Some Multidimensional Unintended Consequences of Telehealth Utilization: A Multi-Project Evaluation Synthesis

Document Type : Original Article


1 Institute of Health and Social Services in Primary Care, Research Center on Healthcare and Services in Primary Care, Laval University, Quebec City, QC, Canada

2 Research Center of Quebec City University Hospital Center, St-François d’Assise Hospital, Quebec City, QC, Canada

3 Faculty of Nursing Science, Laval University, Quebec City, QC, Canada

4 Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec City, QC, Canada


Telehealth initiatives have bloomed around the globe, but their integration and diffusion remain challenging because of the complex issues they raise. Available evidence around telehealth usually deals with its expected effects and benefits, but its unintended consequences (UCs) and influencing factors are little documented. This study aims to explore, describe and analyze multidimensional UCs that have been associated with the use of telehealth.
We performed a secondary analysis of the evaluations of 10 telehealth projects conducted over a 22-year period in the province of Quebec (Canada). All material was subjected to a qualitative thematic-pragmatic content analysis with triangulation of methodologies and data sources. We used the conceptual model of the UCs of health information technologies proposed by Bloomrosen et al to structure our analysis.
Four major findings emerged from our analysis. First, telehealth utilization requires many adjustments, changes and negotiations often underestimated in the planning and initial phases of the projects. Second, telehealth may result in the emergence of new services corridors that disturb existing ones and involve several adjustments for organizations, such as additional investments and resources, but also the risk of fragmentation of services and the need to balance between standardization of practices and local innovation. Third, telehealth may accentuate power relations between stakeholders. Fourth, it may lead to significant changes in the responsibilities of each actor in the supply chain of services. Finally, current legislative and regulatory frameworks appear ill-adapted to many of the new realities brought by telehealth.
This study provides a first attempt for an overview of the UCs associated with the use of telehealth. Future research-evaluation studies should be more sensitive to the multidimensional and interdependent factors that influence telehealth implementation and utilization as well as its impacts, intended or unintended, at all levels. Thus, a consideration of potential UCs should inform telehealth projects, from their planning until their scaling-up.


Main Subjects

  1. Ministère de la Santé et des Services sociaux. Table ministérielle en télésanté: vision, orientations et stratégies de développement de la télésanté au Québec. Quebec: Ministère de la Santé et des Services sociaux; 2001:116.
  2. Fatehi F, Gray LC, Russell AW. Telemedicine for clinical management of diabetes - a process analysis of video consultations. J Telemed Telecare. 2013;19(7):379-382. doi:10.1177/1357633x13506524
  3. Potter AJ, Mueller KJ, Mackinney AC, Ward MM. Effect of tele-emergency services on recruitment and retention of US rural physicians. Rural Remote Health. 2014;14(3):2787.
  4. Liu CK, Hsu CY, Yang FY, Wu J, Kuo K, Lai P. Population health management outcomes obtained through a hospital-based and telehealth informatics-enabled telecare service. IEEE Biomedical Circuits and Systems Conference (BioCAS); 2017. doi:10.1109/BIOCAS.2017.8325127
  5. Alami H, Gagnon MP, Wootton R, Fortin JP, Zanaboni P. Exploring factors associated with the uneven utilization of telemedicine in Norway: a mixed methods study. BMC Med Inform Decis Mak. 2017;17(1):180. doi:10.1186/s12911-017-0576-4
  6. Barr N, Vania D, Randall G, Mulvale G. Impact of information and communication technology on interprofessional collaboration for chronic disease management: a systematic review. J Health Serv Res Policy. 2017;22(4):250-257. doi:10.1177/1355819617714292
  7. Sweeney Haney T, Kott K, Rutledge CM, Britton B, Fowler CN, Poston RD. How to Prepare Interprofessional Teams in Two Weeks: An Innovative Education Program Nested in Telehealth. Int J Nurs Educ Scholarsh. 2018;15(1). doi:10.1515/ijnes-2017-0040
  8. Alami H, Fortin JP, Gagnon MP, Pollender H, Tetu B, Tanguay F. The challenges of a complex and innovative telehealth project: a qualitative evaluation of the eastern Quebec Telepathology network. Int J Health Policy Manag. 2017;7(5):421-432. doi:10.15171/ijhpm.2017.106
  9. Greenhalgh T, Wherton J, Papoutsi C, et al. Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. J Med Internet Res. 2017;19(11):e367. doi:10.2196/jmir.8775
  10. Greenhalgh T, Russell J, Ashcroft RE, Parsons W. Why national eHealth programs need dead philosophers: Wittgensteinian reflections on policymakers' reluctance to learn from history. Milbank Q. 2011;89(4):533-563. doi:10.1111/j.1468-0009.2011.00642.x
  11. Bloomrosen M, Starren J, Lorenzi NM, Ash JS, Patel VL, Shortliffe EH. Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting. J Am Med Inform Assoc. 2011;18(1):82-90. doi:10.1136/jamia.2010.007567
  12. Gogia SB, Maeder A, Mars M, Hartvigsen G, Basu A, Abbott P. Unintended Consequences of Tele Health and their Possible Solutions. Contribution of the IMIA Working Group on Telehealth. Yearb Med Inform. 2016(1):41-46. doi:10.15265/iy-2016-012
  13. Alami H, Lamothe L, Fortin JP, Gagnon MP. Telehealth implementation and the sustainability of its use in Canada: A few lessons to remember. [L’implantation de la télésanté et la pérennité de son utilisation au Canada: quelques leçons à retenir]. European Research in Telemedicine / La Recherche Européenne en Télémédecine. 2016;5(4):105-117. doi:10.1016/j.eurtel.2016.10.001
  14. McGowan JJ, Cusack CM, Bloomrosen M. The future of health IT innovation and informatics: a report from AMIA's 2010 policy meeting. J Am Med Inform Assoc. 2012;19(3):460-467. doi:10.1136/amiajnl-2011-000522
  15. Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care--an interactive sociotechnical analysis. J Am Med Inform Assoc. 2007;14(5):542-549. doi:10.1197/jamia.M2384
  16. Rahadhan P, Poon SK, Land LPW. Issues of Unintended Consequences of Electronic Medical Records: A Proposed Study Framework. Pacific Asia Conference on Information Systems (PACIS) Proceedings. 2012.  Accessed March 4, 2019.
  17. Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The extent and importance of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2007;14(4):415-423. doi:10.1197/jamia.M2373
  18. Weiner JP, Kfuri T, Chan K, Fowles JB. "e-Iatrogenesis": the most critical unintended consequence of CPOE and other HIT. J Am Med Inform Assoc. 2007;14(3):387-388; discussion 389. doi:10.1197/jamia.M2338
  19. Zheng K, Abraham J, Novak LL, Reynolds TL, Gettinger A. A Survey of the Literature on Unintended Consequences Associated with Health Information Technology: 2014-2015. Yearb Med Inform. 2016(1):13-29. doi:10.15265/iy-2016-036
  20. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11(2):104-112. doi:10.1197/jamia.M1471
  21. Ash JS, Sittig DF, Dykstra R, Campbell E, Guappone K. The unintended consequences of computerized provider order entry: findings from a mixed methods exploration. Int J Med Inform. 2009;78 Suppl 1:S69-76. doi:10.1016/j.ijmedinf.2008.07.015
  22. Holden RJ. Cognitive performance-altering effects of electronic medical records: An application of the human factors paradigm for patient safety. Cogn Technol Work. 2011;13(1):11-29. doi:10.1007/s10111-010-0141-8
  23. Khajouei R, Wierenga PC, Hasman A, Jaspers MW. Clinicians satisfaction with CPOE ease of use and effect on clinicians' workflow, efficiency and medication safety. Int J Med Inform. 2011;80(5):297-309. doi:10.1016/j.ijmedinf.2011.02.009
  24. Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. BMJ Qual Saf. 2015;24(4):264-271. doi:10.1136/bmjqs-2014-003555
  25. Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):547-556. doi:10.1197/jamia.M2042
  26. Sveiby K, Gripenberg P, Segercrantz B, Eriksson A, Aminoff A. Unintended and undesirable consequences of innovation. Vienna: XX ISPIM conference, The Future of Innovation; 2009:21-24.
  27. Andreassen HK. Unintended Consequences of Telemedicine Implementation. Lisbon: eTELEMED; 2015:39-40.
  28. Dale A. Le rôle de l'analyse secondaire dans la recherche en sciences sociales. Sociétés contemporaines. 1993;14(1):7-21.
  29. Duchesnes S.  L’analyse secondaire des enquêtes qualitatives: vers de nouvelles expérimentations ou une normalisation accrue de l’activité de recherche? Congrès de l’Association française de sociologie. 2015.  Accessed July 7, 2018.
  30. Merckle P. Analyse secondaire des données qualitatives: Une question méthodologique aux enjeux multiples. Calenda; 2009.
  31. Agboola S, Hale TM, Masters C, Kvedar J, Jethwani K. "Real-world" practical evaluation strategies: a review of telehealth evaluation. JMIR Res Protoc. 2014;3(4):e75. doi:10.2196/resprot.3459
  32. Miles MB, Michael Huberman A, Saldana J. Qualitative Data Analysis: A Methods Sourcebook. 3rd ed. CA: Sage; 2013.
  33. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
  34. Aronson J. A pragmatic view of thematic analysis. Qual Rep. 1995;2(1):1-3.
  35. Paille P. De l’analyse qualitative en générale et de l’analyse thématique en particulier. Recherches Qualitatives. 1996;15:179-194
  36. Paille P, Mucchielli A. L'analyse qualitative en sciences humaines et sociales. Armand Colin; 2012. doi:10.3917/arco.paill.2012.01
  37. Thurmond VA. The point of triangulation. J Nurs Scholarsh. 2001;33(3):253-258.
  38. Hunting G, Shahid N, Sahakyan Y, et al. A multi-level qualitative analysis of Telehomecare in Ontario: challenges and opportunities. BMC Health Serv Res. 2015;15:544. doi:10.1186/s12913-015-1196-2
  39. Farmer T, Robinson K, Elliott SJ, Eyles J. Developing and implementing a triangulation protocol for qualitative health research. Qual Health Res. 2006;16(3):377-394. doi:10.1177/1049732305285708
  40. Fleiszer AR, Semenic SE, Ritchie JA, Richer MC, Denis JL. The sustainability of healthcare innovations: a concept analysis. J Adv Nurs. 2015;71(7):1484-1498. doi:10.1111/jan.12633
  41. Alami H, Gagnon MP, Fortin JP. Telehealth in light of cloud computing: clinical, technological, regulatory and policy issues. Journal of the International Society for Telemedicine and eHealth2016;4:1-7.
  42. Alami H, Gagnon MP, Fortin JP, Kouri R. La télémédecine au Québec: état de la situation des considérations légales, juridiques et déontologiques. European Research in Telemedicine / La Recherche Européenne en Télémédecine. 2015;4(2):33-43.
  43. Gerbet T. Des hôpitaux canadiens sous-traitent les analyses radiologiques en Inde. Radio-Canada website.  Published May 4, 2017. Accessed September 2, 2017.
  44. Ash JS, Sittig DF, Dykstra RH, Guappone K, Carpenter JD, Seshadri V. Categorizing the unintended sociotechnical consequences of computerized provider order entry. Int J Med Inform. 2007;76 Suppl 1:S21-27. doi:10.1016/j.ijmedinf.2006.05.017
  45. Gagnon MP, Fortin JP, Cloutier A. La télémédecine au service des régions: étude évaluative d'un projet de télésanté aux Îles-de-la-Madeleine. Ruptures. 2001;8(2):53-70.
  46. Fortin JP, Labbe F, Gagnon MP, Lamothe S. Projet pilote d’intégration de la télémédecine en services préhospitaliers d’urgence, région de la Chaudière-Appalaches (UCCSPU/télémétrie): rapport d’évaluation. Quebec: Agence de la santé et des Services Sociaux de Chaudière-Appalaches; 2011.
  47. Gagnon MP, Duplantie J, Fortin JP, Landry R. Implementing telehealth to support medical practice in rural/remote regions: what are the conditions for success? Implement Sci. 2006;1:18. doi:10.1186/1748-5908-1-18
  48. Wilson L. National Digital Health Strategy: A submission to the Australian Digital Health Agency. Australia: Australasian Telehealth Society; 2017.
  49. Greenhalgh T, Wherton J, Papoutsi C, et al. Analysing the role of complexity in explaining the fortunes of technology programmes: empirical application of the NASSS framework. BMC Med. 2018;16(1):66. doi:10.1186/s12916-018-1050-6
  50. van Dyk L. A review of telehealth service implementation frameworks. Int J Environ Res Public Health. 2014;11(2):1279-1298. doi:10.3390/ijerph110201279
  51. Khoja S, Durrani H, Scott RE, Sajwani A, Piryani U. Conceptual framework for development of comprehensive e-health evaluation tool. Telemed J E Health. 2013;19(1):48-53. doi:10.1089/tmj.2012.0073
  52. Venkatesh V, Morris MG, Davis GB, Davis FD. User acceptance of information technology: Toward a unified view. MIS Q. 2003;27(3):425-478. doi:10.2307/30036540
  53. Lau F, Price M, Keshavjee K. From benefits evaluation to clinical adoption: making sense of health information system success in Canada. Healthc Q. 2011;14(1):39-45.
  54. Wade V, Gray L, Carati C. Theoretical frameworks in telemedicine research. J Telemed Telecare. 2017;23(1):181-187. doi:10.1177/1357633x15626650
  55. Greenhalgh T, Shaw S, Wherton J, et al. Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study. J Med Internet Res. 2018;20(4):e150. doi:10.2196/jmir.9897
  56. Legare E, Vincent C, Lehoux P, et al. Telehealth readiness assessment tools. J Telemed Telecare. 2010;16(3):107-109. doi:10.1258/jtt.2009.009004
  57. Khoja S, Scott RE, Casebeer AL, Mohsin M, Ishaq AF, Gilani S. e-Health readiness assessment tools for healthcare institutions in developing countries. Telemed J E Health. 2007;13(4):425-431. doi:10.1089/tmj.2006.0064
  58. Nohr C, Villumsen S, Bernth Ahrenkiel S, Hulbaek L. Monitoring Telemedicine Implementation in Denmark. Stud Health Technol Inform. 2015;216:497-500.
  59. NST EKC, NST EH, Kvistgaard L, di Giuseppe G, Lopriore C. European Momentum for Mainstreaming Telemedicine Deployment in Daily Practice (Grant Agreement No 297320) Deliverable 3.2 Towards a Personalised Blueprint-for doers, by doers: consolidated version.  Accessed July 7, 2018. Published December 2014.
  60. Scott RE, Mars M. Principles and framework for eHealth strategy development. J Med Internet Res. 2013;15(7):e155. doi:10.2196/jmir.2250
  61. DeGaetano N, Shore J. Conducting a telehealth needs assessment. In: Tuerk PW, Shore P, eds. Clinical videoconferencing in telehealth: Program development and practice. Springer; 2015:23-54.
  62. van Limburg M, van Gemert-Pijnen JE, Nijland N, Ossebaard HC, Hendrix RM, Seydel ER. Why business modeling is crucial in the development of eHealth technologies. J Med Internet Res. 2011;13(4):e124. doi:10.2196/jmir.1674
  63. Maeder A. Applying change management metaphors to a national e-Health strategy. Global Telehealth 2014. 2014;206:62
  64. Khoja S, Durrani H, Nayani P, Fahim A. Scope of policy issues in eHealth: results from a structured literature review. J Med Internet Res. 2012;14(1):e34. doi:10.2196/jmir.1633
  65. Vassilev I, Rowsell A, Pope C, et al. Assessing the implementability of telehealth interventions for self-management support: a realist review. Implement Sci. 2015;10:59. doi:10.1186/s13012-015-0238-9
  66. Al-Qirim NA. Critical success factors for strategic telemedicine planning in New Zealand. Telemed J E Health. 2005;11(5):600-607. doi:10.1089/tmj.2005.11.600
  67. Rush KL, Hatt L, Gorman N, Janicki L, Polasek P, Shay M. Planning telehealth for older adults with atrial fibrillation in rural communities: understanding stakeholder perspectives. Clin Nurs Res. 2019;28(2):130-149. doi:10.1177/1054773818758170
  68. AlDossary S, Martin-Khan MG, Bradford NK, Armfield NR, Smith AC. The Development of a Telemedicine Planning Framework Based on Needs Assessment. J Med Syst. 2017;41(5):74. doi:10.1007/s10916-017-0709-4
  69. Peters DH, Adam T, Alonge O, Agyepong IA, Tran N. Implementation research: what it is and how to do it. BMJ. 2013;347:f6753. doi:10.1136/bmj.f6753
  70. Strauss AL. Qualitative analysis for social scientists. New York: Cambridge University Press; 1987. doi:10.1017/CBO9780511557842
Volume 8, Issue 6
June 2019
Pages 337-352
  • Receive Date: 26 February 2018
  • Revise Date: 24 February 2019
  • Accept Date: 25 February 2019
  • First Publish Date: 01 June 2019