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Some predict that telemedicine will profoundly transform the delivery of health services in the industrialized world by migrating health care delivery away from hospitals and clinics into homes (13). In low-income countries and in regions with limited infrastructure, telemedicine applications are primarily used to link health-care providers with specialists, referral hospitals, and tertiary care centres (13). Even though low-cost telemedicine applications have proven to be feasible, clinically useful, sustainable, and scalable in such settings and underserved communities, these applications are not being adopted on a significant scale due to a variety of barriers (14). 1.4 Potential barriers to telemedicine diffusion Telemedicine holds great potential for reducing the variability of diagnoses as well as improving clinical management and delivery of health care services worldwide by enhancing access, quality, efficiency, and cost-effectiveness (4, 13). In particular, telemedicine can aid communities traditionally underserved – those in remote or rural areas with few health services and staff – because it overcomes distance and time barriers between health-care providers and patients (4). Further, evidence points to important socioeconomic benefits to patients, families, health practitioners and the health system, including enhanced patient-provider communication and educational opportunities (15). Despite its promise, telemedicine applications have achieved varying levels of success. In both industrialized and developing countries, telemedicine has yet to be consistently employed in the health care system to deliver routine services, and few pilot projects have been able to sustain themselves once initial seed funding has ended (14). Several routinely cited challenges account for the lack of longevity in many telemedicine endeavours. One such challenge is a complex of human and cultural factors. Some patients and health careworkers resist adopting service models that differ from traditional approaches or indigenous practices, while others lack ICT literacy to use telemedicine approaches effectively. Most challenging of all are linguistic and cultural differences between patients (particularly those underserved) and service providers (4, 6, 13). A shortage of studies documenting economic benefits and cost-effectiveness of telemedicine applications is also a challenge. Demonstrating solid business cases to convince policy-makers to embrace and invest in telemedicine has contributed to shortcomings in infrastructure and underfunding of programmes (4). Legal considerations are a major obstacle to telemedicine uptake. These include an absence of an international legal framework to allow health professionals to deliver services in different jurisdictions and countries; a lack of policies that govern patient privacy and confidentiality visà-vis data transfer, storage, and sharing between health professionals and jurisdictions (16–18); health professional authentication, in particular in e-mail applications (17, 19); and the risk of medical liability for the health professionals offering telemedicine services (20). Related to legal considerations are technological challenges. The systems being used are complex, and there is the potential for malfunction, which could trigger software or hardware failure.
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