There exists a tendency worldwide for telemedicine systems to be "driven" from the central bureaucracies with little thought for the clinicians with practical experience in the field, according to Dr. Yellowlees. Surprisingly few telemedicine applications have been embedded into a daily clinical service delivery system in which it is possible to critically assess the actual value of the system. The attention is barely concentrated on the end user and the outcome while the telemedicine system is being managed with a typical "top down" approach. Educational and training needs of the clinicians are neglected, resulting in a telemedicine workload on top of, rather than instead of, the normal clinical tasks.
Apart from the central decision making, a bureaucratically organised project team tends to focus on policy before practice. Usually, the large number of technical demonstrations is not really the most suitable method to promote the actual clinical use of telemedicine. In addition, Dr. Yellowlees finds these groups traditionally being too over-concerned with respect to ethical, legal, and confidentiality issues in relation to innovative applications. They should more worry about privacy and security in normal clinical practices instead. In turn, clinicians have a typical way of learning experimentally, an attitude which might stimulate their enthusiasm to explore the unknown potential of telemedicine in a familiar clinical setting.
Contrarily to what one would logically think, a decision to allocate advanced telemedicine services to the isolated, rural communities where the needs are greatest, most of the time calls for failure. The experience has convinced Dr. Yellowlees that it is far better to identify the "clinician drivers" in a specified geographical area, in order to assess their personal interest and competence. In practice, reasonably sized centres have to be preferred to the remoteness of a community with little or no trained health care personnel. Also, clinicians initially can be intimidated by too largely set up telemedicine centres. The service has to be user-friendly and readily available, otherwise, it will not be used. A simple video-conferencing system, integrated into the clinical setting will have more success than a real telemedicine centre.
Dr. Yellowlees equally deplores the fact that clinicians often do not have any recompense for the time they spend on telemedicine, and are not offered any special training in communication skills, nor specific support in technical or administrative matters. This is extremely demoralising for the worker in the field. The last issue concerns over-evaluation of each installed telemedicine system. Though it be true that high quality academically driven evaluation is crucial for telemedicine to progress, Dr. Yellowlees does not believe in an extensive questionnaire after each telemedicine session. We should start to look for a more creative approach to assess systems, which is not just based on activity statistics. Successful telemedicine implementation requires us to take into account factors like enhanced quality of patient care and improved skills in clinicians.