what are some merging healthcare technology system?
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 importantly, 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
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22 Virtual medical geographies: conceptualizing telemedicine 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 regionalization. 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 Madison, 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
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24 Virtual medical geographies: conceptualizing telemedicine 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 informing 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 commonly involves intranets with considerable structure and limited flexibility. This point does not negate the fact that telemedicine is
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26 Virtual medical geographies: conceptualizing telemedicine 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.
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28 Virtual medical geographies: conceptualizing telemedicine 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
Malcolm P. Cutchin 29
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-
30 Virtual medical geographies: conceptualizing telemedicine 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 benefits 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.
Malcolm P. Cutchin 31
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
32 Virtual medical geographies: conceptualizing telemedicine 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
Malcolm P. Cutchin 33
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
34 Virtual medical geographies: conceptualizing telemedicine 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-
Malcolm P. Cutchin 35
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
36 Virtual medical geographies: conceptualizing telemedicine 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).
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