***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Telehealth ( TH ) and telecare ( TC ) interventions are increasingly valued for supporting self-care in ageing population s ; however , evaluation studies often report high rates of non-participation that are not well understood . This paper reports from a qualitative study nested within a large r and omised controlled trial in the UK : the Whole System Demonstrator ( WSD ) project . It explores barriers to participation and adoption of TH and TC from the perspective of people who declined to participate or withdrew from the trial . Methods Qualitative semi-structured interviews were conducted with 22 people who declined to participate in the trial following explanations of the intervention ( n = 19 ) , or who withdrew from the intervention arm ( n = 3 ) . Participants were recruited from the four trial groups ( with diabetes , chronic obstructive pulmonary disease , heart failure , or social care needs ) ; and all came from the three trial areas ( Cornwall , Kent , east London ) . Observations of home visits where the trial and interventions were first explained were also conducted by shadowing 8 members of health and social care staff visiting 23 people at home . Field notes were made of observational visits and explored alongside interview transcripts to elicit key themes . Results Barriers to adoption of TH and TC  associated with non-participation and withdrawal from the trial were identified within the following themes : requirements for technical competence and operation of equipment ; threats to identity , independence and self-care ; expectations and experiences of disruption to services . Respondents held concerns that special skills were needed to operate equipment but these were often based on misunderst and ings . Respondents ’ views were often explained in terms of potential threats to identity associated with positive ageing and self-reliance , and views that interventions could undermine self-care and coping . Finally , participants were reluctant to risk potentially disruptive changes to existing services that were often highly valued . Conclusions These findings regarding perceptions of potential disruption of interventions to identity and services go beyond more common expectations that concerns about privacy and dislike of technology deter uptake . These insights have implication s for health and social care staff indicating that more detailed information and time for discussion could be valuable especially on introduction . It seems especially important for potential recipients to have the opportunity to discuss their expectations and such views might usefully feed back into design and implementation Background Despite the amount of online health information , there are several barriers that limit the Internet ’s adoption as a source of health information . One of these barriers is highlighted in conceptualizations of the digital divide which include the differential possession of Internet skills , or “ eHealth literacy ” . Most measures of Internet skills among population s at large use self- assessment s. The research discussed here applies a multifaceted definition of Internet skills and uses actual performance tests . Objective The purpose of this study was to assess how ready a sample of the general population is for eHealth . More specifically , four types of Internet skills were measured in a performance test in which subjects had to complete health-related assignments on the Internet . Methods From November 1 , 2009 , through February 28 , 2010 , 88 subjects participated in the study . Subjects were r and omly selected from a telephone directory . A selective quota sample was used divided over equal sub sample s of gender , age , and education . Each subject had to accomplish assignments on the Internet . The Internet skills accounted for were categorized as operational ( basic skills to use the Internet ) , formal ( navigation and orientation ) , information ( finding information ) , and strategic ( using the information for personal benefits ) . The tests took approximately 1.5 hours and were conducted in a University office , making the setting equally new for all . Successful completion and time spent on the assignments — the two main outcomes —were directly measured by the test leader . Results The subjects successfully completed an average of 73 % ( 5.8/8 ) of the operational Internet skill tasks and an average of 73 % ( 2.9/4 ) of the formal Internet skill tasks . Of the information Internet skills tasks , an average of 50 % ( 1.5/3 ) was completed successfully and , of the strategic Internet skills tasks , 35 % ( 0.7/2 ) . Only 28 % ( 25/88 ) of the subjects were able to successfully complete all operational skills tasks , 39 % ( 34/88 ) all formal skills tasks , 13 % ( 11/88 ) all information skills tasks , and 20 % ( 18/88 ) both the strategic skill tasks . The time spent on the assignments varied substantially . Age and education were the most important contributors to the operational and formal Internet skills . Regarding the formal Internet skills , years of Internet experience also had some influence . Educational level of attainment was the most important contributor to the information and strategic Internet skills . Conclusions Although the amount of online health-related information and services is consistently growing , it appears that the general population lacks the skills to keep up . Most problematic appear to be the lack of information and strategic Internet skills , which , in the context of health , are very important . The lack of these skills is also problematic for members of younger generations , who are often considered skilled Internet users . This primarily seems to account for the operational and formal Internet skills . The results of the study strongly call for policies to increase the level of Internet skills Background E-health initiatives hold promise to improve shared-care models of health care . In 2008–2011 we developed and trialled web-based software to facilitate a r and omised trial of a shared-care approach for childhood obesity involving General Practitioners ( GPs ) working with tertiary specialists . We describe the software ’s development , implementation and evaluation , and make recommendations for future e-health initiatives . The web-based software was design ed with the goals of allowing both GPs and specialists to communicate and review patient progress ; integrating with existing GP software ; and supporting GPs to deliver the structured intervention . Specifically , we aim ed to highlight the challenges inherent in this process , and report on the extent to which the software ultimately met its implementation and user aims . Methods The study was conducted at the Royal Children ’s Hospital and 22 general practice s across Melbourne , Australia . Participants comprised 30 GPs delivering the shared-care intervention .  Outcomes included the following . ( 1 ) GPs ’ pre-specified software requirements : transcribed from two focus groups and analysed for themes using content analysis . ( 2 ) Software implementation and performance based on the experience of the research team and GPs . ( 3 )  GP users ’ evaluation collected via question naire . ( 4 ) Software usage collected via GP question naire and qualified through visual inspection of the software meta- data . Results Software implementation posed difficult and at times disabling technological barriers ( e.g. out- date d hardware , poor internet connections ) . The software ’s speed and inability to seamlessly link with day-to-day software was a source of considerable frustration . Overall , GPs rated software usability as poor , although most ( 68 % ) felt that the structure and functionality of the software was useful . Recommendations for future e-health initiatives include thorough scoping of IT systems and server speed , testing across diverse environments , automated pre-requisite checks and up grade s of processors/memory where necessary , and user-created usernames and passwords . Conclusions GPs are willing to embrace novel technologies to support their practice . However , implementation remains challenging mainly for technical reasons , and this precludes further evaluation of potential user-specific barriers . These findings could inform future e-health ventures into shared-care , and highlight the need for an appropriate infrastructure . Trial registration Australian New Zeal and Clinical Trials Registry : ACTRN126080000553 
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Discussion and conclusions Telemedicine is not yet ubiquitous , and barriers vary widely .
The top barriers are technology-specific and could be overcome through training , change-management techniques , and alternating delivery by telemedicine and personal patient-to-provider interaction .
The results of this study identify several barriers that could be eliminated by focused policy .