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.
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