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Telemedicine usage in France and the U.S: an exploratory investigation using the technology acceptance model.
Subject:
Medical laboratory technology (Analysis)
Medical technology (Analysis)
Telemedicine (Analysis)
Authors:
Edwards, Jude E.
Halawi, Leila A.
Pub Date:
09/01/2007
Publication:
Name: International Journal of Business Research Publisher: International Academy of Business and Economics Audience: Academic Format: Magazine/Journal Subject: Business, international Copyright: COPYRIGHT 2007 International Academy of Business and Economics ISSN: 1555-1296
Issue:
Date: Sept, 2007 Source Volume: 7 Source Issue: 5
Geographic:
Geographic Scope: France; United States Geographic Code: 4EUFR France; 1USA United States

Accession Number:
178945804
Full Text:
ABSTRACT

Telemedicine represents a broad range of medical applications including education and distance learning, diagnosis, treatment and prevention of disease, exchanging of information with healthcare providers and consumers, research, and evaluation. These functions and more can be accomplished and performed from a distance when a robust information communication infrastructure is deployed. This article is an exploratory study that seeks to determine the levels of telemedicine usage utilizing technology acceptance model (TAM) as its theoretical basis.

Keywords: Technology Acceptance model, e-Commerce; e-Readiness, Diffusion, Tele-Health Networks, Telemedicine, Hard Technologies, Hospital Primary Care Networks.

1. INTRODUCTION

In the civilian world, telemedicine has made many advances around the world. Canada has continued a steady approach to telemedicine as a way of delivering health care services to its geographically dispersed and culturally diverse population (McDonald-Rencz, Cradduck, and Parker-Taillon, 2004 ; Cloutier, 2004). The government of the United Kingdom continues to support numerous Telemedicine initiatives across a wide range of eHealth care services. France has also used Telemedicine and robotics to facilitate surgical procedures. In the U.S. many rural communities are using a variety of telemedicine application to deliver health care services. For example, the U.S. Department of Agriculture recently approved $128 Million for distance learning associated with Telemedicine (USDA Press Release, April 11, 2007).

The roots of telemedicine go back centuries, when medical care was limited to the radius in which the physician was available to deliver medical services. Thus, as the distance between patient and physician played a large role in driving the costs of healthcare, and the volume of healthcare service delivery, it soon became apparent that patients and providers had to be co-located in order to optimize the delivery of health care services. With the advent of the telephone, medical communications was accomplished. The telephone system became the vehicle or the medium that enabled physicians to provide medical information to their patients.

Within the last seventy-five years, in which numerous wars were fought (WWI, WWII, Korea and Vietnam) wide spread use of radio also enabled the transfer of medical information and services across the battle field, and between forward battle positions and field hospitals. Widespread use and acceptance of, and diffusion of a broad range of different technologies have certainly facilitated the growth and delivery of medical services on the battle field.

The key aspect of telemedicine is the use of electronic signals to transfer information from one site to another. At the core of any successful telemedicine initiative then is a robust telecommunications infrastructure that facilitates delivery of health care services. Hence, the delivery of healthcare services is no longer limited by the location of patients and service providers, but it may be linked to the level of technology diffusion or acceptance in the areas where the patient is located. The question then to be addressed is: "are levels of telemedicine practice directly linked to levels of technology acceptance or diffusion in those areas where telemedicine is practiced?" To address this question, we will compare the evolution and practice of telemedicine in France and the U.S. The primary objective of this study is to assess the use of telemedicine in France and the U.S utilizing the technology acceptance model (TAM).

We begin with a brief definition of Telemedicine and list examples of different types of Telemedicine systems. We follow this by a description of Technology Acceptance. The paper then provides a brief but comprehensive description of the French Health Care System. Attention is given to its organization and finance. Selected Telemedicine applications in the U.S. are then discussed. Since this paper makes a comparison between Telemedicine in France and the U.S., the paper provides a short discussion on the differences and similarities between the French and the U.S. telemedicine programs. Some suggestions are presented to explain the different approaches to Telemedicine in both countries, within the context of technology acceptance model. Telemedicine trends in both countries are then discussed. The final section of this paper will seek to address what changes might have to be made to realize comparable Telemedicine system deployment. Areas for further research are also identified.

1.1 Definitions

The following are some of the key definitions and terms used in this article.

Telemedicine: Telemedicine can be defined broadly as the use of telecommunications technology to provide medical information and services (Zundel, 1996). Some Telemedicine applications or systems that are in service today include: Tele-Radiology, Tele-Pathology, Tele-Ophthalmology, Tele-Ultrasound, and Tele-Education. Figure 1 provides a pictorial representation of components associated with Telemedicine.

[FIGURE 1 OMITTED]

Tele-Health: Tele-health is the use of communications and information technology to deliver health and health care services and information over large and small distances. (Picot and Cradduck, 2000). Tele-Medicine Teaching and Education: Where instructors or professors of medicine can use medical image repositories to search for interesting cases, based on diagnosis or anatomical region but also on visual similarity, to present to their students.

Tele-Medicine Information: Where medical information, including image, extracted from a repository of a hospital or clinic, and a wealth of other valuable medical applications in diagnostics, research, and education, may be made available via the World Wide Web.

Hospital Primary Care Networks: Primary or base network center that generates the information needed for specialty referral and consultation, information for decision support and refinement of patient care plans, to facilitate orderly delivery of health care services to any patient.

E-Readiness: The evaluation that is undertaken by a country or community to determine its level of readiness for global electronic commerce. (Oxley & Yeung, 2001; APEC, 2001; McConnell & Docktor, 2001).

Hard Technologies: This may include equipment, factories, tools and other electrical and mechanical devices that are part of the technological infrastructure of a country.

Information Communication Technologies Infrastructure: A combination of various telecommunications media and computer equipment that are interconnected to facilitate electronic transmission of data and information.

Technology Adaptation: A process in which the original technology has been modified to meet or address the specific needs in a local community.

Technology Adoption: Technology is chosen by an organizational, corporate, or governmental level, as the standard application solution. It is a process in which senior members of the organization make the decision to adopt a particular technology as an organizational solution for a particular issue or set of issues.

Transportation Modality: A variety of ways that a country, or society, may employ to transport goods or information. These include: Pipelines, Railways, Air, Sea, Land/Roads, and Telecommunications (digital or analog).

2. TECHNOLOGY ACCEPTANCE MODEL (TAM)

The Technology Acceptance Model (TAM) (Davis, 1986, 1989) is an adaptation of the Theory of Reasoned Action (TRA) (Fishbein and Ajzen, 1975; Ajzen and Fishbein, 1980). According to Davis (1986, 1989) the positive perception of technology's (1) ease of use, (2) usefulness, and (3) attitudes towards technology usage are important determinants of the intention to use a given technology. Technology acceptance, in this case, Telemedicine, may be determined or measured by the End-Users' willingness to embrace and utilize a new or adaptation of existing technologies for specific application to telemedicine, in preference to an old technology (Davis, 1989). Figure 2 is a representation of the original TAM.

[FIGURE 2 OMITTED]

Davis (1989) observed that the user's experience with a particular technology is also a major contributing external factor, and that other external factors should be studied extensively in the future. However, some of these factors are yet to be fully investigated, particularly technology diffusion, or tele-density as a platform for Telemedicine. Figure 3 is a representation of Davis' modified TAM (TAM2) that shows the potential influence attributed to external variables. Using TAM2, and focusing on a number of inter- and extra-organizational variables, Igbaria, Zinatelli, Cragg, and Cavaye (1997) made a number of interesting discoveries relative to computing utilization. For them the external components were (a) internal computing support, (b) internal computing training, (c) management support, (d) external computing support, and (e) external computing training. They illustrated that these external factors do influence the degree of technology adoption and acceptance. Among other findings, it was determined that "external support has a direct positive effect on perceived ease of use and perceived usefulness". They went on to state that external support combined with management support are important factors that can contribute to effective personal computing implementation."

[FIGURE 3 OMITTED]

3. OVERVIEW OF THE FRANCE HEALTH CARE SYSTEM

Modern France has one of the "universal" health care systems in the world and is a leader among European nations. It offers a "high quality services and is easily accessible at the same time". Arguably, the modern French Health Care systems emerged out of the political and social dynamics of World War II, as France transitioned from a colonial power to European Union builder. According to Green and Irvine, (2001) "France has a reputation for state direction and protectionism, but the French healthcare system is based on a compromise between two conflicting ideologies, egalitarianism [in which every one has equal access to healthcare; and liberalism--in which personal choices and competition still exist]".

In France, every employed individual, regardless of the level of employment, is covered by a national health insurance plan known as securite sociale (Social Security). Coverage extends to spouses and children too. People who are not entitled to securite sociale are required to take out special coverage, known as assurance personelle (Personal Insurance). However, many people also choose to purchase additional insurance to complement or supplement their existing national health insurance plan. Thus the French health care system is a unique blend of private and public delivery of Health Care services. Rodwin and Pen (2004) argue that "French policymakers typically view their National Health Insurance system as a realistic compromise between Britain's National Health Service, which they believe requires too much rationing and offers insufficient choice, and the mosaic of subsystems in the United States, which they consider socially irresponsible because 15 percent of the population younger than 65 years of age has no health insurance".

The French health care system is mainly financed by social insurance but there is also a significant supplementary insurance. About two-thirds of hospital beds are in the public sector with the remainder split between the for-profit and non-profit private sectors. Along with much of the developed world, the French authorities have been trying to control government spending. While France has a universal public health insurance system, the coverage it provides is incomplete and the vast majority of the French population has private complementary health insurance, (Buchmueller and Couffinhal, 2004). Private coverage accounts for 12% of total health spending. Given the extent of private coverage and its importance as a source of financing care, an understanding of private health insurance is essential for understanding France's health system and the policy challenges it faces.

3.1 Telemedicine Systems in France

Early French experiences with telemedicine go back to the mid 1940's. It was during that time that the Centre of Maritime Health Care offered a variety of consultation services which represented their initial foray into telemedicine (Sosa-Iudicissa, Wootton, and Ferrer-Roca, 2001). During the 1960's, France experienced significant growth in the use of telephone and radiophone consultations for health care purposes. This growth led to the creation of the SAMU (Service d'Aide Medical d'Urgence) in 1968 and the SAMUR (Service Mobile d'Urgence et Reanimation), which represented important milestones in the history of telemedicine in France. While these organizations did not regulate Telemedicine, they created the framework that enabled Telemedicine in France to have advanced to the degree that it has today. By 1970, fifteen regional health centers were electronically interconnected. In 1984, definitions and regulations concerns about medical private records were established. Standards were also established for telephone numbers assigned for medical services, law enforcement, fire and rescue, and other emergency response agencies.

Since the late 1990's to date, France, being one of the co-founder of the European Community, implemented a number of programs that have catapulted France into the forefront of Telemedicine, not only in Europe but worldwide. France adopted the recommendation of the European Community to implement a single European emergency call number, viz. 112, so that each member county will now have a common emergency number. This is somewhat similar to the 911 emergency number in the U.S. An important milestone was created in 1989 in which the European Institute of Telemedicine, in Toulouse, became heavily involved in a number of European and international telemedicine projects. Some of these projects included: (a) teaching health care professionals using appropriate telecommunication systems; (b) research designed with a view to harmonize training schemes or research programs for telemedicine. (c) Surgical procedures using remotely controlled robots; (d) automated and multi-user-oriented pooling of digital orthopedic procedures (Lareng, 2001).

France has taken many steps to extend telemedicine applications. According to Moore (2002), a team of French and American doctors and engineers used and controlled a robotic system to operate and remove a gall bladder on a patient in a Strasbourg, a France hospital. Also in 2001/2002 an agreement was signed between the Medical Director in French Guiana and the French National Center for Space Studies to establish a Medical Tele-consultation system to cover remote areas in French Guiana. "Since 2000, CNES, MEDES (for MEDEcine Spatiale--Space medicine) and the Centre Hospitalier Andree Rosemon de Cayenne (CHC) have been working together on the contribution of Space systems to public health matters in French Guiana.

Given all that France has accomplished in the area of Telemedicine, it is inconceivable that further advancements will be tempered only by advances in medical technology. With France being a technological leader in Europe and the world, with wide spread technology acceptance in France and adoption in French colonies, it is possible that France may first test some of these technologies in the colonies before wide spread implementation on the continent.

4. THE U.S. HEALTH CARE SYSTEM

Perhaps, driven by the "market-oriented economy of the U.S., the U.S health Care System is a "blend of public and private involvement in the delivery of health care services" (Shi and Singh, 2004). This blend of health care systems delivers a combination of services that result in:

* A multiplicity of financial arrangements

* Numerous insurance agencies that employ a variety of mechanism to hedge against risks

* Multiple payers that make their own determinations regarding how much to pay for each service

* A large array of setting for each service

* Numerous consulting firms that offer their expertise in planning, cost containment, quality of service, and restructuring.

There are ten basic characteristics that make the American health care system unique. These characteristics are listed as follows:

1. There is no central agency that governs the system

2. Access to the health care system is selectively determined by the level of insurance coverage.

3. Health care services are delivered within an imperfect market (where for example the patient is severely at a disadvantage with respect to many dynamics that occur within the health care system)

4. The insurers act as a intermediary between the financing and delivery functions.

5. The existence of multiple payers makes the system cumbersome

6. Balancing of power between various entities makes it difficult for any one entity to have a dominate position

7. Legal risks influence how providers deliver their services

8. Development of new technologies create a demand for their use

9. New service setting have evolved along a continuum of health care (from preventative to end-of-life care)

10. Quality and standards are now looked upon as integral components of the health care system

According to Shi and Singh (2004), there is little standardization within the U. S. health care system; thus we are confronted with a system that is fragmented where the various components fit together in a very loose manner. The health care system in the U.S is financed through (1) Voluntary payers--for those who can afford to pay for health care services; (2) A Multi-payer system that include premiums or general taxes. At this level there are health care insurance services that provide coverage for most employees and their immediate dependants; and (3) Government sponsored (Medicare and Medicaid)--where many that are "under-insured" or "un-insured" rely mainly on this netting to cover basic health care services.

4.1 Telemedicine Systems in the U.S.

In the U.S. Telemedicine has its root back in the 1960's when technology acceptance (particularly Electronic Data Processing systems) began to influence almost every area of society and business processes in general. In the 1970's telemedicine received a tremendous boost from manned space-flight program when Lockheed Missile and Space (now Lockheed Martin) and National Aeronautics and Space Administration (NASA) doctors demonstrated that they provide health care services to people with severe health problems, but who had difficulties accessing health care services. In 1990, Maritime Health Services (MHS), based in Seattle, Washington, initiated a program that allowed medical officers on board fishing trawlers to communicate directly with shore-based physicians as needed, around the clock (Zundel, 1996). In an effort to overcome time and distance barriers, National Aeronautics and Space Administration (NASA) doctors demonstrated that "physiological functions for astronauts in space could be monitored successfully by physicians on earth, NASA's scientists, engineers, and contractors developed sophisticated biomedical telemetry and telecommunications systems for biomedical applications" (Zundel, 1996).

Thus, as electronic data systems proliferated throughout the 1970's, 1980's, 1990's and into the 21st century, and with technology becoming more user friendly, accepted and reliable, medical and health telemedicine usage is becoming more accepted in the U.S..

It may be argued that there are many Telemedicine applications and initiatives that are currently underway in the U.S. that spawn the range of health care applications from Robotic Surgery to basically providing health care information via some hand-held telecommunications devices. However there are three basic areas of telemedicine that are worthy listing: (a) NASA's Telemedicine applications with terrestrial based applications; (b) Telemedicine application in Disaster Response; and (c) Telemedicine in the area of Home Health Care.

NASA Telemedicine Applications: One of the early proponents and users of Telemedicine systems was NASA. Starting in the early 1970's and continuing through to day, NASA has been testing and implementing telemedicine capabilities. Nicogossian, Pober, and Roy (2001) noted that NASA has carried out the majority of terrestrial telemedicine activities in collaboration with other organizations that included: (a) U.S department of Health and Human Services; (b) the Indian Health Service; (c) Medical Informatics and Technology Applications Consortium Commercial Space Center located at the Virginia Commonwealth University; (d) East-West Space Science Center (EWSSC) and the (e) Uniformed Services University of the Health Science; and (f) U.S. Department of Education.

Telemedicine in Disaster Response: In the area of Disaster Medicine, NASA was also the first to use telecommunication technologies to furnish disaster aid following the 1985 earthquake disaster in Mexico City. NASA has also teamed up with the USSR to create a "Space Bridge Project to provide consultation in the areas of neurology, orthopedics, psychiatry, infections disease, and general surgery (Garshnek, and Burkle, 1999).

Telemedicine in Home Health Care: According to Lisetti and LeRouge (2004) Home health Care in the U.S. is "the fastest-growing section of the health care market in the United States". "According to the National Association for Home Care, more than 20,000 medical professionals provided approximately 7.6 million people in the U.S. home care services for acute illness, long-term health conditions, permanent disability, or terminal illness [National Association of systems, vital sign monitoring devices, video conferencing, medication reminder systems, web-based systems and interactive communications systems (synchronous or asynchronous).

To address these health care services, three common forms of interactive healthcare communication system were used: (1) A Video Tele-health System that consists of a videophone, telephone with speakerphone, and electronic peripheral devices including a blood pressure cuff and pulse monitor, stethoscope-sending unit, and thermometer; (2) In Home Messaging Device that connects to a patient's existing home telephone line and allows patients to view questions and reminders from their health care provider; and (3) Health Care Chat Line that allows patients to log into a private Internet site from their home computer at a designated time. In this way a private synchronous communication conversation/discussion may be accomplished with their physician or clinician.

Telemedicine: Rural America Healthcare Delivery: In a report that described healthcare challenges and opportunities in Rural America, Matthews and Woodwell (2005) noted that Telemedicine was in the forefront of delivering state of the art health care services across America's rural communities. Recognizing that the appropriate telecommunication and information infrastructure is vital for successful delivery of telemedicine in these rural communities, it was noted that several communities have taken the lead in accepting the key technologies to make delivery of telemedicine services a reality.

For example to stimulate the economic activity, Garrett County, Md., in cooperation, with the local community college has implemented high-speed Internet access to the region's businesses and individuals through the Garrett Rural Information Cooperative. Local community health care providers are exploiting this capability to facilitate delivery of a variety of IT health care related services.

Similarly, the state of Georgia has one of the largest telemedicine systems. This network that was started in 1987, now involves 60 sites, including rural community hospitals, an ambulatory center, a public health facility, and correctional institutions. Along with interactive patient consultation, the system enables rural physicians to acquire continuing medical education. A future goal of the project is to examine patients with chronic illness via interactive cable television in their homes. Originally financed through telephone company rate overcharges, the system has been expanded and maintained through the joint efforts of the phone companies, a medical college, and the Governor's office (Matthews and Woodwell 2005). Also in Georgia, in November 1991, the Medical College of Georgia introduced an alternative healthcare system-telemedicine in the State of Georgia. Utilizing an interactive voice and video telecommunication system integrated with biomedical diagnostic instrumentation, the telemedicine system allows a physician at a specialty referral hospital to examine a patient at a rural location. By electronically transporting the expertise at the referral hospital, the Telemedicine healthcare delivery system encompasses the following advantages:

* Providing immediate access to specialty consultation;

* Retaining the patient at the rural community hospital;

* Reducing delays in providing acute care;

* Maintaining continuity of care with the patient's primary care physician;

* Providing effective continuing medical education (distance learning), and

* Expanding medical capability as well as the ability to supervise non-physician healthcare personnel;

* Decreasing healthcare costs.

The impact of this system in the State of Georgia has been significant. Thirty (30) sites are currently operational in the state while more than 50 additional sites are planned. (State of Georgia--Rural Healthcare Plan, 2000)

While there are many Telemedicine initiatives currently underway, there are a few concerns that could limit the how deeply Telemedicine will penetrate the Health care profession.

* There is the concern that many rural communities, while desirous of participating in telemedicine health care service, may not have assess and connectivity to an appropriate ICT infrastructure that is capable of supporting needed services. Therefore it is necessary that these communities first invest in developing an appropriate ICT infrastructure (The Lewin Group, Inc., 2000)

* There is the concern that the introduction of new technology carries with it a degree of uncertainty on the part of system operators. Without the assurance of a robust information communications technology infrastructure, users will inevitably experience severe disruptions that will render systems inoperable (The Lewin Group, Inc., 2000)

* Third, there is the area of cost and reimbursement. At what rate(s) should the health care service provider, (those that uses telemedicine to augment delivery of health care services) be paid? Should they be paid or reimbursed at the normal rate when there is human intervention, versus a different rate when there is limited human intervention in a clinical procedure?

* Grisbey and Saunders (1998) observed that some limitations are linked to the concerns associated with liability and malpractice. There is the concern that using more telemedicine may further expose them to malpractice lawsuits. This situation may be compounded by interstate variability in the handling of malpractice claims.

* Finally, in the U.S. the process followed by the Food and Drug Administration may take close to ten years before medical technologies are brought into general use. According to Sorrel (2006) U.S. medical devices could take over three years while in France the process is much shorter. Kaplan et al (2004) explained that while the two countries may have a rigorous approach to certification of medical technologies, the U.S. approach is built upon the efficacy of the devices, while the French (European) approach is more focus on safety.

Thus deployment of telemedicine services is limited due to a variety of constraints. While rural communities are steadily making the necessary telecommunication investments to facilitate delivery if telemedicine services, the slow rate of device approval by the Food and Drug Administration is also a restraining factor. The uncertainty of reimbursement rates is also a restraining factor.

5. TRENDS AND FUTURE

There is a steady trend toward further use of telemedicine. While usage of telemedicine has rapidly increased over that last twenty years, it is still being used in a limited way. One may argue that this limited use may be attributed to some of the limitations discussed above. However it is expected that when cost-effective business models are used there will be more rapid growth in telemedicine usage. For example, currently a considerable amount of federal, state and private funding have been allocated to supported telemedicine in recent years; however legislators (federal, regional, and state policymakers) are struggling with "crafting" appropriate policies that will facilitate a more wide-spread and deeper telemedicine usage. While in the past research on the effectiveness of telemedicine might have been somewhat limited, it is safe to argue that NASA, the U.S. Army (in connection with evacuating wounded soldiers from the battle filed), and the private sector will continue to demand further telemedicine healthcare usage. However, the slow approval rate of technology in this area is likely to restrict the rate and levels of implementation.

6. CONCLUSION AND AREAS FOR FURTHER RESEARCH

There are many areas of telemedicine that both France and the U.S. are exploiting. In the U.S., NASA and the U.S. Army appears to have spearheaded the use and application by bringing medical treatments to the frontline or in combat zones. Telemedicine has also had significant usage in disaster response as well, particularly when the U.S. military is deployed in those disaster areas. However electronic credentialing of civilian health care professional to work in those areas has been a challenge. Recognizing that "credentialing" of health care professional is a central component that facilitate telemedicine, and with "credentialing" being done at the state level, expanded telemedicine utilization across state boundaries are thus limited. To date, neither the federal or state governments have agreed on a generic electronic format for health care credentialing. However, using Telemedicine as an extension of a doctor's medical practice is more readily accepted in France, where there are no credentialing issues. A doctor may physically be located in Paris while he remotely guides surgical procedures in other parts of France without having to acquire appropriate credentials in that remote area. Credentialing of civilian health care personnel is easily overcome. Further research is necessary in this area.

Both the U.S. and France have, and are continuing to adapt technologies that were developed for their respective space programs for telemedicine. France is leveraging and adapting their satellite and Robotic technologies to deliver telemedicine capabilities to remote areas, while the U.S. seems to be focusing on rural health care needs. However it is very likely that France, and Europe in general, will continue to make greater strides in the deploying telemedicine application more than the U.S. due in part to the shorter time it takes to approve medical technologies. Further research is necessary in this area.

Finally, this paper began with the notion that the levels of technology acceptance were a factor or a contributor to the wide-spread use of Telemedicine. While France is less "wired" (France has 41% teledensity) than the U.S., (the U.S. has 64% teledensity), telemedicine utilization in France appears to have had deeper penetration in the area of surgical procedures using remotely controlled robots. On the other hand, the U.S. appears to be taking a cautionary approach in this area. While French telemedicine capabilities have extended into such areas as clinical robotic procedures; telemedicine in the U.S. apparently tends to focus on clinical and patient informatics. France has taken steps to further deliver health care professionals a variety of teaching and educational instructions using appropriate telecommunication systems; in the U.S. some states are further along in this area than others. France is also continuing to design research with a view to harmonizing training schemes or research programs for telemedicine; while the U.S. remains a leader in medical technology research. France appears eager to use emerging technologies to deliver telemedicine services to rural and underdeveloped areas; whereas rural areas in the U.S. must first make the necessary ICT infrastructural investment before gaining access to telemedicine services that are readily available in nearby metropolitan areas.

This is a research in progress. Therefore, we intend to provide a justification of the strength to TAM model and try to support its appropriateness as a suitable and consistent measure of technology acceptance in telemedicine. We intend to determine if significant differences exist between France and the U.S. We are in the process of developing an instrument that can operationalize the dependent variable, that is telemedicine usage and allow us to investigate the following research questions:

* Is there a relationship between France/U.S perceptions of usefulness and usage of Telemedicine?

* Is there a relationship between France/U.S perceptions of ease of use and usage of Telemedicine?

These questions were developed based upon TAM. Empirical research is needed to test the propositions and the results will be provided in a future paper.

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Jude E. Edwards, Capitol College, Laurel, Maryland, USA

Leila A. Halawi, Bethune-Cookman University, Daytona Beach, Florida, USA

AUTHOR PROFILES

Dr. Jude E. Edwards earned his DBA--International, at Nova Southeastern University, Ft. Lauderdale, FL in 2003. He is an Adj. Prof. for Capitol College and Columbia Union College in their MBA programs. He also teaches online for South University. He has over 25 years of experience in IT and business development (ten years with Lockheed Martin). His current research includes Informatics and Knowledge Management in Health Care. He is an international conference presenter.

Dr. Leila A. Halawi earned her DBA--IT, at Nova Southeastern University, Ft. Lauderdale, Fl. in 2005. She is an assistant professor of business administration in the school of business at Bethune-Cookman University. She is also an Adj. Prof. at the University of Tampa. Her current research includes knowledge management, data mining, information systems success and strategy, and ethical impacts of information technology. She is frequently invited to present her research at national and international conferences.
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