The provision of healthcare at a distance, through telemedicine applications, can facilitate universal health coverage, decreasing health and social inequalities (Wootton 2008). The widespread use of information and communication technologies can potentially expand the use of telemedicine approaches to overcome health systems challenges associated with accessing care and coverage of services.
Description of the condition
Access to healthcare is essential for the promotion of health and the management of diseases and chronic conditions. Extensive healthcare coverage traditionally leads to improved access to required healthcare and improved population health, especially for those from more deprived socio-economic backgrounds (Moreno-Serra 2012) and rural and remote areas (Jamison 2013). Mobile access to healthcare and health-related information becomes vital in contexts where access to healthcare is scarce, as those needing clinical information might be particularly vulnerable to ineffective treatment (Royston 2015).
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, time, or both, 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, they are often used synonymously (Hersh 2006; WHO 2016). Mobile health (mHealth) has been more recently defined and refers to the use of mobile telecommunication technologies for delivering healthcare (Steinhubi 2013).
The exchange of information can occur synchronously (when interactions happen in real time) or asynchronously (when there is a lag between the clinical information being transmitted and the response) (WHO 2016), and through different channels, including videoconferencing, mobile applications, and secure messaging (Kruse 2017). The most common examples of telemedicine services are store and forward services, where medical data are transmitted to a healthcare provider for offline assessment; remote monitoring services, where a person is monitored at a distance by a healthcare provider through the use of technologies; and interactive services, where there is real-time interaction between a person and their healthcare provider (WHO 2012; WHO (in press)).
A global survey on eHealth was recently conducted by the World Health Organization (WHO) (WHO 2016), in which the terms telehealth and telemedicine were used interchangeably. Results showed that 57% of 122 surveyed countries had telehealth as part of the national eHealth policy or strategy (70 countries), and 22% (27 countries) had a dedicated national telehealth policy or strategy (WHO 2016). According to the surveyed countries, the most common areas where telehealth was used 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 high-, middle- and low-income countries. Some examples include: the technology enabled care services programme in England (NHS Commissioning Assembly 2015); the Scottish Centre for Telehealth and Telecare (SCTT 2017); telehealth pilot programmes in Australia (Australian Government Department of Health 2017); 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
By enabling exchange of clinical information that otherwise might not be possible, telemedicine promotes access to healthcare services, overcoming barriers such as the existence of services and timeliness of access. The main benefits associated with telemedicine are improved access to healthcare, increased speed at which it can be accessed, and cost reduction (Wootton 2008). This is particularly relevant for settings with limited healthcare resources, for instance low- and middle-income countries and remote areas. By bringing together healthcare providers and clients who otherwise might not be able to exchange clinical information, telemedicine increases the uniformity of clinical practice, promotes universal health coverage, and decreases health and social inequalities. Techonological advances and better telecommunication systems enable broader and less expensive access to healthcare delivered remotely, making the intervention more accessible.
Notwithstanding the possibilities, telemedicine applications have been inconsistently implemented and with varying degrees of success, which can be explained by technological challenges, legal considerations, human and cultural factors, and uncertainty about its economic benefits and cost-effectiveness (WHO 2011). A global eHealth survey conducted recently reported that lack of funding, infrastructure, prioritisation, and legislation or regulations were the most commonly cited barriers to implementing telehealth programmes (WHO 2016). These barriers can only be overcome by 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 means that the field of telemedicine is also hastily evolving. Despite its potential and the exponential growth of telemedicine applications in recent decades, there are still unanswered questions about its effectiveness (Agboola 2016; WHO 2016). The rationale for conducting this review is to assess the effectiveness of mobile-based technologies to support communication of healthcare information. 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 that aim to inform investments of digital health applications for strengthening health systems. This 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 relevant clinical outcomes, but also acceptability, satisfaction, resources use and unintended consequences. Research into unintended consequences has been particularly neglected, but can provide crucial information for the implementation of successful telemedicine programmes.