Table 2. Synthesis of Some UCs That Emerged From Telehealth Projects .

Domains	Observed UCs	Potential UCs
Technological	• Huge storage and archiving needs: images, video, etc • New forms of errors: mixture, truncation, or loss of information • Incompatibility of technological standards between jurisdictions or countries: safety, quality, etc • Several software components in the same system: quality control and security • Saturation or insufficient bandwidth problem in rural and isolated areas • Technological dysfunction: negative impact on the image and reputation of organizations and clinicians	• Attempted monopolization by some technology providers: risk of dependence of organizations, clinicians, or patients upon these suppliers and difficulty with respect to evolving or changing technology • Rapid change and evolution of technology: less time for organizations, clinicians, and patients to become familiar with and adapt to such shifts
Human and cognitive	• Growing dependence of clinicians and patients on technology: alert fatigue, anxiety, stress, etc • Decontextualized information: increased anxiety of the patient if no "e-literacy" and "clinical-literacy" • Feeling of isolation on the part of health professionals: loss of physical contact with patients and colleagues (eg, corridor discussions and informal relationships), loss of a feeling of belonging to the organization • Technological rigidity less adapted to the reality of clinical practice ("technology-driven"): frustration, stress, development of circumvention strategies, and risks of errors • Medicalization and intrusion into people’s living space and privacy: technology as burden • Cognitive overload: handling of large amounts of data by clinicians and patients	• Depersonalization of the clinician-patient relationship: reduction of contact time and increased detachment • Risk of diversion of the technology from its clinical function to a control tool of patients or professionals
Clinical and professional	• High resolution images and large amount of data: overinterpretation and overdiagnosis • Increased data flow and diagnostic capacity that can affect forensic liability • Non-transfer of patients: increased complexity of clinical cases in small hospitals that do not necessarily have expertise to take care of such cases • Non-integrated data: obligations to address fragmented data from different systems, duplicate tasks, increase in clinicians’ workload, etc • Professional jurisdictions and professional equilibriums: reserved acts, new expertise, professional collective agreement, etc • Emergence of new unplanned clinical uses of technology: expansion of the range of services offered by the organization	• Clinical interoperability (between organizations or jurisdictions) and need of protocol standardization, standards of practice and diagnostic methods: risk of hampering innovation and local creativity • Easier access to specialists and experts via telehealth: risk of loss of expertise and culture specific to practice in rural and remote areas
Organizational	• Restructuring of hierarchical relationships within organizations: clinician-clinician, clinician-other professionals, clinician-organization, etc • Standardization of human resources management: staffing (allocation) and unions (associations) • Strategic positioning of organizations: competition and tensions between organizations with respect to concentrating services and increasing revenues • Impact on the distribution of medical staff within the jurisdiction: tendency to concentrate medical expertise in large centres, loss of human resources and difficulty in recruiting and retaining these resources in small rural hospitals • Non-transfer of patients: an additional need for human resources (clinical and administrative) for small hospitals to provide care and services • Changes in the organization of services and professional work: prioritization of internal service requests vs. external requests	• Direct accessibility to specialized and subspecialized services: bypassing and disorganization of traditional service corridors, inflation of requests for expertise, misuse of services, increase in wait times • Modification of pre-existing professional and organizational collaboration networks if telehealth is developed without taking them into account
Legal, regulatory, political, and social	• Dilution of responsibilities due to the multiplicity of stakeholders: clinicians, technology providers, organizations, etc • Legal responsibility of clinicians to use data captured by the patient to make clinical decisions • Delegation of medical activities: need for agreements between professional associations and orders, provincial and federal ministries • Emergence of new modes of practice (smartphone, work or monitoring from home): insurance issues, quality control, labour standards, etc • Central role of insurance agencies (professional risk coverage): recommendations and requirements that are difficult to apply by professionals and organizations • Law on the exchange of personal data and information: obstacle to implementing a "public-private" telehealth network or archiving and sharing of patient data outside Quebec (eg, cloud computing) • Conflicts and inconsistencies of missions between levels of governance: provincial vs. federal vs. communities • Commercial use of patient data: consumer data or health data? Property of the technology provider or that of the patient or organization?	• Practice permit for foreign clinicians: risk of prosecution for illegal practice of medicine • Intellectual property of new uses of technology made by clinicians or patients • Package of technologies and software components from different manufacturers, multiplication of subcontracts: liability in case of damage, compliance with regulatory, quality, and safety standards • Outsourcing and "subcontracting" of certain technical assistance services in other countries: unauthorized external third parties may have access to patient data
Economic and financial	• Cost-sharing (eg, maintenance, storage, operating costs, human resources) and redistribution of benefits between organizations and even jurisdictions • Organizational performance criteria not adapted to telehealth: accounting for activity vs. costs of physical care of the non-transferred patient • Non-transfer of patients: increase of expenses and operation costs for its management in the organization • Strategic positioning and competition between organizations: accounting for the telehealth activity without having to assume the costs of physical care of the patient and competition for "market shares" • Additional costs for some organizations: upgrading technology and infrastructure to align with other participating organizations • Harmonization of salaries or remuneration of clinicians from different organizations or jurisdictions • Displacement of professional jurisdictions: enhancement of remuneration • Opportunism of some technology providers (fees and additional purchases): increased expenses for patients and organizations • Additional expenditure for the health system: ambulance transport companies that increase rates to compensate for the shortfall, etc.	• Circumvention of service corridors: demand inflation for specialized services and increased spending on the healthcare system • Outsourcing of medical activity: problem of the health system financial flows destination • Increased workload of family caregivers (eg, telehomecare): financial compensation by insurance companies for caregiver time

Abbreviation: UCs, unintended consequences.