J Am Med Inform Assoc 10:596-604 doi:10.1197/jamia.M1145
  • Original Investigation
  • Model Formulation

Understanding the Normalization of Telemedicine Services through Qualitative Evaluation

  1. Carl May, PhD,
  2. Robert Harrison, MSc,
  3. Tracy Finch, PhD,
  4. Anne MacFarlane, PhD,
  5. Frances Mair, MD,
  6. Paul Wallace, MD
  1. Affiliations of the authors: Royal Free and University College Medical School, London, England (RH, PW); University of Newcastle upon Tyne, Newcastle upon Tyne, England (CM, TF); National University of Ireland, Galway, Republic of Ireland (AM); University of Liverpool, Liverpool, England (FM), USA
  1. Correspondence and reprints: Carl May, PhD, Centre for Health Services Research, University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, United Kingdom; e-mail: <c.r.may{at}>.
  • Received 10 April 2002
  • Accepted 30 June 2003


Objective Qualitative studies can help us understand the “successes” and “failures” of telemedicine to normalize within clinical service provision. This report presents the development of a robust conceptual model of normalization processes in the implementation and development of telemedicine services.

Design Retrospective and cumulative analysis of longitudinal qualitative data from three studies was undertaken between 1997 and 2002. Observation and semistructured interviews produced a substantial body of data relating to approximately 582 discrete data collection episodes. Data were analyzed separately in each of three studies. Cumulative analysis was conducted by constant comparison.

Results (1) Implementation of telemedicine services depends on a positive link with a (local or national) policy level sponsor. (2) Adoption of telemedicine systems in service depends on successful structural integration so that development of organizational structures takes place. (3) Translation of telemedicine technologies into clinical practice depends on the enrollment of cohesive, cooperative groups. (4) Stabilization of telemedicine systems in practice depends on integration at the level of professional knowledge and practice, where clinicians are able to accommodate telemedicine through the development of new procedures and protocols.

Conclusion A rationalized linear diffusion model of “telehealthcare” is inadequate in assessing the potential for normalization, and the political, organizational, and “ownership” problems that govern the process of development, implementation, and normalization need to be accounted for. This report presents a model for assessing the potential for successful implementation of telehealthcare services. This model defines the requirements for the successful normalization of telemedicine systems in clinical practice.


  • This paper was presented orally at two Royal Society of Medicine telehealthcare meetings, one in the spring of 2002, and the other in January of 2003. A summary abstract of the paper was published in the Telemed03 abstracts book, distributed on the conference CD, and published in the Journal of Telemedicine and Telehealthcare.

  • The studies reported in this paper have been funded by the following organizations: National Health Service Executive North West Region R&D Directorate: (grant RDO/12/20); Manchester West Primary Care Group; UK Department of Health: (grants ICT/032 ICT/167, ICT367); the NHS R&D HTA programme; and the UK Economic and Social Research Council (grant L218 25 2067). The authors thank these agencies for their financial support of the research and they gratefully acknowledge the contribution of Theresa Atkinson, Helen Doyle, and Nicola Shaw to the studies on which the current paper is based. Maggie Mort made a substantial intellectual and practical contribution to studies TM1 and TM2, which the authors acknowledge. The authors thank Dr. Bonnie Kaplan and anonymous reviewers of this article for their detailed critical comments, which greatly improved the final manuscript.

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