Effective communication with other healthcare providers is essential for increasing health services capacity and providing optimal care, especially in areas where there is a shortage of healthcare providers (AAP 2015). The widespread use of information and communication technologies can potentially expand the use of telemedicine approaches to overcome networking gaps between healthcare providers and increase the capacity of health services.
Description of the condition
By 2035, there will be a worldwide shortage of approximately 12.9 million skilled healthcare providers (Campbell 2013). The biggest gaps occur in Southeast Asia and Sub-Saharan Africa, but elsewhere too, ageing populations, rising prevalence of non-communicable diseases, migration patterns and high turnover of healthcare providers all contribute to a worldwide shortage of healthcare providers in remote and rural areas, where populations are likely to be poorer, sicker and less educated (OPHI 2017; Wu 2016). Healthcare providers in those settings can be isolated and have scarce interaction with colleagues and specialists, with few opportunities for mentoring, consultation with experts, or referrals to other healthcare providers.
Description of the intervention
Telemedicine is defined as the use of information and communication technologies for medical diagnostic, monitoring and therapeutic purposes, when participants are separated by distance and/or time, with the ultimate goal of improving the health of individuals and communities (Hersh 2006). Although telemedicine and telehealth have been conceptualised separately, with the latter being a broader term that also encapsulates non-clinical activities such as professional education, the terms are often used synonymously (Hersh 2006; WHO 2016). The definition for mobile health (mHealth) has emerged more recently and refers to the use of mobile telecommunication technologies for delivering healthcare (Steinhubi 2013).
The exchange of information can happen synchronously (when interactions happen in real time) or asynchronously (when there is a lag between the clinical information being transmitted and the response) and through different channels, including videoconferencing, mobile applications, and secure messaging (Kruse 2017; WHO 2016). The most common examples of telemedicine services are store and forward services, where medical data is transmitted to a healthcare provider for offline assessment; remote monitoring services, where a healthcare provider uses technologies to monitor a person at a distance; and interactive services, where there is real-time interaction between a person and their healthcare provider (WHO 2012; WHO in press).
The World Health Organization (WHO) conducted a global survey on eHealth (WHO 2016), in which the terms telehealth and telemedicine were used interchangeably. Results showed that 57% of the 122 surveyed countries used telehealth as part of the national eHealth policy or strategy, and 22% had a dedicated national telehealth policy or strategy (WHO 2016). The most common areas were teleradiology, telepathology, remote patient monitoring and teledermatology, all of which were in use in more than half of the surveyed countries (WHO 2016). Of those, teleradiology programmes were most established, whereas the other programme types were mainly informal or at the pilot stage.
In a bid to maximise the coverage of healthcare services, decrease the costs associated with providing healthcare and optimise the shortage of healthcare professionals, governments and healthcare agencies all over the world have been funding telehealth programmes in countries of all income brackets. Some examples include the Technology Enabled Care Services programme in England (NHS Commissioning Assembly 2015), the Scottish Centre for Telehealth and Telecare (SCTT 2017), the Telehealth pilot programmes in Australia (Australian Govt Dept of Health), the telehealth services provided within the Medicare programme in the USA (MedPAC 2016), the Asia eHealth Information Network (AeHIN 20017), and the KwaZulu-Natal Experience in South Africa (Mars 2012).
How the intervention might work
The use of telemedicine between healthcare providers for communication, consultations and client management might contribute to developing professional skills and expertise, as well as optimising multidisciplinary communication (AAP 2015). This is particularly relevant for settings where there is a shortage of healthcare providers, for instance in low- and middle-income countries and in rural and remote areas. By enabling healthcare providers who are geographically separated to exchange clinical information, telemedicine can improve their performance, as well as foster the uniformity of clinical practice and facilitate universal health coverage. Technological advances and better telecommunication systems allow for broader and less expensive access to remotely delivered healthcare, making the intervention more accessible.
Notwithstanding the possibilities, telemedicine applications have been inconsistently implemented, with varying degrees of success due to technological challenges, legal considerations, human and cultural factors, and uncertainty around economic benefits and cost-effectiveness (WHO 2011). A global eHealth survey from 2016 reported that lack of funding, infrastructure, prioritisation, and legislation or regulations were the most common barriers to implementing telehealth programmes (WHO 2016). Overcoming these barriers requires the implementation of comprehensive regulatory guidelines, driven both by governmental and professional medical organisations; legislation on confidentiality, privacy and liability; and the involvement of all stakeholders in designing, implementing and evaluating telemedicine applications, focusing on the safety and the effectiveness of applications (Agboola 2016; WHO 2011).
Why it is important to do this review
The rapid progress in information and communication technologies is accelerating the evolution of telemedicine. Despite its potential and the exponential growth of telemedicine applications in the last decades, there are still unanswered questions about its effectiveness. The rationale for conducting this review is to assess the effectiveness of mobile technologies as a method for healthcare providers to communicate, diagnose and manage clients. Although these technologies are now ubiquitous, their rapid expansion has not been accompanied by a close assessment of their impact, which led the WHO to commission guidelines to inform investments of digital health applications for strengthening health systems. This review is one of a suite of six Cochrane Reviews that will contribute to those guidelines. We aim to assess the effectiveness of telemedicine not only on communication between healthcare providers, but also acceptability, satisfaction, resources use and unintended consequences. Research into the latter has been particularly neglected but can provide crucial information for implementing successful telemedicine programmes.