Telehealth for long term conditionsBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4201 (Published 21 June 2012) Cite this as: BMJ 2012;344:e4201
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The evaluation of‘Telehealth/Telemedicine’: Problems with the definition of the intervention and target population are more than just semantics.
The term Telehealth is often used synonymously with telemedicine in the literature. Some investigators call for a distinction to be made such that telehealth is reserved as a more general term referring to clinical and non-clinical services such as administration, education and research. The analogy is that telemedicine should not be synonymous with teleheath, just as medicine is not synonymous with healthcare . Likewise, ‘e-medicine’ or ‘e-health’ is used mainly by European health systems as a general term that includes the practice of telemedicine with other aspects of innovative healthcare infrastructure such as electronic patient information records and internet-based referral services.
The definition of telemedicine is made complicated by an attempt to find a unifying description for a diverse range of technological methods supporting a diverse range of medical practices.
Telemedicine refers to communication amongst health professionals, as well as communication between the healthcare professional and the patient (teleconsulting). Communication between health professionals has acquired definitions based on specialty (e.g. teleradiology, telepathology), but some specialties have adopted specialty specific terms to describe their interactions with patients (teledermatology, telepsychiatry). The patient may be the provider of information through answers to questions or through the active or passive transfer of physiological data. This data may form part of the diagnostic process, provide information used to assess the response to a treatment, or provide information to monitor wellbeing.
The mode of communication may be through telephone communications (audio only/facsimile/mobile telephones ‘m-health’), audiovisual communications (teleconferencing), data transfer (telemetry, biotelemetry, radiotelemetry, remote monitoring, biomonitoring, telemonitoring), or internet based (email, ‘medicine online’, patient websites/chat rooms). Communication can occur in real-time (synchronous) or, in the case of data acquisition and subsequent transfer, ‘store and forward’ (asynchronous) methods may be utilized.
Despite the fact that the telephone remains the cornerstone of all modern day telecommunications, there are divided opinions as to whether the telephone consultations between healthcare professionals and patients should be included in the broad definition of telemedicine. Some investigators prefer to restrict the use of the term telemedicine to two or more modes of communication i.e. Audio and visual and/or other data transfer. Several of the systematic reviews of telemedicine to date restrict the definition in this way [2, 3].
This inherent heterogeneity within the umbrella of telemedicine has led to difficulties with its evaluation. Attempts at furthering knowledge of the effects of telemedicine through meta-analysis of published results have been largely unsatisfactory due to the implementation of a wide range of methodologies on an ill-defined population . In a systematic review of literature between 1966 and 2000, which was designed to investigate which areas of telemedicine showed clinical or cost effectiveness, only 50 of the 1124 identified articles were deemed to fulfill the inclusion criteria . A systematic review in 2006 by Hersh et al. analysed 106 studies, but only 25 of these were considered to have a well designed RCT methodology, with many of the remainder using inadequate control groups . Some researchers have set out to perform a systematic review but the quality of data has meant that they fall short of their aims, with the “intended systematic analysis abandoned in favour of a more general review” . Even high quality systematic reviews in telemedicine were unable to answer fundamental questions on clinical or cost effectiveness [2, 3, 6].
As Car et al  allude to in their editorial, the ambitious NHS evaluation of ‘Telehealth’ is destined for mixed outcomes and inconclusive bottom lines. This wieldy all-inclusive definition needs to be broken down into its component parts and digested piecemeal. Only then can the merits of specific telehealth interventions on well-defined populations be evaluated.
1. Roine, R., A. Ohinmaa, and D. Hailey, Assessing telemedicine: a systematic review of the literature. CMAJ, 2001. 165(6): p. 765-71.
2. Currell, R., et al., Telemedicine versus face to face patient care: effects on professional practice and health care outcomes. Cochrane Database Syst Rev, 2000(2): p. CD002098.
3. Whitten, P.S., et al., Systematic review of cost effectiveness studies of telemedicine interventions. BMJ, 2002. 324(7351): p. 1434-7.
4. Hersh, W.R., et al., Diagnosis, access and outcomes: Update of a systematic review of telemedicine services. J Telemed Telecare, 2006. 12 Suppl 2: p. S3-31.
5. Brignell, M., R. Wootton, and L. Gray, The application of telemedicine to geriatric medicine. Age Ageing, 2007. 36(4): p. 369-74.
6. Bergmo, T.S., Can economic evaluation in telemedicine be trusted? A systematic review of the literature. Cost Eff Resour Alloc, 2009. 7: p. 18.
7. Car, J. Huckvale, K. Hermens, H. Telehealth for long term conditions. BMJ,2012;344:e4201
Competing interests: The author declares that he is employed as a Clinical Research Fellow by the Centre of Excellence in Personalized Healthcare, which is funded by the Wellcome Trust and EPSRC under grant number WT 088877/Z/09/Z.