977) suggests that region-
alization is a slippery concept that varies from writer to writer.
Regardless of definition,
the intention of regionalization programs is to improve access,
quality, cost and equity
(Ginzburg, 1977). While the literature on regionalization
acknowledges key intra- and
interorganizational components to some forms of
regionalization, the primary process
is a geographic one. Regionalization programs can accentuate
one or a combination of
the following: the distribution of physicians, the distribution of
capital expenditures
and the control of patient movement within the system
(Ginzburg, 1977).
Discussions of regionalization usually recognize that a
vertically organized hierarchy
must be imposed across a landscape by ordering services
spatially following the orga-
nizational structure and the regionalization emphasis (Lewis,
1977). Christaller’s con-
tribution to such thinking through his central place theory is
recognized in the health
services literature (e.g., Hassinger, 1982; Luke, 1992) as well as

the geographic literature
(e.g., Shannon and Dever, 1974). The net effect is argued as a
‘rationalization’ or
‘appropriate distribution’ of scarce resources to better meet the
needs of a population in
a defined area (Ginzburg, 1977; Lewis, 1977).
A reorganization of delivery systems can thereby result in either
decentralization or
centralization. One form involves the devolution of power at a
larger scale to regional
entities resulting in decentralization (Sheps and Madi son,
1977). Yet regionalization is
also used to describe the formation of regional coalitions of
community-based organi-
zations to share resources and improve efficiencies (Sheps and
Madison, 1977). The
perspective from which one views organizational change has
much to do with how one
characterizes a regionalization process (Hassinger, 1982).
Individualism and
‘community independence’ are often based in anti-centralization
positions and are seen
as barriers to regionalization (Lewis, 1977).
More recently, regionalization has been discussed in terms of
both multihospital
systems and community-based care. The former is a type of
centralization as formerly
independent hospitals begin to share resources and identities as
well as coordinate and
centralize decision-making (Luke, 1992). The latter suggests a
decentralization of care
to local providers, citizens, and hospitals so that decision-
making can be based in local
knowledge and local relationships (Hurley et al., 1995).

Strangely enough, it appears
that both processes are occurring simultaneously in the USA.
Nonetheless, local or
regional hospital systems have deeper ties to emergent
telemedicine networks than
community-based systems, and hospital systems appear more
central to regionalization
as set out by Ginzburg (1977).
Regionalization as an idea and a practice seems to evoke several
ideologies. One
ideology of regionalization appears to focus on the
rationalization of service distribu-
tion. This conviction tends to jibe with a welfare-based
approach and government
objective of service equity across a bounded population.
Arguments for regionalization
are also used to serve the needs of medical care organizations,
particularly privately
owned ones. This cost-savings ideology is based more directly
on the organization’s
ability to manage a regional system to save expenditures and
increase net operating
results. A third regionalization ideology appears to be that of
local control, where
community care offers greater equality of service provision.
Rather than the state or
medical care organization, grass-roots health care advocates
seem to promote this
ideology. The varied influence of these ideologies in a
regionalization argument will
help to define the type of geographic changes to take place in
the medical care system.
In Canada, regionalization has been implemented to a
significant degree. The

provinces have taken different paths to regionalization, but a
cost-savings ideology has
served as the primary motive for action across the country
(Reamy, 1995) even if equity
and enhanced citizen participation are also part of provincial
governments’ rationale
and regionalization
(Church and Barker, 1998). Some have found fault with the
outcomes of this process,
focusing on the negative impact on rural communities as
hospitals have been consoli-
dated and closed (James, 1999). Others have suggested that
Canadian regionalization
faces significant hurdles in creating savings, efficiency and
increased participation
(Church and Barker, 1998). Yet others view Canadian reforms
as positive when
compared to the US situation because of the compensating
effect of better access to
primary care in Canada (James et al., 1996).
The USA has not made significant progress in regionalizing its
medical care system
for improved access, quality, cost or equity. Regions of
differentiated care do exist in the
USA (e.g., Bohland and Knox, 1989), but such regions are not
based as much on the goal
of creating organized, efficient patient care as they are on the
historical development of

competitive advantage in a largely privately run, fee-for-service
marketplace. This is
most evident in California where regionalization is driven ‘by
managed care market
forces with significant limitations in access’ (James et al.,
1996: 758). Moreover, there
have been barriers to achieving the advantages of such
idealized, organized regional
systems. Beyond those discussed above, there is the lack of
federal will, and thus power,
to affect change in a market-based system (Lewis, 1977;
Ginzburg, 1977). There also is
the lack of initiative or momentum behind such a movement,
both with the public and
within the medical sector (Sheps and Madison, 1977). In
addition, there has not been the
requisite mechanism in place to provide the feedback needed by
regional systems to
adjust and care for their populations effectively (Ginzburg,
1977). Finally, because the
USA does not, as does Canada, offer universal health insurance,
enhanced primary care
access and organized referral systems, regionalization is
unlikely to live up to the more
idealistic ideologies of rationalization and local control
(Grumbach and Anderson,
1996).
This subsection has set out the basics of what analysts have
suggested regionalization
could be, should be, and is. Furthermore, it has pointed to
problems in forming a type
of regionalization that improves access, quality and cost of care.
I will now turn to a
conceptualization of telemedicine vis-à-vis communications and
information

technology. That discussion serves as a basis for understanding
how telemedicine is
unfolding – and is likely to unfold – with respect to
regionalization. While the
movement toward regionalization has remained a very gradual
one, new networks,
and thereby regions of telemedicine, have been put in place
across the USA.
Telemedicine is likely to accelerate health care regionalization
in the USA. Because of
this and other developments, the rise of telemedicine generates
conceptual and applied
challenges to medical geography.
2 Telemedicine as geographical technology
The re-emergence of telemedicine in the 1990s occurred for
various reasons – some
related to need, others to the advance in telecommunications
technologies and
networks such as the internet and world wide web. Telemedicine
involves the use of
two-way interactive audio, video and/or computer technology to
deliver care to distant
patients and facilitate the exchange of information between
specialist and primary care
physicians (Bashshur, 1997). The result of telemedicine
consultations is ‘virtual’
medicine – care that intends to be the same as if the doctor were
physically present but
does not take place as a ‘material’ (physical) medical care
consultation. This aspect of
telemedicine as virtual medicine necessitates a brief

consideration of how it fits into
recent analyses of new communications technologies and
associated geographies.
Hillis (1998: 543) argues ‘the issue of communications has been
underpursued,
underexamined, and undertheorized by geographers’. Hillis
(1998) suggests that,
because communication signals are not visible and because
communications technolo-
gies have become ‘naturalized’, geographers have failed to
critically assess the social
relations both informi ng and affected by communication
technology use. One answer
is to try to understand the place-based processes bound up in the
interaction of humans
and technology (Hillis, 1998). Batty (1997) adds to the
understanding of how geography
might address this lacuna. He suggests (Batty, 1997: 340) that
new information tech-
nologies have created a virtual geography which:
. . . is the study of place as ethereal space and its processes
inside computers, and the ways in which this space
inside computers is changing material place outside computers.
Around this Janus-like face of virtual
geography lies the study of the geography of computers and
networks from a traditional, non-ethereal
standpoint.
Batty (1997) further articulates virtual geography to include
place/space, cspace,
cyberspace and cyberplace. The first is the original domain of
geography, whereas the
second entails abstractions of space inside computers and their
networks. Cyberspace

includes the spaces that are created through intercomputer
communication, and
cyberplace is the effect on place of cyberspace infrastructures.
Establishing the importance of geography within technology-
society relations is one
step; another is how geographical theory might be created or
used to understand these
relations. Graham (1998: 167) argues that ‘substitution and
transcendence’ theories that
focus on the deterministic impact of information and
communication on society are
utopian and highly problematic, often because of their reliance
on metaphors that
mislead and ‘obfuscate the complex relations between new
communications and
information technologies and space, place, and society’. The
best theoretical solution
according to Graham lies in the ‘relational’ view that creates
recursive and ‘recombina-
tory’ linkages between technologies and space and place –
linkages that help us define
and understand effects of each on the other in an ongoing and
changing way. Kitchin
(1998a; 1998b) also argues for a geographical analysis of
cyberspace that is broad in its
inclusion of social constructivism, political economy, feminist
and postmodern per-
spectives. Kitchin (1998a: 402) suggests that such an
‘integrative approach allows us to
deconstruct carefully the implications of cyberspatial
technologies within the context of
the world we do live in and to understand the symbiotic
relationship between the
virtual and nonvirtual worlds’. In particular, tensions between
geographic centraliza-

tion and decentralization, along with questions of power and
inequality, result from an
initial critical view of cyberspace (Kitchin, 1998a).
Together, Hillis, Batty, Graham and Kitchin make important
conceptual and
theoretical contributions to a geographical understanding of the
change in communica-
tion and information technologies during the last decade.
Telemedicine technology
used in clinical care (e.g., diagnosis and therapy) is not yet as
complex as the networks
and interactions considered by these scholars, such as those
entailed in various aspects
of the internet. Telemedicine most commo nly involves intranets
with considerable
structure and limited flexibility. This point does not negate the
fact that telemedicine is
and regionalization
developing in the direction of more flexible web and wireless
structures (Shannon,
2000; Löytönen, 2000). Whether considering the more fixed or
more flexible telemedi-
cine structures, however, medical geographers should heed
these theorists’ arguments
because the innovation and implementation of telemedicine
technologies produce
virtual medical geographies. Besides concentrating on the role
of space and place in

understanding the reflexive role between telemedicine and
society, medical
geographers need to address another important type of
geography resulting from
telemedicine – the virtual region.
III Virtual regions, material regions and their integration
1 Virtual care regions and networks
By definition, telemedicine is regional.
A telemedicine system is an integrated, typically regional,
health care network offering comprehensive health
services to a defined population through the use of
telecommunications and computer technology.
(Bashshur, 1997: 9)
Although they may be constituted across geographical scales,
telemedicine systems
usually rely on technological networks organized in a regional
manner to deliver
virtual services to a population. This new ‘virtual care region’
is established in
conjunction with already existing, on-the-ground medical care
facilities, the most
important being a tertiary care hospital. Such a hospital is
normally at the center of a
function medical care region, serving as the highest-order
facility that receives upward
referrals in a regional constellation of care providers and
organizations. One regional
telemedicine system states the desire to ‘make telemedicine an
ubiquitous part of
clinical practice’ (Telehealth Magazine, 2000). In effect, the
proposal suggests that the

virtual network and region shall eventually be embedded within
– indeed be the
backbone of – the entire existing brick-and-mortar network of a
region. Moreover, the
implication is that the attainment of such a goal is entirely
unproblematic. I argue,
however, that the advances in telemedicine notwithstanding, the
virtual region of care
should not be taken-for-granted as a straightforward networking
of an existing regional
system.
Networks underlie virtual regions of telemedicine, both in
concept and in actual
infrastructure, and are thus fundamental to any understanding of
telemedicine.
Networks on which telemedicine systems develop are structured
predominantly in a
hierarchical manner with hubs and remotes (consulting and
referring sites) forming the
essential nodes (Grigsby, 1997). Tertiary care centers have
dominated the hub positions
to date, with some secondary care centers beginning to arise as
secondary hubs (Adams
and Grigsby, 1995). Even though not put into practice in any
sizable system,
‘distributed’ networks with less hierarchy and more capability
of selected referral
patterns are thought to be a large component of telemedicine in
the future (Grigsby,
1997).
Another issue that arises from an analysis of these exemplary
networks is the areal
coverage vis-à-vis that of the material medical care system.
There is a geographical non-

conformity of material and virtual regions – many places are
left out of the region
defined by such networks. Many places currently fall in between
the ‘spokes’ of the
telemedicine network.3 The arteries are in place, but not the
capillaries, so to speak, and
thus a good deal of current access inequality in the USA exists.
This phenomenon has
been noted in Australia as well (Mitchell, 1999). Perhaps an
acceptable explanation for
the current situation is the novelty of the telemedicine
networks; they just have not
developed enough to reach all the locations that they will
eventually. Nevertheless, the
question remains: will the networks be diffuse and equitable? If
other telecommunica-
tions networks are any precedent, many rural areas will not be
included, just as the
most advanced telecommunications networks have bypassed
many developing world
locations.
This concern about telemedicine has been raised in conjunction
with innovation and
network theory. The success of telemedicine networks, and
thereby the cohesion of
regions of care, depend not only upon the adoption of the
innovation but also the
continued and useful implementation of telemedicine at the
remote, referring sites
(Wells and Lemak, 1996). Moreover, referring providers must
want to engage in an
equal relationship with consulting providers in the telemedicine

network, but there are
numerous barriers to such successful network transactions,
including: (Wells and
Lemak, 1996)
� a necessary critical mass of local providers and time to
participate;
� geographic distance between nodes and few social ties
between providers;
� the perceived threat to remote physicians’ status; and
� the lack of support by local populations for such services.
Thus, telemedicine networks may be put in place, but their
ability to support and serve
a region is dependent on a host of factors. In other words, to a
large degree the virtual
care system is reliant upon the material care system to prosper.
At the same time, virtual
systems of telemedicine are likely to be selective in their
inclusiveness of material care
locations and providers.
The emphasis of this section has been on a virtual telemedicine
region formed by a
tertiary care center and network sites that exist in the same
general area. The virtual
telemedicine region is generally considered to be similar in
extent to material regions of
care shaped by utilization patterns of a tertiary care center.
Maps of existing networks,
however, exhibit virtual regions much larger than those of the
material care system (see
note 3). It is noteworthy that even larger regional constructions
are being forecast. One
futurist writes of a telemedicine based ‘quaternary care center’
and ‘national or inter-

national centers of excellence’ or ‘quinternary’ levels of care
through telemedicine that
could offer ‘super-specialty care’ (Satava, 1997: 401). Existing
telemedicine networks
and regions are seen as being subsumed into larger regions
shaped by telemedicine
technology’s ability to provide greater care access, quality and
cost savings (Satava,
1997).
2 Integration of virtual and material regions of care
While the potential benefits of telemedicine are numerous, there
are various possible
new problems to be addressed. Among those problems are the
internal integration of
telemedicine regions and the integration of the virtual with
material regions – what I
term external integration. We shall first look at problems that
lie within telemedicine
itself and affect the integration of the virtual system as a whole .
and regionalization
Sanders and Bashshur (1995) call attention to a series of
potential barriers to the
creation of ‘seamless regions’ of care by new telemedicine
networks. The first is
licensing that currently limits the practice of medicine to the
state for which one holds
a medical license. The ability to consult with patients within

one’s own state limits the
specialist, and therefore the natural extension of telemedicine
systems, to expand their
region beyond state boundaries. Another concern is that of legal
liability. Who is to be
held liable for telemedicine services not meeting medical
standards? How are such
cases to be litigated and who is most as risk? A third concern is
the protection of
individual privacy. How is the privacy of persons and medical
data to be sufficiently
maintained over networks? A fourth potential barrier is
reimbursement. Although an
intricate and complex issue, the primary subissues are who gets
reimbursed for services
provided, in what proportion, if at all? The federal government
and private insurers
have been slow to enact policies that will enable full
reimbursement for telemedicine
consultations. A final concern is the flexibility of system
architecture. Telemedicine
systems need to be able to incorporate technological
developments and system modifi-
cations with ease. The development of desktop systems and
other ‘open architecture’
designs are suggested as vital to any long-term success in
maintaining and growing
care regions (Sanders and Bashshur, 1995).
The regional framework in which telemedicine networks have
been developed
offers its own challenges of external integration to the new
practice. One such
problem is the non-homogeneity of medical culture within a
region connected by a
telemedicine network. The variation in medical practices –

medical cultures as defined
by the way practitioners think about and treat different illnesses
– is distinct from one
hospital service area to another (Gesler, 1991; Wennberg and
Gittelsohn, 1971). With the
growth of telemedicine networks into larger regions, clashes in
medical culture are
more likely to disrupt the smooth functioning of telecare.4 The
reality of medical
beliefs and practices on the ground will not be subsumed easily
into a network
environment.
As previously stated, telemedicine networks will thrive only
when organizations and
individuals both want to use the technology and use it with each
other (Wells and
Lemak, 1996). This means that cultural differences will
certainly act as obstacles to the
development of ‘seamless regions’. The resource differential
between places in a region
is conceivably an even larger problem. Regional telemedicine
systems derive from hier-
archical networks, usually centered on a more or less ‘urban’
hub with more ‘rural’
locations acting as remote or satellite nodes. While the greatest
possible gain lies with
the remote site that may receive improved information and care,
there clearly is a
resource and power differential between hub and remote node.
Furthermore, that dif-
ferential is not as potentially problematic as the difference
between remote nodes. Many
small communities do not have the resources, or social -medical
connections, to be
included in a telemedicine network. Other communities may

perceive telemedicine
networks as predatory and be passed by because of their
mistrust (Reid, 1996). Even
those places connected to a telemedicine network may not have
the right complex of
factors to thrive on the network. For example, elderly residents
and physicians may
find telemedicine difficult to use (Swanson, 1999). As a result,
integration becomes a
never-ending struggle in telemedicine networks and regions.
Differential contexts and differential abilities to adapt within a
regional telemedicine
network impact the coherence of a network. In addition, this
situation affects the
character of the region and the ability to provide equitable care
within it. Whereas a
telemedicine network is supposed to enhance the care
opportunities for a regional
population, it may only do that along the ‘circulatory system’ of
wires and nodes that
makes the network. Places and areas within the region that are
not served by arteries of
the network may wither, or at best remain unequal to those well
supported by the
network. In the end, telemedicine networks will most likely
create new types of regions,
but those regions will be part developed, and part
underdeveloped – bifurcated by the
placement and ability to use the virtual network. Not only will
there be two worlds in

a region – virtual and material – but part of the material may be
adversely impacted by
the virtual.5
The probable situation of inequality will not be static.
Innovations within telemedi-
cine and within each network will assure each region of
continual change. There is hope
that at some point in time, as the networks becomes less
hierarchical, and as technolo-
gies become easier to adopt and use, virtual care regions might
exceed levels of access
currently offered by material regions of medical care. Because
of the way medical care
in the USA is currently organized and delivered, however, this
is unlikely. As will be
discussed below, the political and economic interests underlying
medicine and
telemedicine signify that the deployment is strategic. Before
moving into that issue, we
should note several changes in medical care organization that
pose additional problems
for the integration of virtual and material regions of care.
American medicine ‘is in a state of hyperturbulence
characterized by accumulated
waves of change . . .’ (Shortell et al., 1995: 131). It is within
these circumstances of radical
change that telemedicine is being established. More recent
telemedicine networks are
designed to be flexible and readily modified as the system
changes. Yet that is only the
technological side of telecare. Telemedicine also relies upon
management and
governance. These components are being created within the
structure of the overall

medical care system – an unsteady environment.
One environmental shift that presents particular difficulties for
telemedicine is
decentralization in medical care. In many OECD countries, the
planning, delivery and
management of medical services are being decentralized
through privatization or
otherwise (Hurley et al., 1995; Eyles and Litva, 1998). Hurley
et al. (1995) argue that such
decentralized decision-making and allocative structures have
the potential to be more
efficient than centralized ones. In the USA, decentralization is
taking place in a more
established market context, where central planning has not
played an important role in
health services delivery. There are many aspects to such
decentralization, but two are
worth noting here. One is the change taking place in USA
hospitals. In thought and
practice, hospitals are being recreated as servant organizations,
rather than dominant
ones (Shortell et al., 1995). In both function and management,
some hospitals are
beginning to move away from their role as hubs and changing
their relationship with
physicians, the clinical process and communities (Shortell et
al., 1995). Decision-making
becomes more complex in these new formations but, we hope,
more responsive to local
needs. The bottom line, however, is flexibility – not unlike that
which has been driving
economic restructuring during the last two decades.
Restructured hospitals denote less hierarchical regions of
material care. ‘Integrated

rural health networks’ are intended to do the same. A variant of
similar types of orga-
nizations across the rural USA such networks establish a formal
organizational
arrangement between care providers where resources and goals
will be shared in a col-
and regionalization
laborative manner (Moscovice et al., 1997). The presumed goal
is to reduce risk and
increase cost efficiency for providers working in a very
competitive environment. While
integrated rural health networks provide greater power to local
or regional organiza-
tions, and thereby achieve a type of decentralization, local
providers also give up
autonomy in the process. Both types of decentralization, then,
imply a recentralization,
but at an intermediate geographical level.
The potential effects on telemedicine and regions are several.
Such changes in the US
medical care system suggest less hierarchy, yet telemedicine is
currently hierarchical in
nature – hospital networks that have not yet been reinvented are
driving the imple-
mentation of new technological networks. Virtual care regions
appear to be going in one
direction as material care regions go in another. More
decentralized regions of care are
based on adaptation and responsiveness to local needs. On the
other hand, current

telemedicine networks are highly structured with only selected
locales and providers
participating. As Ricketts (1999) points out, the potential
benefits of health care tech-
nologies for rural areas are clear, but a serious problem is that
ownership and control of
such technologies often lies outside the rural community. It is
questionable whether
telemedicine networks will be able to adapt to local needs, or if
consulting physicians
outside the local area will be interested in the goals of the
regional health network. If all
members of an integrated rural health network were to be wired
and equally in control
of their own telemedicine system, for example, the outcome
would, in theory, be
positive. This is not likely to happen any time soon, however,
because of financial and
expertise constraints. Moreover, as regional and subregional
changes in material
medical care occur, participation in telemedicine networks is
likely to change. As
providers and organizations move in and out of telemedicine
relationships, the stability
of regional telemedicine systems, especially rural ones, is
compromised. The material
world of medicine – providers trying to survive in practices on
the ground but in ever-
changing geographic coalitions – will offer constant challenges
to nascent and less
flexible telemedicine networks.
If there are so many drawbacks for telemedicine’s future, then
why is it proceeding
apace, and why are so many invested in the effort to
demonstrate its potential? To

answer these questions, we have to consider the benefi ts of
telemedicine outside of the
context of equality of care for all. Telemedicine has been
supported by the federal
government in large part because of the arguments for how it
can help to provide care
to currently underserved populations. Yet a more critical
geographic assessment may
yield a different relationship between regionalization,
telemedicine and the economics
of medicine.
IV The regional economic context of telemedicine
1 The relevance of regional economic geography
As indicated, Christaller’s model of economic location has been
used to analyze the dis-
tribution of medical care services (Shannon and Dever, 1974;
Hassinger, 1982; Luke,
1992). This model suggests the optimal spatial arrangement of
services based on the
underlying demand for such services in a given area and
population. As medical care
has become more complex, indeed as it has become more like
any economic industry,
Christaller’s model fails to explain much about economic
location and behavior.
Economic geographers have long realized the limitations of
Christaller for understand-
ing the modern economy. Few medical geographers have applied

the economic
geography literature, particularly that of the last decade, to the
problem of medical care
systems. Telemedicine is an appropriate development for which
to initially sketch
connections between medical geography and this literature.
Of necessity here, I will limit the coverage of how the new
economic geography
literature can inform our conceptualization of telemedicine and
regions. I will try to
connect economic arguments in the telemedicine literature with
geographic scholarship
on regional economic processes and exhibit a set of concepts
with which medical
geographers can begin to evaluate telemedicine in its regional
context. This section is
based on the assumption that the medical care sector is in many
ways a ‘medical
industry’. When put together with the technology industry at the
root of telemedicine,
we have a ‘telemedicine industry’, as it is often referred to in
the literature (e.g.,
Watanabe et al., 1999; Larkin, 1997). This means that we need
to think of telemedicine
systems as more than a social service network and that
economic-geographic concep-
tualizations can and do apply.
The medical care sector has lagged behind other sectors in the
economy in its imple-
mentation and use of such new communications and information
technologies
(Economist, 1998; Field, 1996). A likely explanation for the
current development of
systems is the temporal connection to various restructuring in

the medical industry.
Indeed, some of the most in-depth texts on telemedicine (e.g.,
Field, 1996) explicitly
focus on business and economic factors of telemedicine.
Telemedicine, it is argued,
makes economic sense for medical care organizations.
The potential economic advantages of telemedicine are
numerous and are both
explicit and implied in the literature. More explicit arguments
suggest that telemedicine
will save costs in a variety of ways. For instance, it is
maintained that fewer
unnecessary referrals will be made when telemedicine is used
for consultations to
remote or otherwise costly locations (prisons, homes) and
patients are not
transported to the hospital or a practitioner to them (Burgiss et
al., 1998; Taylor, 1998;
Wootton, 1999). Moreover, proponents state that telemedicine
will allow organizations
to spread out capital costs through a region by offering non-
clinical uses, such as
continuing medical education (Field, 1996). Others go as far as
to suggest that telemed-
icine will stimulate regional growth in jobs, markets, products
and services
(Information Highway Advisory Council, 1997, cited in
Watanabe et al., 1999).
Telemedicine networks may also allow medical care
organizations to establish
economies of scale, by the enhancement of vertical integration
and the reduction of
transaction costs. Such potential competitive advantages within
a region are attractive
to those in the medical industry. Cost savings through

telemedicine should be compli-
mented by increased revenue from enhanced referral volume
(Field, 1996; Reid, 1996).
There exists, however, a dearth of reliable information to
support such claims (Bashshur
et al., 2000).
These economic factors are likely to affect the extent of a
telemedicine network and
its economic viability. Yet if telemedicine is going to be a
successful and overwhelm-
ingly positive force in regional medical care development, it
will have to meet a more
complex set of conditions. The work of Michael Storper (1997)6
offers a useful
framework for thinking about the economic geography of
regional telemedicine
systems. While Storper is not concerned with telemedicine per
se, his arguments about
and regionalization
regional economic systems can be used to provide insight into
regional medical care
and telemedicine.
Storper bases his understanding of territorial economic
development on the so-called
‘holy trinity’ of regional economics – technology, organizations
and territory. Rather
than take the traditional view that territorial formations are
outcomes of organizations
and technology, Storper articulates a reflexive relationship

between the three where
innovation remakes the relationships and provides the fuel for
regional economic
development. Instead of traded inputs as key, Storper proposes
that technologies and
untraded interdependencies among firms (conventions, informal
rules and habits) in a
territory, or ‘relational assets’, become the focus for
coordination and adaptation in a
regional economy. Relational assets are regionally specific –
they will differ by region
and be more or less successful by region dependent upon how
well the reflexive
relation between the holy trinity is managed via institutional
means.
The desired outcome is ‘economic reflexivity’ based on the
‘destandardization’ of
technology and the ‘generation of variety’. This goal is
sometimes reached in the
context of a ‘learning economy’ where heightened reflexivity
among human agents and
organizations allows the adoption and/or innovation of new
technologies and
techniques at a rapid pace. The manner in which organizations
act in a regional setting,
however, and the way that technology is deployed or developed,
is structured within
regional ‘conventions’. Conventions are frameworks of action
and lead to several
models for organizational structure. The most popular model is
‘lean management’
where fixed costs are reduced by subcontracting work to
individuals or firms. The
secondary model is ‘managed coherence’, also known as the
‘communitarian’ firm.

Here the firm does not stress reduced costs as much as enhanced
synergies inside and
outside the organization boundaries through loyalty and
reciprocity. Both models rely
upon increased flexibility in the firm to adapt to changing
markets and production
processes. The outcome is strong regional economic growth and
prosperity for many
(but not all).
The insertion of new technologies and techniques into the
production chain to
increase the flexibility of production is a central concept in
economic geography. It also
applies to medicine in the case of the ‘reinvented hospital’
(Shortell et al., 1995). Studies
of regional economies based in flexible production schemes –
often called new
industrial districts – tend toward a hierarchical interfirm
relationship with a large ‘lead’
firm at the center (Harrison, 1994). What is supposed to be a
flexible production process
based in decentralization tends toward centralization and
coercive power relations.
Therefore, the reinvented hospital or the integrated rural health
network can be
expected to evolve only partially toward decentralization.
Telemedicine networks will
serve the tendency for centralization, for all the reasons
previously mentioned. Not
unlike the theory of cumulative causation, benefits of
telemedicine will accrue to the
top of the organizational hierarchy, lending more power and
medical care access to
some areas of the region.
Telemedicine is well suited to settings akin to new regional

economic arenas.
Although the ‘production of medicine’ is distinct from most
industries considered in
the regional economic geography literature, telemedicine,
together with organizational
changes in medicine, is moving the medical industry closer to
those of any other
production process. Storper’s regional economic theory is
introduced here not to
suggest that telemedicine systems and their underlying medical
care systems should be
operated along the lines of regional economies. It is probable,
however, that, at least in
the USA, regional medical care systems, especially those
innovating with telemedicine
technologies, are likely to find themselves up against the same
problematic as those
faced by other industries. Competition and the increased move
toward markets as the
final arbiter of medical care delivery mean that policy and
institutional governance of
regional medical care systems is important. Telemedicine holds
both innovative and
destructive potential. Proper management of the technology and
the conventions in
each specific regional context can make an important difference
in how well access, cost
and quality of care is affected. Such effective use of
telemedicine would most assuredly
push medical care regionalization forward. It could be a major

tool of territorial rede-
velopment of medicine. Policy must come to grips with how
technology, organizations
and territory interact in these instances. Moreover, the
territoriality inherent in the
formation of new regions of care should be understood along
with its potential conse-
quences. Territoriality stretches the power of medical care
organizations from the
economic realm to that of policy and governance.
2 The territorial imperative in telemedicine
In the most in-depth treatment of the concept, Sack (1986) has
argued that territoriality
is a fundamental aspect of personal and organizational
experience. Territoriality is ‘a
spatial strategy to affect, influence and control resources and
people, by controlling
area’ (Sack, 1986: 1). In other terms, territoriality is ‘a strategy
to establish different
degrees of access to people, things, and relationships’ (Sack,
1986: 20). Furthermore, ter-
ritoriality is a ‘primary geographical expression of social
power’ (Sack, 1986: 5). The
role of territoriality in the geography of medical care remains
underexamined (for one
exception see Gesler, 1991). Telemedicine, even though being
put in place with many
good intentions, is generating a new phase of medical care
territoriality and the power
that goes with it. Territoriality is especially important in the
context of hierarchies and
bureaucracies (Sack, 1986).
We have already suggested that telemedicine is hierarchical,

and modern medical
care organizations are complex bureaucracies. The important
connection to be made is
that telemedicine creates new power for medical care
bureaucracies by allowing them
to exert more control over new areas and thereby resources,
people and access to the
network. The extended control and dominance enhances power
further, and so on. Such
a view opposes the optimistic telemedicine discourse that
dominates the medical care
literature, a literature oriented toward the demonstration of
telemedicine’s promise.
There may be much promise, but the territorial basis of
telemedicine networks suggests
that the promise may bring negative consequences with it. This
is especially the case
when considering the territorial imperative of medical care
organizations as firms.
There is a territorial imperative for organizations who want to
form a strong
competitive strategy by dominating technological development
and thereby territory
(Storper and Walker, 1989). Some medical care organizations
looking to compete in an
increasingly challenging marketplace will implement
telemedicine as a solution.
Subsequently, care will be reconstructed over time based on the
question of how the
technology of territorial formation – telemedicine – can be
improved. It has been
suggested that managed care organizations (MCOs) may see
telemedicine as making

and regionalization
standardization of specialty care possible as well as giving them
the ability to expand
their catchment areas (Weissert and Silberman, 1996).
Furthermore, medical care
administrators and practitioners are concerned about protecting
their patient base as
well as enhancing or building a strategic advantage in referral
patterns; thus telemedi-
cine becomes an attractive solution (Field, 1996; Reid, 1996).
Such expansionist strategy
is often a concomitant of territoriality. The patient stream from
peripheral areas of a
territory adds increasing income while infrastructure costs
decrease through the imple-
mentation of more efficient telemedicine technology. Indeed,
telemedicine networks
facilitate a regional extension of the largest tertiary care
centers.
An initial challenge to the study of telemedicine and regions is
the question of ‘how
new information technologies actually relate to the spaces and
places bound up with
human territoriality’ (Graham, 1998: 167). From that point the
understanding of
medical care regions as larger manifestations of organizational
territoriality can
develop. A political-economy perspective takes this even
further to suggest that new
telecommunications infrastructures are value-laden and their
development is based in
the goal of controlling space and gaining social power (Graham,

1998). Telemedicine
systems are types of new telecommunication systems that can be
regarded similarly.
When such systems are viewed within their political-economic
context, this assertion is
more credible.
Telemedicine systems have been stimulated by federal
investment during the last
decade, but special interests – telecoms, the defense industry
and MCOs – now increas-
ingly drive the investment pattern (Weissert and Silberman,
1996). Moreover, there is a
convergence of four major forces that are shaping the
development of telemedicine
systems in the USA: rural health interests, the telemedicine
industry, physicians and
members of Congress (Weissert and Silberman, 1996). These
actors have been central in
the social construction of the meaning and role of telemedicine
to date. As the key
political-economic actors, they have the power to construct the
narrative that
accompanies territorial regional constructions and the amount of
power to be entailed
in such constructions. Although the public or non-profit sector
currently dominates the
implementation of regional telemedicine systems, this situation
is expected to change
in favor of private interests. The arguments still hold, however,
because of the bureau-
cratic nature of both non-profit and for-profit medical care
organizations and the need
for both to establish competitive territorial advantage to
survive.
Greater territorial power for organizations leads to the

probability of monopolization
and loss of consumer power, the combined results of which are
dangerous and well
understood. For this and other reasons, there is a need for
geographical analysis of the
territoriality of new technological networks of medical care.
While the territoriality of
telemedicine will exist at different geographical scales from the
local to the global, the
regional, or meso-scale, character of nascent networks will
provide an essential point of
entry for critical investigations of how, why and for whom they
are evolving.
V Conclusions
This paper argues that telemedicine is a new and important area
of inquiry for medical
geographers, and that critical geographical assessments of
telemedicine are necessary
to balance the pro-telemedicine bias in the academic literature.
The context of regional-
ization is important for conceptualizing the present and future
effects of telemedicine
on the geography of medical care in the USA. This new
technological basis of medical
care delivery creates virtual care regions. Through networks of
telemedicine, virtual
regions challenge existing, or material, regions of care. Virtual
regions also cause a

problem of integration with material care regions and thereby
overall system
integration. A large motive behind the current wave in
telemedicine is the regional
economic geography of medical care organizations.
Telemedicine can be viewed as an
essential element of the regional economic development of such
organizations. The
concept of territoriality adds additional understanding to why
telemedicine is so
important to regional medical care formations. The paper
therefore lays out various
aspects of telemedicine through which geographers and other
analysts can approach an
increasingly important element of medical care infrastructure
and practice.
Telemedicine is both a technological and a sociocultural
innovation (Bashshur et al.,
2000). Simultaneously, telemedicine is a complex geographic
phenomenon leading to
new geographic processes in medical care provision. It
encompasses space-time issues
of medical care delivery and access (Shannon, 1997). In
addition, the implementation of
systems impacts places, especially rural ones, and their medical
and non-medical
communities. Telemedicine is also going global, with
intercontinental initiatives in
development. Each of these broad geographic areas of
telemedicine needs much in the
way of empirical study and theoretical development. A regional
orientation such as the
one presented here will contain some features of geographical
experience that run
across these additional foci and scales, e.g., territoriality. Yet a

regional examination
must also be aware of the particular dimensions that shape it,
medical care regionaliza-
tion and regional economic geography, for instance.
The effects of telemedicine will be both beneficial and
detrimental to the way medical
care is carried out and experienced. The varied interests
currently shaping the telemed-
icine literature are focused more on the benefits. There are
geographical positives to
note, such as improved access to specialists for some patients.
This paper has argued,
however, that there are numerous, complex processes that will
produce additional
problems such as inequality and power differentials. Although
this appears particular-
ly relevant for the United States’ case, the continuing
convergence in health care
systems in the more developed world (Graig, 1999) means that
these processes and
concerns should apply to other countries in which telemedicine
plays an important role
in medical care.
Perhaps one reason why telemedicine is currently
underexamined in the ways
suggested here is its relatively recent development and
implementation. Another
possible explanation is the possibility that telemedicine may
once again fail and fade
away and therefore it is not being taken seriously. It may be ‘a
solution looking for a
problem to solve’ (Weissert and Silberman, 1996: 1). In
addition, it is difficult to discern
exactly where along the course of regional processes

telemedicine currently exists; the
evolutionary speed of telemedicine offers a moving target for
analysis. Whatever the
case, I argue that the tendencies discussed in this paper will
affect the geography of
medical care – care involving telemedicine – in the future.
If this is indeed the case, we not only need to conceptualize and
study telemedicine;
we need to create a connected set of normative ethics to the
problem. For example,
should rural society be made to accept that telemedicine is
sufficient for their care? In
other words, is it ethical to give up on creating material systems
of care for the needy
and regionalization
that equal those who have more? Each ideology of
regionalization adopts an
adjustment of perceptions and values (Ginzburg, 1977). In the
same manner, the
unquestioning willingness to demonstrate, support and
implement telemedicine
embraces a set of values closely allied to capital and (perhaps
unwittingly) opposes the
right of greater power and equality for the rural poor.
The need for normative ethics in geographical inquiry is
becoming increasingly
recognized (e.g., Proctor and Smith, 1999; Smith, 2000).
Geographers can use various
philosophical bases for generating a normative ethics for

telemedicine – of what
telemedicine should evolve to be. While there is no space in this
paper to develop such
an ethics, I will conclude by suggesting that John Dewey’s work
is of particular interest
for a normative analysis of telemedicine because of his longtime
emphasis on both the
social meaning of technology (Hickman, 1990) and ethics
(Pappas, 1998). Whatever the
philosophy utilized, it will be up to the medical geographer to
make the connection to
the geographical in such an ethics. Altogether, in its
implementation and utilization as
well as its conceptualization, empirical study and ethical
analysis, telemedicine
presents a new challenge to those who need and provide medical
care and to medical
geographers.
Acknowledgements
I would like to acknowledge Gary Shannon as one who has
fostered my interest and
understanding of telemedicine and who suggested the problem
of telemedicine regions
in the first place. I am grateful for the many constructive
comments of Guntram Herb,
Alexander Murphy and anonymous reviewers on previous drafts
of this paper.
Notes
1. I use the term ‘medical geography’ instead of ‘health
geography’ not to privilege one term over
the other in naming the subdiscipline. The distinct medical
nature of the paper’s topic, however, along

with the remedicalization that accompanies the implementation
of telemedicine, justifies the use of
medical geography. In order to maintain consistency, I will use
the term ‘medical geographers’ to refer
to those who might study the phenomenon. Likewise, I will use
the term ‘medical care’ as often as
possible to refer to the system within which telemedicine exists,
but the term ‘health care’ is often used
with the same meaning in the literature and should be equated
with medical care when it appears in
the text.
2. A full discussion of the meaning of region and
regionalization is not possible here, and readers
should note that when using the term regionalization by itself I
am referring to a health care organi-
zation and delivery process.
3. Maps of regional telemedicine systems that illustrate this and
related points may be found at:
http://www.telemed.med.ecu.edu/map.htm
http://zeki.radiology.arizona.edu/artn/architecture_frame.htm
http://www.vtmednet.org/telemedicine/map.htm
4. While the suggested case refers to intra-state sized
systems/regions, the problem will be even
more pronounced in intercontinental scale projects now being
proposed and implemented.
5. This point is not made to suggest a presently even geography
of care without telemedicine.
Rather, the point is that telemedicine will create new
geographies of uneven and unequal care.
6. The discussion here derives primarily from Chapters 2 and 11
of Storper’s The regional world

(1997).
References
Adams, L.N. and Grigsby, K.R. 1995: The
Georgia state telemedicine program: initiation,
design, and plans. Telemedicine Journal 1,
227–35.
Bashshur, R.L. 1995: On the definition and
evaluation of telemedicine. Telemedicine Journal
1, 19–30.
–––– 1997: Telemedicine and the health care
system. In Bashshur, R.L., Sanders, J.H. and
Shannon, G.W., editors, Telemedicine: theory and
practice, Springfield, IL: Charles C. Thomas,
5–35.
Bashshur, R.L., Reardon, T.G. and Shannon,
G.W. 2000: Telemedicine: a new health care
delivery system. Annual Review of Public Health
21, 613–37.
Batty, M. 1997: Virtual geography. Futures 29,
337–52.
Beyers, W.B. and Nelson, P.B. 2000:
Contemporary development forces in the non-
metropolitan west: new insights from rapidly
growing communities. Journal of Rural Studies
16, 459–74.

Bohland, J. and Knox, P. 1989: Growth of
proprietary hospitals in the USA. In Scarpaci,
J., editor, Health services privatization in
industrial societies, New Brunswick: Rutgers
University Press, 27–64.
Burgiss, S.G., Blaine, L.E., Brooks, C., Foster,
C.D. and Smith, G.T. 1998: Medicine without
boundaries. Forum for Applied Research and
Public Policy 13, 101–105.
Charles, D.R. 1996: Information technology and
production systems. In Daniels, P.W. and
Lever, W.F., editors, The global economy in
transition, Harlow: Longman, 83–102.
Church, J. and Barker, P. 1998: Regionalization of
health services in Canada: a critical
perspective. International Journal of Health
Services 28, 467–86.
Crampton, J. 1999: Virtual geographies: the ethics
of the internet. In Proctor, J.D. and Smith, D.M.,
editors, Geography and ethics: journeys in a moral
terrain, London: Routledge, 72–91.
Dicken, P. 1998: Global shift: transforming the world
economy (third edition). New York: Guilford
Press.
Economic Research Service. 1995: Understanding
rural America. Washington, DC: USA
Department of Agriculture, Agriculture
Information Bulletin No. 710.

Economist 1998: IT and health care: bugs and
viruses. 28 February, 66-68.
Eyles, J. and Litva, A. 1998: Place, participation,
and policy: people in and for health care policy.
In Kearns, R. and Gesler, W.M., editors, Putting
health into place: landscape, identity, and well-
being, Syracuse, NY: Syracuse University Press,
248–69.
Field, M.J., editor, 1996: Telemedicine: a guide to
assessing telecommunications in health care.
Washington, DC: National Academy Press.
Florida, R. 1996: Regional creative destruction:
production organization, globalization, and the
transformation of the Midwest. Economic
Geography 72, 315–35.
Gesler, W.M. 1991: The cultural geography of health
care. Pittsburgh: University of Pittsburgh Press.
Gesler, W.M., Hartwell, S., Ricketts, T.C. and
Rosenberg, M.W. 1992: Introduction. In
Gesler, W.M. and Ricketts, T.C., editors, Health
in rural North America: the geography of health
care services and delivery, New Brunswick:
Rutgers University Press, 1–22.
Ginzburg, E. 1977: The many meanings of
regionalization in health. In Ginzburg, E.,
editor, Regionalization and health policy, US
Department of Health, Education, and Welfare
Publication no. 77–623, Washington, DC:
Government Printing Office, 1–6.

Graham, S. 1998: The end of geography or the
explosion of place? Conceptualizing space,
place and information technology. Progress in
Human Geography 22, 165–85.
Graig, L.A. 1999: Health of nations (third edition).
Washington DC: Congressional Quarterly
Press.
Grigsby, J. 1997: Telemedicine in the USA. In
Bashshur, R.L., Sanders, J.H. and Shannon,
G.W., editors, Telemedicine: theory and practice,
Springfield, IL: Charles C. Thomas, 291–325.
Grumbach, K. and Anderson, G.M. 1996: Access
to care in regionalized health care systems –
reply. Journal of the American Medical Association
275, 759.
Halfacree, K.H. 1993: Locality and social repre-
sentation: space, discourse and alternative
definitions of the rural. Journal of Rural Studies
9, 23–37.
Harrison, B. 1994: Lean and mean: the changing
landscape of corporate power in the age of flexibility.
and regionalization
New York: Basic Books.
Hassinger, E.W. 1982: Rural health organization:
social networks and regionalization. Ames, IA:
Iowa State University Press.

Hickman, L.A. 1990: John Dewey’s pragmatic
technology. Bloomington, IN: Indiana
University Press.
Hillis, K. 1998: On the margins: the invisibility of
communications in geography. Progress in
Human Geography 22, 543–66.
Hugill, P.J. 1993: World trade since 1431: geography,
technology, and capitalism. Baltimore: Johns
Hopkins University Press.
Hurley, J., Birch, S. and Eyles, J. 1995:
Geographically-decentralized planning and
management in health care: some information-
al issues and their implications for efficiency.
Social Science and Medicine 41, 3–11.
Information Highway Advisory Council. 1997:
Preparing Canada for a digital world: final report of
the information highway advisory council. Ottawa:
Industry Canada.
James, A. 1999: Closing rural hospitals in
Saskatchewan: on the road to wellness? Social
Science and Medicine 49, 1021–34.
James, P., Wysong, J.A., Rosenthal, T., Bliss, M.,
Osborne J., and Lin, G. 1996: Access to care in
regionalized health care systems. Journal of the
American Medical Association 275, 758–59.
Kearns, R.A. and Joseph, A.E. 1997:
Restructuring health and rural communities in
New Zealand. Progress in Human Geography 21,

18–32.
Kitchin, R.M. 1998a: Towards geographies of
cyberspace. Progress in Human Geography 22,
385–406.
–––– 1998b: Cyberspace: the world in the wires.
Chichester: John Wiley.
Knox, P. and Agnew, J. 1998: The geography of the
world economy (third edition). New York: John
Wiley.
Larkin, M. 1997: Telemedicine finds its place in
the real world. Lancet 350, 646–47.
Lewis, C. 1977: Improved access through region-
alization. In Ginzburg, E., editor,
Regionalization and health policy, US Department
of Health, Education, and Welfare Publication
no. 77–623, Washington, DC: Government
Printing Office, 71–84.
Löytönen, M. 2000: Telemedicine and the
geography of health. Paper presented at the 9th
International Symposium in Medical
Geography, Montreal, 3 July.
Luke, R.D. 1992: Local hospital systems:
forerunners of regional systems? Frontiers of
Health Services Management 9(2), 3–51.
Malecki, E.J. 1997: Technology and economic
development: the dynamics of local, regional and
national competitiveness (second edition).

Harlow: Longman.
Marsden, T., Lowe, P. and Whatmore, S., editors
1990: Rural restructuring: global processes and
their responses. London: David Fulton
Publishers.
Mayer, J. 2000: Place, telemedicine, and the
doctor-patient relationship. Paper presented at
the 9th International Symposium in Medical
Geography, Montreal, 3 July.
Mitchell, J.G. 1999: The uneven diffusion of
telemedicine services in Australia. Journal of
Telemedicine and Telecare 5(S1), 45–47.
Moscovice, I., Wellever, A., Christianson, J.,
Casey, M., Yawn, B. and Hartley, D. 1997:
Understanding integrated rural health
networks. Milbank Quarterly 75, 563–88.
Murdoch, J. and Marsden, T. 1996: Reconstituting
rurality. London: University College London
Press.
Pappas, G.F. 1998: Dewey’s ethics: morality as
experience. In Hickman, L.A., editor, Reading
Dewey: interpretations for a postmodern
generation, Bloomington, IN: Indiana
University Press, 100–23.
Proctor, J.D. 1998: Ethics in geography: giving
moral form to the geographical imagination.
Area 30, 8–18.
Proctor, J.D. and Smith, D.M. 1999: Geography

International Journal of Technology Assessment in Health Care,

International Journal of Technology Assessment in Health Care,

Recommended

Recommended

More Related Content

Similar to International Journal of Technology Assessment in Health Care,

Similar to International Journal of Technology Assessment in Health Care, (20)

More from TatianaMajor22

More from TatianaMajor22 (20)

Recently uploaded

Recently uploaded (20)

International Journal of Technology Assessment in Health Care,