Monfort-Vinuesa C., et al.
in healthcare provision, as well as education, consulting and re-search
(9).
In the provision of healthcare services, it supports the troops
both in operative and non-operative areas, broadening its scope
to healthcare professionals, non-healthcare personnel, military
and civil population in the area where the Armed forces may be
running their mission. In operative areas, it represents a higher
hierarchy Role 4 (HCDGU) for healthcare support, providing
24h coverage 7 days per week all year long (10). This important
role is performed through teleconsultations with healthcare spe-cialists
located in HCDGU, running complementary tests in real
time (i.e. electro cardiograms, eco cardiograms, ultrasounds) as
well as surgical tele assistance and tele-endoscopy, among others
(11).
The development of this role started with the assistance to the
troops deployed in Mostar (Bosnia-Herzegovina) in peace-keep-ing
operations. It was possible to transmit bone x-rays to diag-nose
potential fractures (9).
Since that first case, the service has evolved to nowadays,
when it provides more than two hundred teleconsultations per
year.
Globally, the first articles from the article search on which
this manuscript is based on appeared in 1990. However, across
articles there are a number of concepts that are used indistinc-tively
although they indeed are distinct. The key concepts to
clarify are:
1. eHealth: «the cost effective and secured use of Infor-mation,
Communication and Technology (ICT) in support of
health and health related fields, including Healthcare servic-es,
health surveillance, health literature and health education,
knowledge and research» (World Health Assembly resolution
WHA 58.28 in 2005).
2. mHealth: «the use mobile devices, mobile phones, patient
monitoring devices, PDAs and wireless devices for medical and
public health practice (ex. Telephone helplines, text message ap-pointment
reminders, mobile telehealth and mobile access to
Electronic Patient info)».
3. TeleHealth: «The practice of medicine at a distance – in-volves
the interaction between a Healthcare provider and a pa-tient
where the two are separated by a distance» (12).
Despite TeleHealth being a concept that has been around for
nearly 20 years, and the increasing number of World Health Or-ganization
(WHO) member states that report an eHealth strate-gy
(58% in the latest GOe report) (12), there are still very limited
studies that report its effectiveness in a conclusive way.
The objective of this article is to define and scope the concept
of «effectiveness» in the implementation of telemedicine.
MATERIALS AND METHODOLOGY
We conducted a literature review on Pubmed database from
January 2014 to March 2019 using the english words of Tele-medicine
and Telehealth together with the words cost effective-ness,
economics and military. The review has been established
according to the following inclusion and exclusion criteria.
This manuscript focuses on Telemedicine as synonym to
Telehealth.
162 Sanid. mil. 2020; 76 (3)
Inclusion criteria:
• WHO published documents plus four articles from the
Global Observatory of Health from the World Health Organi-zation
(WHO), specifically «Making universal health coverage
achievable». «Report of the third global survey on eHealth»,
«Global strategy on human resources for health: workforce
2030», «Public Spending on Health: A Closer Look at Global
Trends» y «Atlas of eHealth country profiles: the use of eHealth
in support of universal health coverage» based on the findings
of the third global survey on eHealth 2015 were also included to
contextualize the reviewed articles within the WHO perspective
• Bibliographic search in Pubmed database of articles in
english language with keywords Telemedicine, Telehealth, cost
effectiveness, economics and military in the period between Jan-uary
2014 to March 2019.
• Articles defined as reviews.
Exclusion criteria:
• It has been limited to the articles that NOT included those
words (Telemedicine, Telehealth, cost effectiveness, economics
and military).
• Article’s abstract did not correspond to this review’s ob-jective.
• Articles that despite having some of the target words in the
abstract, the article did not cover the topic of this review.
CONCEPTS
Definition of «effectiveness»
A core part of this difficulty is the fact that there is not a
single way of evaluation its effectiveness. In the Dec 2016 GoE
Global survey on eHealth (12), only 29 countries reported that
there was a Government sponsored TeleHealth evaluation and
of those, only 22 reported the criteria. Even more, when re-porting
the criteria this varied across countries from program
acceptance by the providers (16 of the countries) to cost effec-tiveness
in target groups (10 countries) including program ac-ceptance
by the target groups (14 countries) or health outcome
(11 countries).
Relevance
Universal Healthcare Coverage is a global challenge both in
terms of sustainability and accessibility. In 2016, total Health
care expenditure was $7.5 trillions equivalent to ≈10% of global
Gross Domestic Product (GDP). Moreover, from 2010 to 2016
global Healthcare expenditure grew at an annual rate of 4%, well
above GDP growth (2.8%) (13).
Expenditure per country varied from a very small 1.3% of
GDP at Timor Leste to a 17.1% in USA. Access to practition-ers
also shows huge dispersion from 0.02 physicians per 10.000
inhabitants in Malawi or Niger to 7.74 physicians per 10.000 in-habitants
in Qatar (14).
TeleHealth is expected to be an answer to these challenges
by delivering cheaper – and more convenient - care to patients
in specific diseases, leveraging adjacent professionals (i.e. Phar-