Care at a Distance: On the Closeness of Technology . Amsterdam : Amsterdam University Press , 2012 , £35.50 (pbk) 204 pp. ISBN: 978-90-8964-397-1,
The latest contribution to this Care and Welfare series uses an ethnographic approach to reflect the pros and cons of telecare as experienced both by patients and deliverers of healthcare – particularly nurses. The contents are divided into three parts: Norms and nightmares; Knowledge and promises; and Routines and efficiencies.
There is continuing debate about the effectiveness of telecare in the management of long term conditions. Despite the appearance of more studies evaluating individual telecare projects, these have mainly been efficacy studies, using gold standards, such as randomised controlled trials (RCTs) or pilot projects using suboptimal study designs. While quantitative studies have a predefined outcome from the outset, the complexity of interventions – with organisational changes in healthcare practice frequently being required – poses a problem for evaluation. Ensuring personalised healthcare involves variation in how interventions are applied. These variations are rarely reported in research outputs and this makes it difficult to assess implementation fidelity or integrity, thus limiting possibilities for further research or replication in practice. Composite outcomes arise from various interventions, sharing a common medium of delivery – i.e., the telecare device. This book demonstrates, ‘that innovative care practices are characterised by a process of identifying and adjusting new goals’ and ‘the type of outcome is not fixed but participants are on the way to define them’.
This book takes an ethnographic approach to better understand technological innovations in healthcare from the perspectives of intervention users and deliverers to gain insight into the acceptability and usability of telecare devices. The author has focused on ongoing telecare projects in the Netherlands, designed for people with asthma, cancer, COPD, diabetes, and heart failure. She also draws on resources from conferences, consumer panels, secondary research (from the UK, Spain and Norway), and document analysis. Observation of both the patients and providers using telecare devices in their daily life and work practices was augmented by interviews with telecare implementers. The ethnographic approach allowed the researcher to witness participants in action using the technological device.
The book focuses on three types of innovative care practices: an automated device linked to a telephone for monitoring symptoms; webcam supported management, allowing for social support via peer interactions; and a monitoring device for people with heart failure (facilitated by call centre nurses liaising with acute centre nurses). The author has made a clear distinction between telecare and telemedicine, and the latter has been excluded from the analysis. Telecare participants are actively engaged in refining care and strive to ‘make implicit practices explicit’. This concept is emphasised throughout the book. The author uses an elaboration of domestication theory – i.e. ‘the idea that people and objects shape each other in mutual relations’– to critically appraise the three telecare projects and to demonstrate how patients and carers adapt to fit technology into their daily activities. However, there is also the possibility that this can lead to total rejection of technology.
Most of the argument relates to how patients are constructed by telecare interventions – either as individual subject or as object. The author points to nurses’ concerns about the danger of overlooking patient’s symptoms, as telecare interventions challenge the notion of ‘seeing the patient’ as the gold standard for good nursing care. Nevertheless, nurses appreciated the additional contact afforded by telecare interventions and highlighted the opportunities that provided for early identification of exacerbations and/or deteriorations. Benefits of telecare can encompass both improvements in health and wellbeing of patients and reductions in nurses’ administrative tasks.
The book elucidates how both recipients and deliverers accept, adapt and interact with telecare, drawing on quotes from patients and healthcare professionals. The innovative care practices selected for study varied in terms of interactivity. The automated device empowered patients to monitor their signs and symptoms. The monitoring device involved a partnership, where patients measured their vital signs, but nurses interpreted the results and facilitated further interventions. The webcam allowed multiple interactions with health professionals and peer groups. A separate section detailing the three interventions would have been helpful in addition to the table provided in the appendix.
Although the book addresses some of the criticisms of telecare, celebration of success may be premature. There are still many issues that need to be addressed – particularly the question about effectiveness. The author’s view is that evaluation of innovative telecare practices requires a new approach. This is made explicit in the conclusion, where she discusses the lack of fit between RCTs and evaluation of innovative care practices. Being a proponent of evidence based healthcare, I would incorporate Pol’s guidelines (outlined on p.142) in the development stage of an innovative care practice, but would then proceed in accordance with MRC complex interventions guidance (http://www.mrc.ac.uk/complexinterventionsguidance). This is a great book that critically appraises various types of innovative practices and elucidates the practicalities involved in the delivery of telecare services. Healthcare researchers interested in developing novel telecare interventions can use its insights to refine interventions, or to develop user-friendly/acceptable telecare interventions.