the health care system, including insurance coverage. User preferences may also be considered. For example, if color is preferred to black and white video, user aesthetic preferences may be relevant to decisionmakers considering video options. Even if a strategy may fail without such accommodation, financial considerations will undoubtedly affect the extent to which decisionmakers are willing to accommodate user preferences.

One pressing challenge is to develop methods and tools for assessing potential users' needs and for matching characteristics of particular telemedicine technologies to these needs. One study that attempted to determine clinicians' information needs employed a multidisciplinary evaluation team that (1) directly observed a randomized sample of clinicians for an eight-week period, (2) developed a process flowchart to identify process deficiencies and information requirements, (3) conducted semi-structured interviews, and (4) surveyed a larger group of clinicians to assess their experience with computers and their perceptions about the value of information system options (Tang et al., 1995). The results indicated not just a need for simple patient information but a need for information that was integrated, analyzed, and available when clinical decisions are actually being made.

Cultural and Socioeconomic Factors

Professional Culture and Image

Health care professionals take many of their cues from their colleagues. Thus, acceptance of a new technology by peers as well as opinion leaders may determine a clinician's receptivity to new practices. Most physicians have, however, developed referral patterns to specialists and subspecialists whom they know personally and see periodically on a face-to-face basis in professional or social settings. Telemedicine may disrupt this "culture" and perhaps damage local colleagues economically, as noted below.

In addition, appearances are important in the healing arts, and clinicians may be as concerned and self-conscious as anyone else about their appearance on camera. Because confidence is thought to be reassuring to patients and may, in and of itself, affect patient outcomes, clinicians may be concerned about the possibility that electronic media could weaken the patient's trust.

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