We conducted a systematic review of 15 relevant databases for articles about telemedicine. After eliminating articles that did not meet the inclusion criteria, 1615 remained for analysis. Three raters coded the articles to assess various theoretical and methodological variables. Only 5% (n = 85) of the telemedicine articles made mention of any theory or paradigmatic approach. Studies commonly reported the objectives (96%) but rarely stated a research question or hypothesis (11%). Randomized selection of the subjects was reported in 11% of patient studies and 4% of studies where providers were the subject. There was a wide range in the number of subjects employed, although the majority of studies were based on sample sizes of less than 100. Only 26% of the studies reported a time frame. Until the telemedicine field adheres to agreed standards of reporting methodological details it will be difficult to draw firm conclusions from review studies.

The aim of this paper is to contribute to strategies applicable to vendors who want to move their locally designed and highly integrated systems to a larger market. A further aim is to explore how such systems developed for a local practice, and tightly integrated with the existing infrastructure, can be adapted to a larger market. We analyse the socio-technical mechanisms in play, the roles that the vendor and the users have in order to facilitate this, and the delicate interplay in relation to the other vendors. The analysis draws on the CSCW field, notions of generification of packaged software products, and boundary work. We argue that this process involves boundary work in relation to the installed base, as well as to other vendors and users. We also argue that the roles of the actors involved change during this process. The case described in this paper is the evolution of a system in which general practitioners can order laboratory services from the hospital electronically. The system integrates the general practitioners' information systems with the laboratory information system in the hospital. The development of the system started out in close cooperation with one customer, but as it evolved more customers bought the system. The system has been designed in an iterative and evolutionary way using agile development methods.

IntroductionThe relevance of engaging users in the development of information systems is well recognized. On the one hand, users are expected to provide designers with valuable insight into the users' work practice. On the other, users need an understanding of the technical possibilities and limitations of a new system. This collaboration is facilitated through a range of techniques, spanning from traditional requirement specifications to state-of-the-art, agile methods. 1 Agile methods are seen as "lightweight " methods characterized by short development cycles and by continuous releases of working software. This method enables users to regularly assess and give feedback on the quality of the information systems throughout the whole development process.As a branch of design studies, the Participatory Design field has been particularly concerned with giving users a direct role in decision making about the development of new systems. Participatory Design generally adheres to "bottom-up" approaches to ensure "empowered" and satisfied users, on the basis of a general belief that this approach leads to better systems. 2 This paper is positioned in this tradition, and, in accordance with the theme of the 2008 Participatory Design conference, "Experiences and Challenges," we call for the Participatory Design field to broaden its range of interest and intensify its research efforts on large-scale integrated systems in complex organizational settings.The rationale for this call is that the general tendency in the Participatory Design community has been to report on small-scale experimental and prototype-based projects of limited scope and duration. 3 We acknowledge the value of these contributions while also suggesting that they do not reflect the challenges that many current organizations face when implementing new information systems. First, many new information systems presuppose integration with a large portfolio of existing systems. Second, small-scale Participatory Design projects ignore the full organizational complexity of establishing robust and sustainable systems. 4 Because Participatory Design researchers are not active in this arena, their

Summary Objectives: This study asks: What theories are employed in telemedicine studies? How might they be categorized in ways that help distinguish the knowledge base of telemedicine? Methods: Theories in use were identified from a database of telemedicine-related publications between 1990 and 2005. Eighty-three (5% of 1615) articles referred to a theoretical concept. Grounded Theory procedures were used to analyze and categorize theories, while descriptive statistics were used for supplementary information. Results: The proportion of studies with theory was 3% in 1999 and 7% in 2005. The 83 articles were dispersed among 48 of the in total 795 different journals in the original sample. Identified theories were grouped into two main categories; ‘shared’ (used in two or more studies) and ‘lone ranger’. All of the shared theories are social science theories employed without notable adjustments to any uniquely defining features of telemedicine; diffusion, technology acceptance, health behavior, science and technology studies (STS), and economics. Theoretical concepts within the lone ranger category may well address unique features of telemedicine, but have yet to attract the attention of colleagues. Conclusion: The theories identified as ‘shared’ play an important role, but are inadequate in illuminating any unique features of telemedicine. The future of telemedicine as a field will need to identify its underlying theo - retical components. Frameworks employed in the field of evaluation may aid in identifying the types of theo - ries worth articulating in telemedicine.

The user role in the design of information systems is increasingly portrayed as active and complex, and the relationships between users and developers are portrayed as blurry. Information systems have become ubiquitous in most work processes, and users typically rely on several large scale information systems tightly integrated into other information systems, machines and work practices. In this paper we propose the notion of generativity as a framework to assess generative socio-technical characteristics of such systems, conceptualized as information infrastructures. Further, the paper will discuss the role these characteristics play in users' involvement by exploring the ways in which users can contribute as designers and thereby expand on the conceptual views of users and design processes of generative information infrastructures.Empirically, this paper presents the evolution of an information system for cooperation between general practice and hospital laboratories, where users in both settings participated in the design process. The system was designed using agile methods, and design and implementation were continuous and iterative co-existing processes. The case showed that a high degree of generativity in the system itself is a necessary condition for users to make changes. However, in an integrated and complex setting the flexibility of the existing and integrated systems will heavily influence the possibility to make changes. The paper also provides an in-depth illustration of how user and designer roles evolve together with circumstances and relationships. However, we argue that this type of evolvement requires dedicating a considerable amount of time and effort to achieve a climate in which such evolvement can take place. Finally, design is more than just the development of technology. It is also the development of work practices in which users' contributions are decisive. Designing work practices alongside the design of the technology has given rise to insights that feed directly into the design process. Acknowledging users' substantial contributions in design processes can aid in refining conceptualizations of users and developers along with bolstering efforts to facilitate appropriate user involvement.