Review of effectiveness criteria in the application of Telemedicine
Sanid. mil. 2020; 76 (3) 167
or interoperability. Many of these barriers could be addressed
through training and /or focused policy making.
For example, in the State of Mississippi (42), they embraced
since 2003 Telemedicine as a way to address the low physician
density. One of the key actions was taken by the Mississippi In-surance
Code which in its Parity Law required reimbursement
for Telemedicine services at the same rate as regular medical ser-vices,
solving the concerns about reimbursement amongst prac-titioners.
Another important barriers are legal issues and uncertainty
(30). For example, whose responsibility it is if due to a misunder-standing
the patient missuses a device, proliferation of devices
not yet approved by the FDA, privacy protection of the solution
creator and safety.
Finally, an additional concern is that with a proliferation of
medical applications available, patients would do their own diag-nosis
and avoid visiting a practitioner with the associated health
risk (16).
Acceptance
In general, studies show a positive acceptance of Telemedi-cine
by patients. There are examples of indigenous tribes tending
to be satisfied with telehealth (19), although it is not clear if this
is about telehealth per se or about the benefits of receiving any
service at all in a remote community. Another broader article
(43) found that patients expectations were met when providers
delivered healthcare via videoconference or any other telehealth
method. The main sources of satisfaction listed were improved
outcomes, preferred modality, decrease travel time, ease of use
and improved communication.
Additional applications and growth
Beyond the examples described above, there are specific initi-atives
that had been launched to assess the effectiveness of Tele-medicine
to address concrete health challenges.
One of them, the Kidney Health Initiative (44) identified
several benefits of using Telehealth in renal patients including
a potentially increased acceptance and uptake of home-based
dialysis modalities giving patients higher level of independence
while simultaneously providing a strong support network to
ensure good outcomes. Another identified benefit included on-going
training, education and counseling opportunities for the
patient as a telehealth care team would monitor the patient and
avoid infections and injuries. A final benefit could be to moni-tor
the treatment and collect parameters for immediate action or
storage for later analysis.
Another initiative is to address home blood pressure meas-urement
(45). Hypertension guidelines recommend the use
of home pressure monitoring for hypertension management.
However, patients seem to do it wrongly or at no specific times.
Telemonitoring of home Blood Pressure readings overcomes
many of these barriers and has the potential to increase the
accuracy, efficiency and convenience of home Blood Pressure
monitoring. Nevertheless, certain structural and financial bar-riers
must first be overcome including the concern for security
and data privacy.
Scope expansion
To address the physicians shortage, especially in developed
countries where Healthcare costs are growing due to popula-tion
aging, there have been some interventions focused on lev-eraging
pharmacists to provide telemedicine in outpatient or
ambulatory care setting (46). The studies analyzed had mainly
a positive impact with higher impact rate when the intervention
was scheduled and continuous vs responsive and reactive. A
variety of technologies were utilized including telephone, vid-eoconsultation,
text or electronic messaging, email, automated
electronic reports and fax. The interventions included pharma-cist-
led telephonic clinics, post discharge follow up, medication
counseling, virtual management by an interdisciplinary team,
remote monitoring of lab values and vital signs, medication
therapy management, text reminders and instructional videos
or calls. Illnesses included hypertension, diabetes, anticoagu-lation,
depression, hyperlipidemia, asthma, heart failure, HIV,
PTSD, chronic kidney disease, stroke, COPD and smoking
cessation. Positive outcomes were measured on three aspects:
clinical disease management, patient self-management and ad-herence.
Another application of telemedicine techniques in a broad
setting was reviewed in an article that evaluated 23 controlled
trials of eHealth interventions for reducing mental health condi-tions
in employees (47). Three main types of interventions were
identified including cognitive Behavioral Therapy, Stress man-agement
and mindfulness based treatments. Of these, Mindful-ness
showed larger effects than the other two although organiza-tions
should be aware that achieving the best outcomes depends
upon providing the right type of intervention to the correct pop-ulation.
CONCLUSIONS
Telemedicine experiences are growing across the world and
a growing number of countries are adopting eHealth strategies
and launching initiatives. While Telemedicine can solve two basic
issues -accessibility and sustainability – most studies are focused
on the latter: how to provide a sustainable service in developed
countries where the percent of GDP dedicated to Health care
is growing faster than GDP. When studying sustainability, there
are two main concepts that are analyzed: cost – effectiveness
and health outcomes. The studies reviewed showed that there is
limited evidence of both mainly based from a lack of common
approach to which costs should be included (direct, indirect, op-portunity
costs) and proper controlled trials. Still, there seems
to be some areas of telemedicine that are growing faster than
others, specifically Teleradiology, Telepathology, remote patient
monitoring, Teledermatology and Telepsychiatry and patients
acceptance seems to be overall positive (12).
In order to build Telemedicine’s growth on strong founda-tions,
we recommend a higher degree of coordination in the defi-