Evidence for telehealth

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If you would like to know the most up to date evidence in any particular area of telehealth, you can ask us and we will help find it for you. This may take from a couple of days to several days, depending on the question.

The material below is a small beginning. As well as expanding this list of existing reviews, we will aim to post information on new ones as they are produced.

Introduction: about the evidence in telehealth

How much has been written about telehealth?

There has been a huge amount written about telehealth. For example, searching MedLine, the most commonly used academic database for medical science, and using the terms “telehealth” and “telemedicine”, produced 14,870 responses on the 24th August 2012. More are being added every day. Of course, not all of these are about the effect telehealth has on clinical care. There are a lot of articles about technical details and a lot of opinions.

To help with understanding the evidence, let’s start by looking at reviews.

Why look at reviews of the evidence?

Reviews bring the evidence together and produce a summary of what is known. A systematic review gives enough information about how the review was done so that someone else could repeat it if they wanted to check its results. This is very different to the sort of review where someone has just gathered together a group of interesting articles, or collected what they think is the evidence without any particular method, or have based their opinions on a Google search.

A systematic review will tell you what databases were searched, what terms were used in the search, what type of articles were included, and what was excluded. So the results of a systematic review are more robust than a non-systematic review. Some systematic reviews have interesting results but very timid conclusions, such as “we don’t know very much yet”, or “more research is needed”, so it is worth looking at the results and making up one’s own mind about the conclusions. As well as a basic description of each review, I’ve added my commentary, but don’t take my commentary as the absolute truth: if you are really interested in the area, get the original article and decide for yourself.

The limitations of systematic reviews

Coverage

Systematic reviews do not cover every aspect of the evidence. Most of the major areas in telehealth have been reviewed, but many smaller topics have not been reviewed. Also some reviews only include more rigorous types of evidence, such as randomized controlled trials, and do not include other research, such as different types of comparison studies, feasibility tests, and evaluation reports.

Timeliness

Systematic reviews are not usually completely up to date. This is because it takes time to bring all the evidence together, write it up and get the review published. So in most cases systematic reviews contain evidence up to about one or two years before they were published. More recent research evidence may exist, but can only be found by conducting a new search.

Reviews and Summaries of the Evidence in Telehealth by Topic

Autism Spectrum Disorders

There is very little in the literature about the use of telehealth for the assessment and treatment of autism. Here are a few articles, but the whole area is really at the level of preliminary development and feasibility tests.

Boisvert M, Lang R, Andrianopoulos M, Boscardin ML. Telepractice in the assessment and treatment of individuals with autism spectrum disorders: A systematic review. Dev Neurorehabil. 2010;13(6):423-32.

I found one systematic review in this area, which covered 8 studies. The conclusions were that this is a promising area that warrants further research, or in other words, we have very little hard data yet. These 8 studies together only looked at 46 participants. Only one article directly compared video and face-to-face; Vismara 2009, discussed in more detail below. The others were all case studies of one or very small numbers indicating that it is possible to conduct a functional analyses, assist teachers to conduct assessments and functional analyses, and assist teachers to do behavioural interventions.

Parmanto B, Pulantara IW, Schutte JL, Saptono A, McCue MP. An integrated telehealth system for remote administration of an adult autism assessment. Telemed J E Health. 2013 Feb;19(2):88-94.

The authors describe a system they developed to assess autism remotely. It includes videoconferencing, stimuli (image, and video) presentation, recording, and electronic scoring to a software platform. Their aim was to replicate the Autism Diagnostic Observation Schedule by telehealth as closely as possible. There was only one part of the assessment that could not be done remotely, the construction task. Patients found the assessment easy to use and were comfortable with the process. My comment on this is that it is an expensive system in the early stages of development, and the next step of equivalence research has not yet been done. This is promising but it is still very early days.

Terry M. Telemedicine and autism: researchers and clinicians are just starting to consider telemedicine applications for the diagnosis and treatment of autism. Telemed J E Health. 2009 Jun;15(5):416-9.

This article is commentary rather than a research report; it draws attention to using technology to capture video recordings in natural situations and use these for assessment instead of artificial environments, and mentions that some are using Second Life as a way of teaching social skills, on the assumption that a virtual environment may be less threatening than the real world.

Vismara LA; Young GS; Stahmer AC; Griffith EM; Rogers SJ; Dissemination of evidence-based practice: can we train therapists from a distance? Journal of Autism & Developmental Disorders, 2009 Dec; 39 (12): 1636-51.

This was a trial to test the effectiveness of training community-based therapists to treat autism spectrum disorder; they found that both video and live instruction were equally effective for teaching therapists to deliver an intervention to children and to train their parents. The skills of the parents and the improvements in the children were the same in both groups. This is one step removed from the direct delivery of treatment by telehealth, but does show that it is possible to train therapists at a distance, which is important as there is a need to make treatment programs more widely available.

Lung Diseases

This review covers three types of lung conditions:

Jaana M, Pare G, Sicotte C. Home telemonitoring for respiratory conditions: a systematic review. Am J Manag Care. 2009;15(5):313-20. Epub 2009/05/14.

The value of home telemonitoring was considered for asthma, obstructive lung disease, and patients who have had a lung transplant. The type of telemonitoring was mainly electronic symptom diaries, plus measuring lung function by spironmetry or peak flow meters. Overall, there were positive effects on patient behaviour, so better adherence with medication and self-monitoring, although this decreased over time. There were some clinical effects as well, such as better disease control and earlier detection of complications, however the authors say that most of these studies were short term with small numbers of patients so more research should be done to confirm these results.

 

McLean, S., Chandler, D., Nurmatov, U., Liu, J., Pagliari, C., Car, J., et al. (2011). Telehealthcare for asthma: a Cochrane review. Canadian Medical Association Journal, 183(11), E733-742

This is the only review I’ve found so far that is just about asthma. It included 21 randomised controlled trials, ranging across telephone, video and internet based forms of care, in both children and adults. Only patients with asthma were included; not COPD (chronic obstructive pulmonary disease). A meta-analysis of the 21 studies showed that there was a decrease in hospital admissions, but no significant improvement in either patient quality of life or number of visits to emergency departments for asthma attacks. The authors cautioned that many of the control groups in these studies received enhanced in-person care, so comparing telehealthcare with enhanced in-person care is different from making the comparison with standard care.

Heart Failure

Summary in a nutshell: there is now seriously strong evidence that home telehealthcare is beneficial for patients with cardiac failure; this is one of the few areas of clinical care in which telehealth interventions have been shown to reduce patient mortality.

Heart failure is a serious disease with a high death rate. Patients often have frequent hospital admissions for exacerbations of the disease. There are, however, clear early warning signs that the patient is getting worse, such as weight gain, which signals fluid retention, and symptoms such as shortness of breath.

For these reasons managing heart failure is a good candidate for home telehealth care. The usual form of telehealth used is telemonitoring, where information such as weight, blood pressure, and symptom reports are regularly sent in to the patient’s health care provider. Real time video is usually not a substantial part of the intervention in the telemonitoring studies. Some studies also had patients taking their own ECGs which is a more complex task, even if it is just a rhythm strip.

One of the reasons why it is possible to show reduction in mortality is that the mortality rate in patients with cardiac failure is very high, so this research can be conducted with relatively small numbers of people. For other conditions with lower mortality rates much larger numbers of people would need to be studied in order to either find a difference or demonstrate there is no difference. See summaries of the evidence in these systematic reviews. I have organised these starting with the most recent ones.

Nakamura N, Koga, T and Iseki H A meta-analysis of remote patient monitoring for chronic heart failure patients. J Telemed Telecare. 2014;20(1):11-17

The most recent meta-analysis, including 13 RCTs with a total of 3337 patients. Overall, the patients receiving remote monitoring had lower mortality, as previous meta-analyses have shown, but the interesting thing about this work is that the authors did subgroup analysis to find out what types of remote monitoring are more effective. The important characteristics turned out to be rapid intervention (by which they meant that the patients were monitored frequently and problems addressed early), and the inclusion of medication management.

Clarke M, Shah A, Sharma U. Systematic review of studies on telemonitoring of patients with congestive heart failure: a meta-analysis. J Telemed Telecare. 2012;17(1):7-14.

This is a recent meta-analysis of 13 articles, with a total of 3480 patients, so is high quality evidence about the effectiveness of telemonitoring. It showed:

Reduction in all-cause mortality

Reduction in hospital admissions for heart failure (but not in the number of admissions for all causes)

No difference was found in length of hospital stay, medication adherence or costs.

 

Klersy C, De Silvestri A, Gabutti G, Raisaro A, Curti M, Regoli F, et al. Economic impact of remote patient monitoring: an integrated economic model derived from a meta-analysis of randomized controlled trials in heart failure. European journal of heart failure. 2011;13(4):450-9.

Given that there is a lot of evidence that telemonitoring for heart failure reduces the number of hospital admissions (although not the length of stay once the patient has been admitted), this study asked if telemonitoring was cost-effective. The answer was yes. They concluded that it was “dominant”; in health economics circles, this means that it produced better health outcomes at a lower cost.

 

Polisena, J., Tran, K., Cimon, K., Hutton, B., McGill, S., Palmer, K., et al. (2010). Home telemonitoring for congestive heart failure: a systematic review and meta-analysis. J Telemed Telecare, 16(2), 68-76

21 studies of home telemonitoring for patients with cardiac failure were reviewed, and the average effect of treatment across all these studies calculated; this showed a reduction in mortality. Several of the studies showed reductions in hospitalizations and emergency department visits. Of the studies that measured patient quality of life, seven found no difference and five found an improvement compared with usual care. The studies reviewed included a wide variety of methods of home telemonitoring, except for telephone follow up, which they did not include. Telephone follow up for cardiac failure has been widely used and studied; see the next review below which deals with this approach as well.

 

Inglis, S. C., Clark, R. A., McAlister, F. A., Ball, J., Lewinter, C., Cullington, D., et al. (2010). Structured telephone support or telemonitoring programms for patients with chronic heart failure. The Cochrane Library(8)

This Cochrane review included 16 studies on structured telephone support, and 11 on telemonitoring. Both approaches reduced hospital admissions for cardiac failure, improved quality of life, patient knowledge and self care. Both approaches reduced healthcare costs. Telemonitoring significantly reduced all-causes mortality, whilst structured telephone support had a non-significant positive effect.

 

Dang S, Dimmick S, Kelkar G. Evaluating the evidence base for the use of home telehealth remote monitoring in elderly with heart failure. Telemed J E Health. 2009;15(8):783-96.

Nine randomised controlled trials were included in this review. Six studies suggested reductions in hospital admissions, three a reduction in mortality, three a reduction in health-care utilisation costs, two a reduction in length of stay and two a reduction in emergency department visits. Overall, because they did not do a meta-analysis, they could only conclude that telemonitoring was “promising”. This is a good example of where a meta-analysis would have been helpful. They did discuss what the key information collected in the telemonitoring of cardiac failure should be, and concluded these were weight, ankle swelling, and shortness of breath.

 

Klersy C, De Silvestri A, Gabutti G, Regoli F, Auricchio A. A meta-analysis of remote monitoring of heart failure patients. Journal of the American College of Cardiology. 2009;54(18):1683-94.

This meta-analysis contained 32 studies, 20 or which were randomised controlled trials, and 12 were cohort studies. Both types of studies showed significant reductions in mortality and all-cause hospital admissions. Now only read on if you are a methodology nut:

Randomised controlled trials (RCTs) give more valid results about what effect the intervention had, but they are conducted on selected groups of patients under fixed conditions, so the problem is that the effects may not be reproduceable for the whole population of people with heart failure in the real world.

Cohort studies more closely resemble what happens in the real world of health care, but they are at risk of being biased. For example, the patients receiving home telehealth might all be volunteers, and so more highly motivated. This will over-represent the differences between those who receive telehealth and those who do not.

The take home message from this review is that both types of studies showed benefits, with the cohort studies showing larger benefits.

 

Chaudhry SI, Phillips CO, Stewart SS, Riegel B, Mattera JA, Jerant AF, et al. Telemonitoring for patients with chronic heart failure: a systematic review. Journal of cardiac failure. 2007;13(1):56-62.

Seven studies were reviewed, and six of these suggested reduction in mortality and in hospital admissions. Because this is an older review, with all the studies being pre-2007, I will not dwell on the findings, but it is worth noting that the less complex programs were four times less costly than the more complex programs, and seemed to be just as effective.

 

Some cautions:

Most of this research is based on short term studies of one to two years in length. There is very little evidence as to the effect of telehealth in the longer term. We do not know what impact telehealth has on things like how much longer people are able to live independently, and this is an important question for the operations and sustainability of the whole health and social care system in the future.

There have been two recent individual randomized controlled trials that have shown telemonitoring to be no better than usual care. These would need to be added to a meta-analysis to see if this changes the overall conclusions.

Koehler F, Winkler S, Schieber M, Sechtem U, Stangl K, Bohm M, et al. Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study. Circulation. 2011;124:1873-80.

Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin Z, et al. Telemonitoring in patients with heart failure. New England J Med. 2010;363:2301-9.

 

Dermatology

Dermatology is an area where there are real problems with access to services in both rural and urban locations. While there are life threatening conditions in dermatology (think malignant melanoma), there are not that many situations where the time from presentation to diagnosis and treatment needs to be measured in hours or a single day, rather than days or weeks. It used to be the case that most patients who would benefit from a specialist dermatology consultation have just had to wait. Dermatology, along with psychiatry, is a very visual mode of practice and is one of the areas of telehealth that developed early. There is a debate going on at present as to whether or not it can all be conducted by using still images, or whether there is value to adding real time video. Have a look at these two reviews: it looks like teledermatology is very good, but perhaps not quite as good as in-person dermatology. However, bearing in mind the circumstances of the patient, teledermatology is a great improvement on no access. Also, most of the still image teledermatology is done in conjunction with the patient’s usual GP, so this mode of practice ends up improving the GPs knowledge and skill in dermatology, which can only be a good thing.

Warshaw, E., Greer, N., Hillman, Y., Hagel, E., MacDonald, R., Rutks, I., et al. (2009). Teledermatology for diagnosis and management of skin conditions: a systematic review of the evidence. Minneapolis, MN: Dept of Veterans Affairs

This systematic review is about comparing the effectiveness of teledermatology with in-person care. It included 41 studies using store-and-forward, and 11 studies using real time video communication. Before we go too much further, a couple of definitions are helpful: Accuracy: compares the diagnosis or management plan developed by either teledermatology or in-person dermatology, with the diagnosis or management plan developed when the results of pathology tests are known. This is known as a comparison against a “gold standard”. Concordance: compares the diagnosis or management plan developed by teledermatology with in-person dermatology, without any additional information, so there is no “gold standard” comparison. This situation is more like the real world of clinical practice. Diagnostic accuracy: comparing against the “gold standard”, teledermatology is good, but not as accurate as in-person dermatology. Diagnostic concordance: concordance is essentially the same for teledermatology as for in-person dermatology. Management accuracy: there were only two studies in this group, with overall accuracy being equivalent for both teledermatology and in-person dermatology, however teledermatology was not as good for pigmented lesions. Management concordance: concordance rates were moderate to excellent for both store-and-forward and real-time video management. Clinical Outcomes: Patient satisfaction and clinical outcomes were similar for teledermatology and in-person dermatology.

Levin, Y. S., & Warshaw, E. M. (2009). Teledermatology: a review of reliability and accuracy of diagnosis and management. Dermatologic Clinics, 27(2), 163-176.

Their conclusions were: Teledermatology demonstrated good performance in comparison with clinic-based consultation for diagnostic agreement and diagnostic accuracy; teledermatologists agreed with each other and with clinic-based dermatologists at a rate comparible with intragroup agreement among clinic dermatologists. This distinction is important to make because the agreement between different dermatologists seeing the same patient in-person is less than 100%, and as noted above, is about the same as the agreement between teledermatology and in-person dermatology. For clinical management, they say that there were fewer studies so the conclusions are less convincing. Finally, they note the importance of taking good quality photographs in a skilled manner for best results.

Diabetes

Diabetes is a very common condition, which is not yet possible to cure, but which can be effectively treated. However, effective treatment is often hard to achieve, because much of the work has to be done by patients themselves, requiring substantial management of diet and lifestyle. Anyone who has tried to make such changes and stick to them for the rest of their life, will know that this is not always easy. Several different types of telehealth have been tried as a means of improving diabetes management, with the most common form being home care telemonitoring, whereby the patient sends data such as blood sugar, weight, and blood pressure to their health care service. Real time video has also been used, either on its own or in combination with sending data, often by installing an “all-in-one” telehealth unit in the patient’s home. Here are three reviews about telehealth for diabetes:

Verhoeven, F., Tanja-Dijkstra, K., Nijland, N., Eysenbach, G., & van Gemert-Pijnen, L. (2010). Asynchronous and synchronous teleconsultation for diabetes care: a systematic literature review. J Diab Sci Technol, 4(3), 666-684.

It is worth commenting on this systematic review in some detail, because it illustrates how hard it is to achieve good results in diabetes. The review looked at two types of telehealth consultations for diabetes: 1. asynchronous teleconsultations, in which the patient monitors themselves and delivers the data to their health care provider by email, mobile phone or via a website. 2. synchronous teleconsultations, such as videoconferencing or telephone calls. They included 90 studies in their review; about two thirds were asynchronous, so used store-and-forward methods without any real time interaction. Fifteen of the studies measured HbA1C as an outcome: this is a blood test which gives a measure of how good the person’s diabetic control has been over the past three months. The combined results of these 15 studies found that the use of telehealth in treating diabetes made no significant difference. I also found it interesting that 11 studies reported that the technology was viewed negatively by the users. This is noteworthy because patient satisfaction with telehealth is usually very high. Ten of these studies concerned asynchronous systems where the patient needed to interact with a website or use a home telehealth unit, and one was because of poor quality videoconferencing due to connectivity problems. Even without a significant improvement in HbA1c, is telehealth for patients with diabetes useful? Looking at all the studies, telehealth was as good as usual care, and patients sent more information and had more contact with their health care providers. Sending data improved self care and having video or telephone consultations reduced travel costs and reduced unscheduled consultations. So telehealth can be used in diabetes management, and might improve the efficiency of care delivery; this would be a good thing, as there are ever-increasing numbers of patients and a limited number of clinicians to provide the care.

Siriwardena, L. S. A. N., Wickramasinghe, W. A. S., Perera, K. L. D., Marasinghe, R. B., Katulanda, P., & Hewapthirana, R. (2012). A review of telemedicine interventions in diabetes care. J Telemed Telecare, 18(3), 164-168

This review was published two years later, and has rather more positive conclusions about the use of telehealth for diabetes care; it included 27 randomized controlled trials comparing telehealth with usual treatment, so only consisted of research with good quality methodology. Twenty-five of these studies used HbA1c as their outcome measure. Their review found that: 12 studies (44%) had significant improvement in patient outcomes 11 studies (41%) had a non-significant improvement in patient outcomes 2 studies (8%) had a negative outcome (the telehealth group did not do as well) The telehealth patients also benefited by saving time travelling to clinics and waiting for consultations. The studies in the review used videoconferencing (8), mobile phones (10), telephone calls (9), and letters giving feedback about telemonitoring data (2). There was no clear indication that one of these methods was better than any other.

Franc, S., Daoudi, A., Mounier, S., Boucherie, B., Dardari, D., Laroye, H., et al. (2011). Telemedicine and diabetes: achievements and prospects. Diabet Metab, 37(463-476).

This review is not a meta-analysis, but is useful because it divides up the research into the different types of telemedicine interventions for diabetes, so this helps to drill down into the mixed results described above. In brief these different types are:

  • Telephone consultations; regular telephone contact with patients seemed to improve outcomes. This was most useful for the more straightforward patient, not so helpful for complex patients or those who do not want to cooperate.
  • Educational programs; can be delivered as effectivly by telehealth as in-person.
  • Transmitting blood sugar data to care providers with feedback; overall, the results from this method of care have been disappointing, across a variety of technologies and platforms.
  • Electronic diaries on smartphones; most of these trials are still in the early stages, some are looking very promising.

Economic Analysis: is Telehealth Cost-Effective?

And now a brief description of what the research evidence says about the cost-effectiveness of telehealth. Again there is a large number of individual studies in this area, so here are some systematic reviews. In a nutshell, the evidence for the cost-effectiveness of telehealth is: 1. very patchy 2. very situation specific

Bergmo TS. Can economic evaluation in telemedicine be trusted? A systematic review of the literature. Cost Effectiveness Resource Allocation 2009, 7:18

This review looked at the quality of economic analyses in telehealth rather than the results of the analyses, and concluded that most economic evaluations of telehealth services were not really high quality, because they had some things lacking, such as information about what perspective the analysis was conducted from. Also most didn’t do a sensitivity analysis. What this means is that we need more and better conducted economic evaluations of telehealth services.

Mistry H. Systematic review of studies of the cost-effectiveness of telemedicine and telecare. Changes in the economic evidence over twenty years. J Telemed Telecare 2012, 18(1): 1-6.

This systematic review included 80 economic evaluations of telehealth services. The overall conclusion was that the results of all these studies were highly variable, depending on the type of service, what it was being compared with, how the costs and outcomes are measured, and how much the service is being used. This variability made it difficult to compare the studies with each other and come up with a definitive answer. The author said that there was no evidence for telehealth, in general, being more cost-effective compared with usual care. My comment is that we probably still have a case of absence of evidence, rather than evidence of absence, so the answer is that we still don’t know and (guess what?) we need more and better conducted health economics research.

Peeters JM, Mistiaen P and Franke AL. Costs and financial benefits of video communication in care at home: a systematic review J Telemed Telecare 2011, 17: 403-411.

This review looks in more detail at video communication to the home, and includes 9 studies, mainly conducted in the USA, and they conclude that there is no evidence of cost-effectiveness for home video telehealth. So why is this review and my own review (see Wade below) coming to different conclusions? Well, they used a different search strategy, included cost analyses as well as economic analyses, and their main outcome measure was financial benefits, where as my review looked at cost-effectiveness, ie both clinical and cost outcomes together. Also, they did their work a year or so after mine, so they had some different studies in their review: the devil is usually in the detail! If you are very interested in this question because you are doing or thinking of doing some research in this area, get both of these reviews and make up your own mind.

Polisena J, Coyle D, Coyle K and McGill S Home telehealth for chronic disease management: a systematic review and an analysis of economic evaluations. Int J Technol Assess Health Care 2009, 25(3): 339-349.

This review covered all types of home telehealth for chronic diseases. It included 22 studies, and home healthcare was found to be cost saving for the health care system and insurance providers in 20 of those studies. The authors were concerned that the quality of the economic studies was generally low. They also point out that decreased use of health care service due to the telehealth intervention certainly reduces costs, but there is less certainty that this means the patients’ health outcomes have actually improved.

Seto E. Cost comparison between telemonitoring and usual care of heart failure: a systematic review Telemed J E-Health 2008, 14(7): 679-686.

This review included 11 separate studies, all of which concluded that telemonitoring of heart failure reduced costs compared with usual care. The main reason for this was reduced hospital admissions. Some studies also found reduced cost from fewer emergency department attendances and less home nursing visits.

Wade VA, Karnon J, Elshaug AG and Hiller JE.  A systematic review of economic analyses of telehealth services using real time video communication  BMC Health Services Research 2010, 10:233 doi:10.1186/1472-6963-10-233. See the full article at: http://www.biomedcentral.com/content/pdf/1472-6963-10-233.pdf

I did a systematic review of economic analyses of real-time video telehealth. This is limited to one specific modality of telehealth, but it is the one that is used for the Medicare item numbers in Australia. On the cost side, looking at the 36 articles in the review, 22 (61%) found telehealth was cost-saving, 11 (31%) found greater costs, and 3 (11%) gave the same or mixed results. On the effectiveness side, 12 studies (33%) found improved health outcomes, 21 (58%) found no significant difference in outcomes, and 1 (3%) found outcomes were variable. The organisational model of care was the most important variable affecting the results, with video communication being cost-effective for home care and access to on-call specialists, and not cost-effective for local delivery of services between hospitals and primary care. In delivery to rural areas, the results were mixed, with a common pattern being that health services paid more for telehealth, but because of savings in patient travel, the overall outcome for society as a whole was cost saving.

General Reviews

These try to cover telehealth as a whole, across several clinical areas.To get a broad overview of the effectiveness of telehealth, start with this article:

Ekeland, A. G., Bowes, A., & Flottorp, S. (2010). Effectiveness of telemedicine: a systematic review of reviews. Int J Med Inform, 79, 736-771.

As there have been so many reviews of different aspects of telehealth, a systematic review of reviews has been done. These researchers made a synthesis of 73 reviews that looked at the effectiveness of telehealth, so measured outcomes like patients’ health, or costs of healthcare, or quality of care. Overall, 29% of these reviews concluded that telehealth is effective, 25% that the evidence is promising but not complete, and the remaining half said that the evidence was limited and inconsistent: which is the “we don’t know very much yet” conclusion. However, remember that positive results are more likely to be published than negative ones (publication bias), so the overall effectiveness might be less than this. Effectiveness was found across a whole range of clinical areas, which we will look at individually further down this section. Some other particular conclusions were that:

  • Patients are generally very satisfied with telehealth.
  • There is little evidence for telehealth being cost-effective

While there were reviews that concluded that some aspects of telehealth were not effective, none of the reviews said that telehealth was bad for patients.

Indigenous Health Australia

Peer reviewed publications about the use of telehealth for Australian indigenous communities are scanty. I collected a group of publications through a MedLine, Google Scholar, and Informit search and summarized the ones that are most relevant to clinical practice below. Ear, Nose & Throat

Elliott G, Smith AC, Bensink ME, Brown C, Stewart C, et al. (2010) The feasibility of a community-based mobile telehealth screening service for Aboriginal and Torres Strait Islander children in Australia. Telemed J E Health 16: 950-956.  

A mobile screening service was delivered from a van to indigenous communities. The telehealth aspect of this service was that the screening data and video-otoscopy images were uploaded to a secure web site for reading and specialist advice. Many children were referred for services which improved access to care.

McCarthy M (2010) Telehealth or Tele-education? Providing intensive, ongoing therapy to remote communities. Stud Health Technol Inform 161: 104-111.   

This paper describes the use of videoconferencing providing specialist hearing therapy support and associated therapies to children in rural and remote Australia, including indigenous communities.

Smith, A. C., Perry, C., Agnew, J., & Wootton, R. (2006). Accuracy of pre-recorded video images for the assessment of rural indigenous children with ear, nose and throat conditions. J Telemed Telecare, 12(Suppl 3), 76-80.   

This study compared the accuracy of ENT assessment made by a specialist, comparing an in-person consultation with store-and-forward telehealth, in which a history and video recordings of the patient were utilised. There was a high correlation between in-person and telehealth, both for the diagnosis and decisions made about clinical management. Mental Health

Alexander J, Lattanzio A (2009) Utility of telepsychiatry for Aboriginal Australians. Aust N Z J Psychiatry 43: 1185.  

The Rural and Remote Mental Health Services in South Australia reported 271 telepsychiatry consultations with Indigenous people; they concluded that patient satisfaction is reflected by steadily increasing demand.

Lessing, K., & Blighnault, I. (2001). Mental health telemedicine programs in Australia. J Telemed Telecare, 7(6), 317-323.  

This was a survey of mental health telemedicine programs in Australia. It is rather out of date now, but at the time it found that 16 programs had dealt with 526 clients in the preceding 3 months, and 37 (7%) of these were Indigenous, and access to services was increased by telehealth. Oncology

Sabesan S, Larkins S, Evans R, Varma S, Andrews A, et al. (2012) Telemedicine for rural cancer care in North Queensland: Bringing cancer care home. Aust J Rural Health 20: 259-264. 

This paper describes a service whereby medical oncologists in Townsville have been providing cancer services to rural hospitals in the Townsville and Mt Isa districts since 2007. 18 indigenous patients were in the total number of 158 patients. They conclude that tele-oncology allows rural and indigenous cancer patients to receive specialist consultations and chemotherapy closer to home, reducing access difficulties.

Mooi JK, Whop LJ, Valery PC, Sabesan SS (2012) Teleoncology for Indigenous patients: The responses of patients and health workers. Aust J Rural Health 20: 265-269.  

This is another paper about the tele-oncology service described above, specifically about the satisfaction and responses of indigenous patients to the service. There were high levels of satisfaction from patients, similar to those from non-Indigenous patients. The authors point out, that this is important because indigenous patients have poorer survival rates for cancer, due to receiving less cancer treatment, more delays to surgery, and interrupted treatment patterns. Both patients and health care workers preferred video consulting over face-to-face consulting, because of reducing the waiting time, cost, burden of travel and time away from local support. Ophthalmology

Durkin SR (2008) Eye health programs within remote Aboriginal communities in Australia: a review of the literature. Australian Health Review 32: 664-676.   

This review includes both telehealth and in-person services, and contained four papers on use of digital imaging, two of these specifically for Aboriginal people.

Mental Health

Psychiatry, and mental health more generally, was one of the first areas to be researched in telehealth. This is an area that is very well suited to telehealth, because there are many aspects of assessment and management that can be delivered without a physical examination.

Psychiatry Assessment

Hyler SE, Gangure DP, Batchelder ST. Can telepsychiatry replace in-person psychiatric assessments? A review and meta-analysis of comparison studies. CNS Spectrums. 2005;10(5):403-13.

This article is a review and meta-analysis of 14 studies that compared psychiatric assessments by video consulting with in-person consulting. They only looked at structured methods of doing the assessments, so standard types of interviews and rating scales. Basically, the meta-analysis showed that the two methods of conducting psychiatric assessments gave equivalent results. The patients were equally satisfied with both methods of assessment, and the psychiatrists had mixed feelings.

Forensic psychiatry

Antonacci, D. J., Bloch, R. M., Saeed, S. A., Yidirim, Y., & Talley, J. (2008). Empirical evidence on the use and effectiveness of telepsychiatry via videoconferencing: implications for forensic and correctional psychiatry. Behav Sci Law, 26, 253-269

They only found 5 articles looking at how effective it was to deliver psychiatric services to prisons and hospitals for the criminally insane, so there was not a great deal of evidence. The evidence that did exist said that assessments conducted by video communication were accurate, and that this was a good method to improve access to psychiatric services in correctional facilities.

Post-Traumatic Stress Disorder

Sloan DM, Gallagher MW, Feinstein BA, Lee DJ, Pruneau GM. Efficacy of telehealth treatments for posttraumatic stress-related symptoms: a meta-analysis. Cognitive Behaviour Therapy. 2011;40(2):111-25

 This is a meta-analysis of 13 studies that measured the outcomes of telehealth treatment for post-traumatic stress disorder symptoms. The types of telehealth treatment used included telephone, videoconferencing and internet based modalities. Very briefly, telehealth treatments produced a significant improvement in PTSD symptoms and depression symptoms compared to patients who were on the waiting list for treatment. Compared to in-person treatment, telehealth treatments were as effective for depression symptoms, but not as effective for PTSD symptoms. They did not report comparisons between video, telephone or internet based treatments, so we are not able to say if any of these are better than the others.  The results of this review are quite strong as they quantitatively combined the findings from this group of studies to look at the total effect size of the treatment.

Psychological treatment

Backhaus, A., Agha, Z., Maglione, M. L., Repp, A., Ross, B., Zuest, D., et al. (2012). Videoconferencing psychotherapy: a systematic review. Psychological Serv, 9(2), 111-131.

This review is about delivering psychological therapy by video communication. The authors concluded that a strong therapeutic relationship could be developed over video communication and that treatment outcomes, as well as patient satisfaction, were similar to in-person treatment. About half of the studies used cognitive behaviour therapy and the others were a very wide range of different types of treatment, with some ecclectic or undifferentiated treatments. The conditions treated included post-traumatic stress disorder, other anxiety disorders, anorexia, and mood disorders.

Psychological treatment with children and adolescents

Slone, N. C., Reese, R. J., & J., M. M. (2012). Telepsychology outcome research with children and adolescents: a review of the literature. Psychological Serv, 9(3), 272-292.

This review summarises the evidence on using telehealth to treat children and adolescents. Video consultations: 3 randomised controlled trials found that treatment via videoconferencing delivered outcomes that were equal to or (in one case) better than in-person treatment. Internet based treatments: these include chat, email and discussion forums, interactive games and psychoeducational materials. There were 35 studies in this group; results were quite successful for treating eating disorders, equivocal for smoking cessation, promising but preliminary for drug and alcohol abuse, and useful for reducing emotional distress. In general, telephone based services were about as effective as internet based services. There was not enough research doing comparisons between telephone and video to make a useful comparison.

Psychosis assessment and treatment

Sharp IR, Koback KA, Osman DA. The use of videoconferencing with patients with psychosis: a review of the literature. Ann Gen Psychiatry. 2011;10:14.

This review firstly concludes that psychosis can be accurately assessed via video consultation. Also, patient management can be done to an equivalent standard, and offers benefits of reduction in travel, improvement in access and decreased hospitalizations. Patient satisfaction is generally high, and there were several reports of patients preferring video consultations to in-person consultations. While this has not been researched fully, preliminary indications are that this might be because some patients feel less anxiety in the video situation, because there is a greater distance between themselves and the psychiatrist. It is particularly useful to note that video consultations do not exacerbate psychotic symptoms; in theory one might be concerned that this could happen because it is common for psychotic patients to have delusions about being watched through their television and so forth. Fortunately this does not appear to be the case.

Physiotherapy

Posted 12th November 2012 There are only a small number of peer reviewed publications about delivering physiotherapy by telehealth, and most are associated with rehabilitation services. There is a much larger literature on telerehabilitation, which is multi-disciplinary rather than specific to physiotherapy, so includes services by exercise physiologists and generic rehabilitation therapists. We could not find any systematic reviews just about telephysiotherapy, but have included one about telerehabilitation which contained articles about telephysiotherapy. Focusing on recent articles in which physiotherapists were directly involved in service delivery, most research was about specific conditions or parts of the body, as listed below.

Systematic Review

Huis, M.H.A., van Dijk,  H., Hermens, H.J. and Vollenbroek-Hutten, M.M.R. (2006) A systematic review of the methodology of telemedicine evaluation in patients with postural and movement disorders. J Telemed Telecare 12 (6): 289-297.This systematic review searched for studies of telemedicine delivery for patients with posture and movement disorders, in particular where the delivery included health care providers both with the patient and at a distant site. Rather than looking at the effectiveness of the service delivery, the review was focused on the quality of the research, which in general was limited to feasibility and acceptability studies, although they were about to conclude that telemedicine is acceptable to both patients and professionals when used in rehabilitation. Some of the 22 articles included in the review utilized physiotherapists, but they are all pre-2006.

Knees

Tousignant, M., Moffet, H., Boissy, P., Corriveau, H., Cabana, F., Marquis, F. (2011) A randomized controlled trial of home telerehabilitation for post-knee arthroplasty. J Telemed Telecare 17: 195–198. 48 patients were recruited to compare the effectiveness of home telerehabilitation with conventional rehabilitation following knee replacement surgery. Physiotherapists conducted the rehabilitation via videoconferencing to the patients’ homes. One hour treatment sessions were provided twice weekly for 8 weeks. Results showed that home telerehabilitation was at least as effective as usual care, and has the potential to increase access to therapy in areas with high speed Internet services. Russell, T. G., Buttrum, P, Wootoon, R., and Jull, G. A. Low-bandwidth telerehabilitation for patients who have undergone total knee replacement: preliminary results. J Telemed Telecare 2003; 9 (Suppl. 2): S2:44–47. 21 patients were selected after total knee arthroplasty to receive a 6 week rehabilitation program randomized to telerehabilitation or the ususal face-to-face method. The telerehabilitation consisted of weekly video consultations with a physiotherapist who had a range of software tools to assist in remote assessment and measurement of the patient. Although both arms of the study were conducted in the hospital, the video arm was set up to be a low bandwidth connection comparable to the type of connectivity available in the home. The level of physical and functional improvement was similar in both groups, and the patients were very satisfied with telerehabilitation. Russell, T. G., Buttrum, P, Wootoon, R., and Jull, G. A. (2011) Internet-Based Outpatient Telerehabilitation for Patients Following Total Knee Arthroplasty
A Randomized Controlled Trial. J Bone Joint Surg Am. 93:113-20.After the trial described above, the same group of researchers went on to conduct a formal non-inferiority trial with 65 participants who were randomized to receive the 6 week program of outpatient physical therapy either in the conventional manner or via a weekly videoconferencing session. The outcomes achieved via video rehabilitation were comparable with conventional rehabilitation. Both arms of this trial were still conducted at the hospital, although I would add a comment that bandwidth to the home is now much better than the conditions that were set up for the trial.

Shoulder

Eriksson, L., Lindstrom, B., Gard, G., and Lysholm, J. (2011) Physiotherapy at a distance: a controlled study of rehabilitation at home after a shoulder joint operation. J Telemed Telecare 15(5): 215-220. In this study of 22 patients, 10 had physiotherapy after shoulder joint replacement via video communication to the home and 12 had conventional treatment. Both groups of patients received 2 to 3 sessions of treatment initially, then reducing to once a week in the latter part of the 8 week program. The telehealth group improved significantly more than the control group, and the authors suggested that this may be because the telehealth group had no break in the “rehabilitation chain”, hence no period of inactivity of the shoulder. They conclude that there seem to be clear benefits from physiotherapy at a distance with a telemedicine technique that allows patients to obtain access to physiotherapy at home. Eriksson, L., Lindstro, B. and Ekenberg, L. (2011) Patients’ experiences of telerehabilitation at home after shoulder joint replacement. Journal of Telemedicine and Telecare 2011; 17: 25–30  This study is a qualitative analysis of the 10 patients who received video-based physiotherapy at home in the study above. They speculate that the frequent interplay with the patient during telerehabilitation made it possible for the physiotherapist to make an individual judgment about each patient, and this could be one reason for the positive findings. They suggest that home video-based physiotherapy may be useful for other kinds of conditions.

Elbow

Lade, H., McKenzie, S., Steele, L., & Russell, T. G. (2012). Validity and reliability of the assessment and diagnosis of musculoskeletal disorders using telerehabilitation. J Telemed Telecare, 18(7), 413-418.The anatomical diagnosis, system diagnosis and physical examination findings of 10 patients with elbow problems were assessed by both face-to-face and telehealth physiotherapy examinations. There was good agreement in most categories of examination except for ULNT nerve tests. They conclude that performing a telerehabilitation physical examination to determine a musculoskeletal diagnosis of the elbow joint is valid and reliable. (I would comment that patient numbers were small and more research would be beneficial)

Arm/hand

Huidgen, B.C.H., Vollenbroek-Hutten, M.R., Zampolini, M., Opisso, E., Bernabeau, M., et al (2008) Feasibility of a home-based telerehabilitation system compared to usual care: arm/hand function in patients with stroke, traumatic brain injury and multiple sclerosis. J Telemed Telecare 2008; 14: 249–256. 81 patients were recruited in a randomized controlled multicenter trial to investigate the feasibility of a telerehabilitation invervention for arm/hand function at their homes. The telehealth intervention was a system called the Home Care Activity Desk (HCAD), which is a physical unit which the patients used for hand/arm exercises, plus videoconferencing. The telehealth intervention was as effective as usual care, and the authors conclude that a telerehabilitation intervention using HCAD may increase the efficiency of care. It was not completely clear from the article as to whether the therapists were physiotherapists or another type of rehabilitation therapist.

Rehabilitation Assistance Training

Maeno, R,, Fujita, C., and Iwatsuki, H. A pilot study of physiotherapy education using videoconferencing. Journal of Telemedicine and Telecare 2004; 10 (Suppl. 1): S1:74–75.This was a simulation study to see if it was possible for physiotherapists to give instruction at a distance to people who had no prior knowledge of assistive techniques. The participants were taught how to assist patients with hemiplegia in activities of daily living, via videoconferencing.  From the results, they conclude that the delivery of rehabilitation services is feasible in remote places. My comment is that this conclusion is a bit of an overstatement, but this work does illustrate the important role of physiotherapists in training carers or unskilled assistants at a distance, in order to improve the local care of patients.

Post-Cardiac Surgery Rehabilitation

Scalvini, S, Zanelli, E., Comini, L., Dalla Tomba, M., Troise, G., et al (2009) Home-based exercise rehabilitation with telemedicine following cardiac surgery. Journal of Telemedicine and Telecare 2009; 15: 297–301. 47 patients were enrolled in a home based rehabilitation programme one month after cardiac surgery. Physiotherapists gave training to the patients whilst they were still in hospital and did a single home visit in person the day after discharge. From then on, the patient was in contact by telephone and also by transmitting ECG data before each home exercise session. Results showed that this home based rehabilitation program was able to be implemented as well as a hospital-based program and that patient satisfaction was 95% overall.

Residential Aged Care

Delivering specialist telehealth services to residential aged care facilities (also known in the literature as long-term care facilities or nursing homes), is a part of Australia’s telehealth initiative. The Medicare item numbers are available for medical specialists to deliver video consultations to aged care facilities in any geographic location. Our literature search of delivery of services to aged care facilities has found one review and a group of smaller studies:

Review

Brignell, M., Wootton, R., Gray, L.  (2007)  The application of telemedicine to geriatric medicine.  Age and Ageing.  Doi:10.1093/ageing/afm045

This is a comprehensive review of the use of telemedicine in geriatrics, which aimed to identify current and potential applications to clinical practice. It included 174 clinical studies, of which the vast majority were real time video to patients. There were very few reports of store-and-forward telehealth or contact between health workers only. Several of the studies in this review were about telehealth to nursing homes being used to triage potential hospital admissions, and all of these studies found that a proportion of the patients could be managed without transfer to hospital.

Medical Specialist Consultations

This group of studies are about providing specialist medical services to aged care facilities

Gray, L.C., Edirippulige, S., Smith, A.C., Beattie, E., Theodoros, D., Russell, T. & Martin-Khan, M. (2010)  Telehealth for nursing homes:  the utilization of specialist services for residential care.  Journal of Telemedicine and Telecare, 18: 142-146.

This is a very useful piece of research because it documents the current rate of in-person specialist services to a large (441 bed) urban residential aged care facility in Australia. Therefore it gives a baseline of the pattern of use prior to introducing telehealth. Over a six-month
period there were 3333 consultations (a rate of 1511 consultations per year per 100 beds). They concluded that many services which are currently being provided on site to metropolitan long-term care facilities could be provided by telehealth in both urban and rural facilities.

Wakefield, B.J., Buresh, K.A., Flanagan, J.R., Kienzle, M.G. (2004)  Interactive video specialty consultations in long term care.  Journal American Geriatrics Society: 52: 789-793. 

This study assessed provider and resident satisfaction and the outcomes of specialist physician consultations provided via video consultation to residents of two long-term care centres in Iowa, USA. The most commonly delivered specialist services were neurology, urology, cardiology and general surgery. There was a high rate of physician, patient and nurse satisfaction with interactive video conferencing, and the most frequent outcome of the video consultations was a change in the treatment plans for the residents.

Hui, E. & Woo, J. (2002)  Telehealth for older patients:  the Hong Kong experience.  Journal of Telemedicine and Telecare, 8 (Suppl. 3): S3: 39-41.

This study investigated the feasibility, acceptability and cost-effectiveness of using telemedicine to provide geriatric services to residents of a 200 bed nursing home. A community geriatric assessment team provided videoconferencing to replace conventional outreach or clinic-based geriatric care for one year. Participating specialists conducted 1001 tele-consultations, then evaluated the feasibility of this approach. Telemedicine was cheaper than conventional care, and well accepted by health-care professionals as well as clients. Substantial savings were achieved in the study period through a 9% reduction in visits to the hospital emergency department and 11% fewer hospital bed-days. The authors concluded that telemedicine was a feasible means of care delivery to a nursing home and resulted in enhanced productivity and cost-savings.

Telepsychiatry

We found two studies in this area.

Rabinowitz, T., Murphy, K.M., Amour, J.L., Ricci, M.A., Caputo, M.P., Newhouse, P.A. (2010)  Telepsychiatry to Aged Care Facilities.  Telemedicine and e-Health, Vol. 16, No. 1.

Data from 278 telepsychiatry encounters with 106 nursing homes residents were examined to estimate potential cost and time savings between telemedicine and in-person care.  The authors concluded that videoconferencing is a cost effective and medically acceptable alternative to face-to-face care, providing essential care that would not otherwise be available.  

Yeung, A., Johnson, D.P., Trinh, N-H., Weng, W-C.W., Kvedor, J. & Fava, M. (2009)  Feasibility and effectiveness of telepsychiatry services in Chinese immigrants in a nursing home.  Telemedicine and e-Health, 336-341. DOI: 10.1089/tmj.2008.0138

In this small study a psychiatrist conducted initial consultations with 9 monolingual Chinese residents, and then did follow up visits by telepsychiatry. The authors concluded that it is feasible to provide psychiatry consultations to ethnic immigrants in a nursing home despite the fact that many of them are unfamiliar with the technology and suffer from dementia and psychotic symptoms. Telepsychiatry may decrease the disparities in treatment of mental illnesses among ethnic immigrants in nursing homes.

General Practice or Primary Care Physicians

Weiner, J., Schadow, M.D., Lindbergh, D., Warvel, J., Abernathy, G., Perkins, S.M., Fyffe, M.S., Dexter, P.R., McDonald, C.J.  (2003)  Clinicians’ and patients’ experiences and satisfaction with unscheduled, nighttime, internet-based video conferencing for assessing acute medical problems in a nursing facility. AMIA Annu Symp Proc 709-713.

This study conducted a clinical trial of unscheduled, nighttime videoconferencing in a nursing home, where on-call physicians usually provided care by telephone from remote locations.  Although most calls for medical problems did not lead to videoconferencing, physicians and nursing home residents were satisfied with videoconferencing when it did occur, and physicians reported that making medical decisions was easier with videoconferencing.

LaFlamme, M.R., Wilcox, D.C., Sullivan, J. Schadow, G., Lindberg, D., Warvel, J., Buchanan, H., Ising, T., Abernathy, G., Perkins, S.M., Daggy, J., Frankel, R.M., Dexter, P., McDonald, C.J. & Weiner, M.  (2005)  Journal of American Geriatrics Society, Vol. 53, No. 8.

The aim of this study was to pilot and assess the role of videoconferencing in clinicians’ medical decision-making and their interactions for a 240 bed urban nursing home. The clinicians that participated in the study were providing routine medical care to the residents. They conducted first a videoconference, directly followed by a face-to-face consultation for each episode of service. Face-to-face examination was judged to be superior for most assessments, but videoconferencing was regarded as valuable, especially for wound care, and in situations where a clinician is not immediately available.

Telenursing services

This study is about providing additional specialized nursing services to aged care facilities.

Chan, W.M., Woo, J., Hui, E. & Hjelm, N.M. (2001)  The role of telenursing in the provision of geriatric outreach services to residential homes in Hong Kong.    Journal of Telemedicine and Telecare, Vol. 7, 38-46.

A residential nursing home in Hong Kong was linked to a community geriatric team based in a regional hospital by videoconferencing.  The geriatric team provided patient education on the use of metered dose inhalers, wound management and a falls prevention program. 89% of the services could be provided by telemedicine alone and only 11% required with on-site visits.  The acceptability of the service from residents and nursing home staff was good.

Allied Health Services to Aged Care Facilities

This set of four publications are all from the same Australian study about providing allied health services to aged care facilities in Queensland.

Guilfoyle, C., Wootton, R., Hassall, S., Offer, J., Warren, M., Smith, D., & Eddie, M.  (2002)  Videoconferencing in facilities providing care for elderly people.  Journal of Telemedicine and Telecare, 8 (Suppl. 3): S3 22-24.

Two studies were conducted to test the feasibility of delivering care by videoconferencing to facilities providing care for elderly people. During the first study, no consultations, care plans or assessments were conducted. During the second study, 120 assessments were conducted in just over two weeks, both face to face and by videoconference. Why was one project so successful and the other not? The successful study had greater ownership and direct involvement of key staff, more extensive planning, enthusiastic participants, and more difficulty accessing in-person services.

Guilfoyle, C., Wootton, R., Hassall, S., Offer, J., Warren, M. & Smith, D. (2003) Preliminary experience of allied health assessments delivered face to face and by videoconference to a residential facility for elderly people.  Journal of Telemedicine and Telecare, 9: 230-233.

The study also investigated whether allied health assessments carried out via videoconferencing were comparable to assessments carried out face to face. Five allied health therapists (in dietetics, occupational therapy, physiotherapy, podiatry and speech pathology) conducted 120 assessments, both face to face and by videoconferencing.  Although the therapists expressed a preference for in-person work, care plans formulated via videoconferencing were similar to those formulated in face-to-face assessment. It was concluded that allied health assessments carried out by videoconferencing were feasible.

Guilfoyle, C., Wootton, R., Hassall, S., Offer, J., Warren, M., Smith, D. & Eddie, M. (2003)  User satisfaction with allied health services delivered to residential facilities via videoconferencing.  Journal of Telemedicine and Telecare, 9: S1 52-54.

This article reports the measurement of user satisfaction from the same study as above, measured with questionnaires and focus groups. Most of the allied health providers preferred conducting face-to-face assessments. The aged care facility staff gained greater understanding of allied health services, increased confidence about making allied health referrals, and felt less isolated.

Hassall, S., Wootton, R. & Guilfoyle, C. (2003)  The cost of allied health assessment delivered by videoconference to a residential facility for elderly people.  Journal of Telemedicine and Telecare, 9, 234-237. 

This study compared the cost of providing allied health assessments to high-dependency residents of a rural facility for elderly people by videoconferencing vs face-to-face. The observed costs in a three-month pilot trial were used to estimate the annual costs. Allied health assessments delivered by videoconferencing became cheaper at workloads of approximately 850 occasions of service annually. Additional increases in the workload further improved the financial viability of this approach to service delivery.

Attitudes and Uptake Issues

These two studies focus on the processes of uptake.

Chang, J-Y., Chen, L-K., Chang, C-C. (2009)  Perspectives and expectations for telemedicine opportunities from families in nursing home residents and caregivers in nursing homes.  International Journal of Medical Informatics, 78, 494-502.

This study assessed current perspectives on, and expectations for, telemedicine by conducting 116 interviews of nursing home caregivers and families of nursing home patients in Taipei, Taiwan. The study concluded that nursing home caregivers and families of nursing home patients are highly interested in telemedicine; however, they are only willing to pay a slightly higher cost of nursing care for this service.

Loh, P-K., Flicker, L. & Horner, B. (2009)  Attitudes toward information and communication technology in residential aged care in Western Australia.  Journal of American Directors Association, 10: 408-413.  DOI:10.1016/j.jamda.2009.02.012

A project in Western Australia was conducted to introduce ICT to aged care facilities, with the aim of preventing residents being transferred to hospitals by re-engineering workflow. The intention was that the resident’s usual GP would visit the facility and be with the patient whilst having a video consultation to a distant specialist geriatric service. Only one videoconference occurred in three months, so an evaluation was conducted to discover why the project failed. The investigators concluded that the main issue was that staff needed more training in ICT. I looked a little deeper into this study and I am not convinced: as well as technical issues and lack of experience with ICT by both staff and residents, I note that the GPs were unable to schedule appointments for videoconferencing, and residential facility staff also found it difficult to attend.

Video Communication with Family Members

It has always seemed to me that if an aged care facility has video communication capability, then there is the potential to extend this to the residents’ families, particularly as family members may live across town or interstate and find it difficult to visit regularly. So I was interested to see that this has been tested and found to be useful.  

Savenstedt, S., Brulin, C. & Sandman, P-O. (2003)  Family members’ narrated experiences of communicating via video-phone with patients with dementia staying at a nursing home.  Journal of Telemedicine and Telecare, 9: 216-220.

A qualitative study was conducted on the experience of family members using videophones to communicate with elderly demented patients in a nursing home. In most cases the videophone conversations needed staff assistance in order to be meaningful. Content analysis showed that patients’ relatives became more involved in the caring process, and in some cases the videophone conversations were more focused and of better quality than face-to-face conversations. They concluded that videophones have the potential to be useful tools for family members caring for elderly relatives.

Tsai, H-H., Tsai, Y-F. (2011) Changes in Depressive Symptoms, Social Support, and Loneliness Over 1 Year After a Minimum 3-Month Videoconference Program for Older Nursing Home Residents.  Journal of Medical Internet Research, 13(4):e93.

A longitudinal quasi-experimental study evaluated the long-term effectiveness of a videoconference intervention in improving nursing home residents’ social support, loneliness, and depressive status over 1 year.  Sixteen nursing homes in various areas of Taiwan were selected, and 90 elderly residents were divided into an experimental (n=40) and a comparison group (n=50).  The experimental group received at least five minutes per week for three months of videoconference interaction with family members.  Results showed that videoconferencing with family members had a long-term effect in alleviating depressive symptoms and loneliness for elderly residents in nursing homes.

Hensel, B.K., Demiris, O.D.P., Willis, L.  (2006)  A telehealth case study of videophone use between family members. AMIA Annu Symp Proc 2006:948.

This study explored telehealth communication between nursing home residents and a geographically distant family member.  Participants communicated regularly for three months by video phone.   Conclusions reached were that videophone applications have a positive psychosocial and other health-related effects for residential patients.