Greenhalgh Trisha, Procter Rob, Wherton Joe, Sugarhood Paul, Shaw Sara
Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
BMJ Open. 2012 Jul 19;2(4). doi: 10.1136/bmjopen-2012-001574. Print 2012.
To (1) map how different stakeholders understand telehealth and telecare technologies and (2) explore the implications for development and implementation of telehealth and telecare services.
Discourse analysis.
68 publications representing diverse perspectives (academic, policy, service, commercial and lay) on telehealth and telecare plus field notes from 10 knowledge-sharing events.
Following a familiarisation phase (browsing and informal interviews), we studied a systematic sample of texts in detail. Through repeated close reading, we identified assumptions, metaphors, storylines, scenarios, practices and rhetorical positions. We added successive findings to an emerging picture of the whole.
Telehealth and telecare technologies featured prominently in texts on chronic illness and ageing. There was no coherent organising vision. Rather, four conflicting discourses were evident and engaged only minimally with one another's arguments. Modernist discourse presented a futuristic utopian vision in which assistive technologies, implemented at scale, would enable society to meet its moral obligations to older people by creating a safe 'smart' home environment where help was always at hand, while generating efficiency savings. Humanist discourse emphasised the uniqueness and moral worth of the individual and tailoring to personal and family context; it considered that technologies were only sometimes fit for purpose and could create as well as solve problems. Political economy discourse envisaged a techno-economic complex of powerful vested interests driving commodification of healthcare and diversion of public funds into private business. Change management discourse recognised the complicatedness of large-scale technology programmes and emphasised good project management and organisational processes.
Introduction of telehealth and telecare is hampered because different stakeholders hold different assumptions, values and world views, 'talk past' each other and compete for recognition and resources. If investments in these technologies are to bear fruit, more effective inter-stakeholder dialogue must occur to establish an organising vision that better accommodates competing discourses.
（1）描绘不同利益相关者如何理解远程医疗和远程护理技术；（2）探讨其对远程医疗和远程护理服务发展与实施的影响。
话语分析。
68篇代表了关于远程医疗和远程护理不同观点（学术、政策、服务、商业和大众）的出版物，以及来自10次知识共享活动的现场记录。
在熟悉阶段（浏览和非正式访谈）之后，我们详细研究了文本的系统样本。通过反复仔细阅读，我们识别出假设、隐喻、故事情节、场景、实践和修辞立场。我们将陆续的发现添加到关于整体的一幅逐渐浮现的图景中。
远程医疗和远程护理技术在关于慢性病和老龄化的文本中显著突出。没有连贯的组织愿景。相反，四种相互冲突的话语很明显，且彼此之间的论点很少有交集。现代主义话语呈现了一种未来主义的乌托邦愿景，即大规模实施的辅助技术将通过创造一个随时都能获得帮助的安全“智能”家庭环境，使社会能够履行其对老年人的道德义务，同时实现效率节约。人文主义话语强调个人的独特性和道德价值以及根据个人和家庭背景进行调整；它认为技术只是有时符合目的，并且既能产生问题也能解决问题。政治经济学话语设想了一个由强大既得利益驱动的技术经济复合体，推动医疗保健商品化以及将公共资金转移到私营企业。变革管理话语认识到大规模技术项目的复杂性，并强调良好的项目管理和组织流程。
远程医疗和远程护理的引入受到阻碍，因为不同利益相关者持有不同的假设、价值观和世界观，相互“各说各话”，并争夺认可和资源。如果对这些技术的投资要取得成果，就必须进行更有效的利益相关者间对话，以建立一个能更好地协调相互冲突话语的组织愿景。
