i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771                   ...
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771                   ...
738                           i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 ...
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771              7393....
740                          i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0...
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771               741 ...
742                         i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ...
Table 1 – Systematic reviews reporting that telemedicine is effective.Reference           Conditions        Geographic    ...
744Table 1 (Continued)Reference             Conditions   Geographic         Service/             Outcome             Autho...
Prange et al.      Stroke            USA             Rehabilitation       Health                Eleven studies included. R...
746Table 1 (Continued)Reference             Conditions      Geographic        Service/               Outcome              ...
Demiris and       Older people,   Europe, USA,    Smart home       Behavioural, Health,    Twenty-one projects included (d...
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
Articulo: Systematic  Review Telemedicine
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Articulo: Systematic Review Telemedicine

  1. 1. i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771 journal homepage: www.intl.elsevierhealth.com/journals/ijmiEffectiveness of telemedicine: A systematic review ofreviewsAnne G. Ekeland a,∗ , Alison Bowes b , Signe Flottorp c,da Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, P.O. Box 6060, N-9038 Tromsø, Norwayb Department of Applied Social Science, University of Stirling, Scotland, UKc Norwegian Knowledge Centre for the Health Services, Oslo, Norwayd Department of Public Health and Primary Health Care, University of Bergen, Norwaya r t i c l e i n f o a b s t r a c tArticle history: Objectives: To conduct a review of reviews on the impacts and costs of telemedicine services.Received 23 April 2010 Methods: A review of systematic reviews of telemedicine interventions was conducted. Inter-Received in revised form ventions included all e-health interventions, information and communication technologies11 July 2010 for communication in health care, Internet based interventions for diagnosis and treat-Accepted 29 August 2010 ments, and social care if important part of health care and in collaboration with health care for patients with chronic conditions were considered relevant. Each potentially relevant sys- tematic review was assessed in full text by one member of an external expert team, usingKeywords: a revised check list from EPOC (Cochrane Effective Practice and Organisation of Care Group)Telemedicine to assess quality. Qualitative analysis of the included reviews was informed by principles ofTelecare realist review.Systematic review Results: In total 1593 titles/abstracts were identified. Following quality assessment, theEffectiveness review included 80 heterogeneous systematic reviews. Twenty-one reviews concluded thatOutcome telemedicine is effective, 18 found that evidence is promising but incomplete and others that evidence is limited and inconsistent. Emerging themes are the particularly problem- atic nature of economic analyses of telemedicine, the benefits of telemedicine for patients, and telemedicine as complex and ongoing collaborative achievements in unpredictable processes. Conclusions: The emergence of new topic areas in this dynamic field is notable and review- ers are starting to explore new questions beyond those of clinical and cost-effectiveness. Reviewers point to a continuing need for larger studies of telemedicine as controlled inter- ventions, and more focus on patients’ perspectives, economic analyses and on telemedicine innovations as complex processes and ongoing collaborative achievements. Formative assessments are emerging as an area of interest. © 2010 Elsevier Ireland Ltd. All rights reserved.Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737 2. Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 ∗ Corresponding author. Tel.: +47 952 66791. E-mail address: anne.granstrom.ekeland@telemed.no (A.G. Ekeland). URL: http://www.telemed.no (A.G. Ekeland).1386-5056/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ijmedinf.2010.08.006
  2. 2. i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771 737 3. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.1. Inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.1.1. Population/participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.1.2. Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.1.3. Comparisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.1.4. Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.1.5. Languages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.2. Exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.2.1. Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.2.2. Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.2.3. Interventions considered not relevant for the review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.2.4. Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738 3.3. Information sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739 3.4. Search. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739 3.5. Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739 3.6. Data collection process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739 3.7. Data items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739 3.8. Quality of systematic reviews and risk of bias in individual studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739 3.9. Summary measures and synthesis of results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739 4. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739 5. Telemedicine is effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739 6. Telemedicine is promising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 740 7. Evidence is limited and inconsistent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 740 8. Economic analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741 9. Is telemedicine good for patients? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741 10. Asking new questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741 11. Reflections on the methodology of our study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742 12. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742 Appendix 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742 Appendix B. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769 study focused on cost-effectiveness interventions concluded1. Introduction that there is no good evidence that telemedicine is or is not a cost-effective means for delivering healthcare [5].Previous reviews of telemedicine have concluded that The quality of studies is a recurrent concern in theseirrefutable evidence regarding the positive impact of reviews [1,2,4–6]. There is also a debate about appropriatetelemedicine on clinical outcomes still eludes us. One research methodologies. For example, economic analysis ofreview [1] of more than 150 articles concluded that poten- telemedicine has not yet met accepted standards [5]; there istial effectiveness could only be attributed to teleradiology, a relative lack of exploration of the socio-economic impacttelepsychiatry, transmission of echocardiographic images of telemedicine [7]; evidence on factors promoting uptake ofand consultations between primary and secondary health telemedicine is lacking [8]; there is relatively undeveloped use,providers. Another systematic review [2] that assessed more at the time, of qualitative methods [9]; many studies have notthan 1300 papers making claims about telemedicine out- been well-designed [4,10]; and, considering perceived difficul-comes found only 46 publications that actually studied at ties of building a robust evidence base for recent innovations,least some clinical outcomes. A review that analyzed the researchers have argued that simulation modelling needs fur-suitability of telemedicine as an alternative to face-to-face ther development [11].care [3] concluded that establishing systems for patient care The lack of consensus raises questions about the qualityusing telecommunications technologies is feasible; however, of research evidence in terms not only of the data collectedthe studies provided inconclusive results regarding clinical and analysed, but also in terms of the approaches to evalua-benefits and outcomes. A report on peer-reviewed litera- tion, that is, the underlying methodologies used, which mayture for telemedicine services that substituted face-to-face not be capable of addressing the questions to which differentservices with ICT-based services at home and in offices or stakeholders seek answers. Others have noted that evaluationhospitals [4] identified 97 articles that met the inclusion traditions do not sufficiently collaborate to cross borders andcriteria for analysis. The authors concluded that telemedicine that a common language for evaluation is missing [12].is being used even if the use is not supported by high quality This paper reports on research funded under EU SMARTevidence. Reviews on cost outcomes have fared similarly. A 2008/0064, which sought to review the evidence on the
  3. 3. 738 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771effectiveness of telemedicine with particular reference to 3.1.3. Comparisonsboth outcomes and methodologies for evaluation. This paper Reviews of studies comparing telemedicine to standard care orfocuses mainly on the evidence about effectiveness, and to another type of care, as well as reviews of studies comparingassesses the range of conclusions drawn by reviewers about different e-health solutions were included.the effectiveness of telemedicine and the gaps in the evidencebase. A companion paper focuses on the methodologicalissues and recommendations [13]. 3.1.4. Outcomes Only reviews reporting relevant outcomes were included, specified as health related outcomes (morbidity, mortality, quality of life, patient’ satisfaction), process outcomes (qual-2. Objectives ity of care, professional practice, adherence to recommended practice, professional satisfaction) and costs or resource use.The objective of the work was to conduct a review of reviews Systematic reviews reporting emerging issues, such as anon the impacts and costs of telemedicine services and con- unexpected finding or important new insights were alsosider qualitative and quantitative results, with the purpose included.of synthesizing evidence to date on the effectiveness oftelemedicine. The key questions addressed were firstly, howare telemedicine services defined and described in terms of 3.1.5. Languagesparticipants, interventions, comparisons and outcome mea- No articles were excluded based on language, although thesures; secondly, what are the reported effects of telemedicine: main focus of the project was telemedicine in Europe.thirdly which methodologies were used to produce knowl-edge about telemedicine in studies included; fourthly, what 3.2. Exclusion criteriaare the strengths and weaknesses of these methodologies,including HTA methodologies; and finally what are the knowl- 3.2.1. Designedge gaps and what methodologies can be recommended for Reviews considered not systematic, including commentariesfuture research? The present paper addresses the first two of and editorials, were excluded. Systematic reviews with majorthese questions, and identifies assessments of the evidence limitations (low quality reviews) according to a revised check-base provided within the reviews and knowledge gaps in terms list for systematic reviews from EPOC (Cochrane Effectiveof outcomes. Practice and Organisation of Care Group) were excluded. If the same authors had produced several publications of the same review, the most updated and/or the full report of3. Methods the review was selected, and other versions excluded. Disser- tations, symposium proceedings, and irretrievable documentsAn initial search identified systematic reviews of telemedicine were excluded.published from 1998. A systematic review was defined as anoverview with an explicit question and a method section witha clear description of the search strategy and the methods 3.2.2. Participantsused to produce the systematic review. The review should Studies with participants considered not relevant for thealso report and analyse empirical data. In addition, reviews review, for instance studies on use of ICT on people outsidewhich described or summarised methods used in assessing health care were excluded. Animal studies were excluded.telemedicine were included. Because of the large number ofreviews retrieved, a decision was taken to include only reviewspublished from 2005 and onwards in the final review. 3.2.3. Interventions considered not relevant for the review Other exclusions were studies on interventions considered not relevant for the review, such as studies on Internet and other3.1. Inclusion criteria ICT media used for information seeking; quality of informa- tion on the Internet; Internet based education of students and3.1.1. Population/participants health professionals, including use of games; medical tech-Systematic reviews on patients and consumers, health pro- nology in clinical practice in general, i.e. medical and surgicalfessionals and family caregivers, regardless of diagnoses or examinations and treatments based on computer technolo-conditions, were included in the searches for systematic gies, except when used as remote diagnosis and treatmentreviews. (telehealth); ordinary use of electronic patient records; use of telephone (including cell phones) only; e-health as only a very limited part of an intervention; use of Internet for surveys and3.1.2. Interventions research; online prescriptions; mass media interventions andAll e-health interventions, information and communication veterinary medicine.technologies (ICT) for communication in health care, Internetbased interventions for diagnosis and treatments, and socialcare if an important part of health care and in collaboration 3.2.4. Outcomeswith health care for patients with chronic conditions were Articles without relevant outcomes, i.e. not on the list of out-considered relevant. comes specified above under inclusion criteria, were excluded.
  4. 4. i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771 7393.3. Information sources to which the systematic reviewers had assessed risk of bias in individual studies.Literature searches of the following databases: ACM Digital Systematic reviews with major limitations were excluded.Library (ACM – The Association for Computing Machin- We assessed the methodological quality of studies in theery), British Nursing Index, Cochrane library (including field of telemedicine based on the review authors’ assess-Cochrane database of systematic reviews (CDSR), Database ments of risk of bias in the primary studies they hadof reviews of effects (DARE), Health Technology Assess- included.ment Database (HTA), CSA, Ovid Medline, Embase, HealthServices/Technology Assessment Text (HSTAT), Interna- 3.9. Summary measures and synthesis of resultstional Network of Agencies for Health Technology Assess-ment (INAHTA), PsycInfo, Pubmed, Telemedicine Information The authors analysed the data collected by the members ofExchange (TIE), Web of Science. the expert team. Due to the expected heterogeneity of stud- The main search was performed in February 2009, and an ies, regarding participants, interventions, outcomes and studyupdated search was performed in July 2009. designs, a quantitative summary measure of the results was not planned. We did a qualitative and narrative summary3.4. Search of the results of the systematic reviews. The results of the literature review were presented and discussed in two work-The search strategies are available on the website: (to be shops intending to validate results. In the first workshopinserted). different user groups took part and in the second workshop methodology experts participated. The analysis was inspired3.5. Study selection by principles of realist review [14], considered appropriate for complex interventions.Based on the criteria for inclusion and exclusion, AGE and SFindependently screened the lists of titles/abstracts identified 4. Resultsthrough searches for systematic reviews. Any discrepancieswere solved by discussion with the third member of the team, We identified 1593 records through the searches and excludedAB. The potentially relevant systematic reviews were retrieved 1419 following screening. We retrieved 174 potentially rel-in full text. evant articles in full text. We excluded 94 of these based on the pre-specified inclusion and exclusion criteria. The3.6. Data collection process qualitative synthesis below relate to 73 of the 80 included articles.Data collection was carried out online using a data extrac- The results of the 80 systematic reviews included are sum-tion form. Each potentially relevant systematic review was marised in seven tables in Appendix 1. Tables one throughassessed in full text by one member of an expert panel of six list populations, interventions, outcomes, results and con-reviewers. A revised check list from EPOC (Cochrane Effective clusions for the reviews cited in this paper, according to thePractice and Organisation of Care Group) was used to assess headlines presented in the discussion below. Table 7 list thethe quality of the systematic reviews. The quality domains seven included reviews not cited in this paper.assessed according to this checklist were methods used toidentify, include and critically appraise the studies in thereview, methods used to analyse the findings and an overall 5. Telemedicine is effectiveassessment of the quality of the review. The review team (AGE,AB and SF) subsequently checked review reports for agreement Twenty reviews (Table 1) concluded that telemedicine worksregarding the inclusion and exclusion criteria. and has positive effects. These include therapeutic effects, increased efficiencies in the health services, and technical3.7. Data items usability. Types of interventions that were found to be therapeuti-Data on type of participants, interventions and outcomes cally effective include online psychological interventions [15];included in the reviews were collected. Other data items were: programmes for chronic heart failure that include remotegeographical coverage of review, time frame of included stud- monitoring [16]; home telemonitoring of respiratory con-ies, range of data collection methods used in studies included ditions [17]; web and computer-based smoking cessationin the reviews, disciplines/areas covered and methodologi- programmes [18]; telehealth approaches to secondary preven-cal traditions included in the review. The reviewers were also tion of coronary heart disease [19]; telepsychiatry [20]; virtualasked to indicate emerging issues identified by the authors of reality exposure therapy (VRET) for anxiety disorders [21];the reviews. robot-aided therapy of the proximal upper limb [22]; inter- net and computer-based cognitive behavioural therapy for the3.8. Quality of systematic reviews and risk of bias in treatment of anxiety [23,24]; home telehealth for diabetes,individual studies heart disease and chronic obstructive pulmonary disease [25]; and internet based physical activity interventions [26]. AThe members of the expert team assessed the quality of the review comparing telepsychiatry and face-to-face work [27]systematic reviews, including questions regarding the degree found no differences between the two, and suggested that
  5. 5. 740 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771telepsychiatry will increase in use, particularly where it is are heterogeneous and interventions complex, making thesemore practical. difficult to understand [49]. Interventions that are effective in reducing health serviceuse include vital signs monitoring at home with telephonefollow-up by nurses [28]; computerised asthma patient educa- 7. Evidence is limited and inconsistenttion programs [29]; and home monitoring of diabetes patients[30]. Twenty-two reviews (Table 3) however concluded that the evi- Technical effectiveness and reliability are reported in dence for the effectiveness of telemedicine is still limited andrespect of remote interpretation of patient data [31]; smart inconsistent, across a wide range of fields.home technologies [32]; and home monitoring of heart failure In terms of therapeutic effectiveness, there is some lim-patients [33]. ited evidence regarding telemonitoring for heart failure [50]; One review concluded that home based ICT interventions despite reviewers suggesting that electronic transfer of self-in general give comprehensive positive outcomes for chronic monitored results has been found to be feasible and acceptabledisease management, despite only identifying a small number in diabetes care, they find only weak evidence for improve-of heterogeneous studies [34]. ments in HbA1c or other aspects of diabetes management [51]; others found only weak evidence of benefit relating to infor- matics applications in asthma care [52]; and no evidence of6. Telemedicine is promising improvement in clinical outcomes following teleconsultation and video-conferences in diabetes care [53].Nineteen reviews (Table 2) were less confident about the effec- Frequently, these reviewers call for further research,tiveness of telemedicine, suggesting that it is promising, or has notably in the form of RCTs. Examples include calls relatingpotential, but that more research is required before it is pos- to web-based alcohol cessation interventions [54]; and vir-sible to draw firm conclusions. In some cases, in which the tual reality in stroke therapy, despite this being found [37] tosame conditions and interventions are discussed, these more be ‘potentially exciting and safe’. More work on telemonitor-tentative conclusions must temper those of authors who find ing in heart failure is called for [55]; on e-therapy for mentalconclusive evidence. health problems [56]; on smart home technologies [57]; and One review [35] for example found internet-delivered CBT on technological support for carers of people with demen-to be a ‘promising’ and ‘complementary’ development, but did tia [58]. Others [28] underlined that lack of evidence does notnot provide the endorsements that others [23,24] did for CBT imply lack of effectiveness, and that in many cases interven-for the more specific conditions of anxiety and depression. tions are simply ‘unproven’. Caution is also urged by reviewersSimilarly psychotherapy using remote communication tech- [59] who identified small numbers of heterogeneous studiesnologies was seen as promising [36], but still requiring more in relation to chronic disease management. One review [60]evidence. found it impossible to draw any significant conclusions about Areas in which review authors agreed that telemedicine the impact of interventions to promote ICT use by health careshows therapeutic promise, but still requires further research, personnel.include virtual reality in stroke rehabilitation [37,38]; improv- Several reviewers found that research has been somewhating symptoms and behaviour associated with and knowledge narrowly focused and suggested further research which takesabout specific mental disorders and related conditions [39]; a broader perspective or a different one. They suggested thatdiabetes [40,83]; weight loss intervention and possibly weight telemedicine researchers have not yet asked all the impor-loss maintenance [41]; and alcohol abuse [88]. tant questions, or conducted research in appropriate ways. Other authors found promise in terms of health service For example, in the cases of dermatology, wound care andutilisation. One review [42] for example suggested that asyn- ophthalmology, it was argued that evaluation has exploredchronous telehealth developments could result in shorter ICT-based asynchronous services for efficacy, but outcomeswaiting times, fewer unnecessary referrals, high levels of or access issues have not been considered [61]. In a simi-patient and provider satisfaction, and equivalent (or better) lar vein, although most of the studies of smart homes founddiagnostic accuracy. Another [43] found that home telehealth technical feasibility, there remain certain topics that requirehas a positive impact on the use of many health services as further research, notably, ‘technical, ethical, legal, clinical,well as glycaemic control of patients with diabetes. economical and organisational implications and challenges’ Positive patient experiences were highlighted as promising [32]. Others [44], whilst seeing significant potential for teleon-in relation to home telemonitoring for respiratory conditions cology, especially in rural areas, suggested that local studies[17]. There is potential for using Internet/web-based services may be needed to confirm this. A further contribution to thefor cancer patients in rural areas [44], and telemonitoring can debates about CBT (see above), found that whilst it appears toempower patients with chronic conditions [45]. be effective for panic disorders, social phobia and depression, Promising impacts on service delivery were identified its effects on obsessive–compulsive disorder and anxiety and[46,47] in use of electronic decision support systems and depression combined remain insufficiently clear [62]. Causaltelemedicine consultations promise to support improved pathways in HbA1c decline in diabetes care remain unclear,delivery of tPA in patients with stroke (a treatment which and this conclusion can be linked with the variations in pro-requires to be administered within 3 h) [48]. Computer gramme designs [63]. Whilst smoking cessation programmesreminders to professionals at the point of care show ‘small to appear to be effective across a range of studies, neverthelessmodest improvements’ in professional behaviour, but studies the mechanisms of action are not well understood [64].
  6. 6. i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771 741 Telemedicine is a dynamic field, and new studies and One review found that health service users with ICTnew systematic reviews are rapidly being published. As used in support, education and virtual consultation feeltelemedicine extends into new clinical areas, it is unsurpris- more confident and empowered, with better knowledge anding that reviewers give renewed accounts of limited evidence. improved health outcomes, as well as experiencing betterSome examples of new areas from our review include little nurse-patient relationships [73]. The reviewers call for moreresearch on health promotion provided through the Internet research on the mechanisms for these changes. Generally[65]; a Cochrane review that found no studies of smart homes there is evidence of high patient satisfaction ratings for telere-that met their inclusion criteria [57]; a review of studies on habilitation, but reviewers argue that more process research,spiritual care that found little systematic research in this area case studies and qualitative studies are needed to improve[66]; and a review concluding that formative evaluation is our understanding of these outcomes [74]. Interactive healthneeded for remote monitoring in hypertension [90]. communication applications (IHCAs) for people with chronic disease appear to give benefit in terms of improved sup- port, better knowledge and improved health outcomes, but8. Economic analysis the authors asked for more larger studies to be conducted [75].An important emerging issue from our review is the lack of Others found no consistent results regarding user expe-knowledge and understanding of the costs of telemedicine riences, though suggested that access can be improved [69].(Table 4). Alongside development of technologies which aim to ben- Several reviewers suggested that telemedicine seemed to efit patients and citizens as well as professionals, we needbe cost-effective, but few draw firm conclusions. One review research on the impacts of technologies for these groups [76].found that 91% of the studies showed telehomecare to be cost- An example is that information websites relating to dementiaeffective, in that it reduced use of hospitals, improved patient are geared more to carers than to people with dementia them-compliance, satisfaction and quality of life [67]. This was the selves, and that the websites do not usually offer personalisedclearest conclusion, with others being much more cautious: information [77].telemedicine was found to be cost-effective for chronic diseasemanagement, but the authors cautioned that studies were fewand heterogeneous [34]. A comparison of the costs of telemon- 10. Asking new questionsitoring and usual care for heart failure patients found thattelemonitoring could reduce travel time and hospital admis- We have already noted the emergence of new topic areas insions, whilst noting that benefits are likely to be realised in the this dynamic and complex field. The focus on patient bene-long term [68]. Others found home telehealth for chronic con- fits however indicates a more basic development, namely thatditions to be cost saving, though underlining that studies were reviewers are starting to explore new questions beyond thosegenerally of low quality [25]. One review found remote inter- of clinical and cost-effectiveness. Our review produced twopretation in medical encounters to be more expensive than its key examples (Table 6). Firstly, a review that identified genderalternatives [31]. differences in computer-mediated communications relating Other reviewers did not find good evidence about cost- to online support groups for people with cancer cautioned thateffectiveness; the cost-effectiveness of home telecare for studies are limited and heterogeneous [78]. Nevertheless, theolder people and people with chronic conditions is uncer- authors suggested that this issue needs to be considered bytain [28]; there is a lack of consistent results regarding costs those designing interventions of this kind. This implies a con-of synchronous telehealth in primary care [69]; there is lit- sideration that telemedicine is an ongoing intervention wheretle evidence for the economic viability of home respiratory users influence its development and hence that effectivenessmonitoring [17]; the cost-effectiveness of IT in diabetes care of outcome is a complex collaborative achievement. Secondly,is undetermined [40]; one review was able to identify only one a review focusing on stroke thrombolysis service configura-study of the costs of CBT, with significant weaknesses [70], tions, their potential impact and ways of recording data towith another finding little evidence in the same area [62]. inform which configuration could be most suitable for a partic- A particular limitation identified in terms of costs concerns ular situation, highlighted the need to consider a wider rangethe wider social and organisational costs of telemedicine. One of service delivery issues [79]. Similarly, it was argued that inreview found that a societal perspective on costs has not yet post-stroke patients, the consideration of caregivers’ mentalbeen developed for home telehealth [71] and another high- health and high levels of patient satisfaction should be anlighted the need to consider not only costs to health services integral element of studies [80].of interventions, but also costs to service users and their social Furthermore, some of the papers included in the reviewnetworks [72]. explored issues which can inform the future development of telemedicine, that is, they provide formative assessments. Examples include a review of 104 definitions of telemedicine9. Is telemedicine good for patients? [81] which, in identifying four broad types of definitions, suggested how stakeholder interests can alter perceptionsA second emerging issue concerns patient satisfaction with of priorities in telemedicine interventions, such that sometelemedicine, and indications that telemedicine may alter may focus on delivering healthcare over a distance andthe relationships between patients and health professionals others on the potential of technology per se; and work argu-(Table 5). ing that clinical and technical guidelines can inform the
  7. 7. 742 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771future development of telemedicine and facilitate evaluation[20,82]. Summary points “What was already known on this topic”11. Reflections on the methodology of our • Evidence regarding the effectiveness of telemedicinestudy is patchy and incomplete. • The quality of much of the research conducted is poor.Our study is a review of systematic reviews. There are someinherent weaknesses in this approach. In general we have to “What this study added to our knowledge”rely on the information in the included reviews. The qualityof the reviews may vary; the reviews may have done a poor • The evidence base is accumulating robust knowledgejob in specifying their inclusion and exclusion criteria, the about the effectiveness of telemedicine.searches may not be comprehensive, the review authors may • As the field is rapidly evolving however, new knowl-not have assessed or extracted data from the primary studies edge is constantly needed.adequately, nor analysed and synthesised the findings across • Continuing areas of weakness but also of great interestthe studies properly. But even using high quality reviews, we include economic analyses, understandings of patientnecessarily lose information and details that we can only find perspectives, of effectiveness and outcomes as com-if we go back to the primary studies. plex and ongoing collaborative achievements, and Although we did a thorough job in developing the search formative assessments.strategy and identified a vast amount of reviews on the effectsof telemedicine, we might have missed relevant systematicreviews. Some of the included reviews are probably outdated. Stud- 12. Conclusionsies that are published after the search date in the reviews arenot included. Ideally we could have supplemented the review Despite large number of studies and systematic reviewswith more recent primary studies not included in the reviews, on the effects of telemedicine, high quality evidence tobut we did not have the resources to do this. inform policy decisions on how best to use telemedicine We did not check whether reviews included the same ref- in health care is still lacking. Large studies with rigorouserences. Several reviews have studied similar or overlapping designs are needed to get better evidence on the effects oftopics, and have at least partially included the same studies. telemedicine interventions on health, satisfaction with careIt may therefore be that evidence is counted twice, or that and costs. As the field is rapidly evolving, different kindsdifferent interpretations of effectiveness are given by review of knowledge are also in demand, e.g. a stronger focus onauthors. We have not analysed the degree to which there are economic analyses of telemedicine, on patients’ perspec-discrepancies in the analyses of similar studies, nor the rea- tives and on the understanding of telemedicine as complexsons for different interpretations of the same findings, for development processes, and effectiveness and outcome asinstance did we not analyse the heterogeneity of the results ongoing collaborative achievements. Hence formative assess-among the reviews based on the quality of the reviews. ments are also pointed out as an area of weakness and The data collection and assessment of each included interest.review was accomplished by one external expert, while twois considered to be optimal in order to reduce risk of bias. AcknowledgementsWe did not train the data extractors, and we did not pilotthe data extraction form. The experts were not completely The study was funded by the EU under SMART 2008/0064consistent in their judgments. This limitation was partly due and was conducted as part of the MethoTelemed project. Weto the resources and organisation of the project, in that two acknowledge the support of our MethoTelemed colleagues, theworkshops were held, intending to validate results. In addi- group of external review experts, the workshop participants,tion, the review team made a quality check of the reviews by the project officers at the Norwegian centre for integrated carecomparing the reported data with information in the full text and telemedicine, and Ingrid Harboe at the Norwegian Knowl-papers. Any unclear themes were discussed in the team to edge Centre for the Health Services, who did the literaturereach consensus. searches. We have limited information regarding effect sizes and thestrength of evidence for the outcomes that we have studied. We have however demonstrated that it is possible to make Appendix 1.such a large overview in quite a short time, involving bothmethodology and content experts. We have used systematic In Tables 1–7, columns listing results and conclusions quotemethods in the literature searches and the assessment of the from the authors’ work. Where a review appears in more thanreviews, and we have excluded reviews of low methodological one table, this reflects the range of evidence produced. Fullquality. access to a searchable database of abstracts of items included In combining rigorous and systematic methods with a in the review will be available on the MethoTelemed web-pragmatic approach we have produced a relevant and rich site, which also includes guidance for evaluating telemedicine.overview of the field. www.telemed.no/MethoTelemed.
  8. 8. Table 1 – Systematic reviews reporting that telemedicine is effective.Reference Conditions Geographic Service/ Outcome Authors’ summary of results Authors’ conclusions included area interventionBarak et al. [15] Mental health Not stated Internet based Behavioural, Sixty-four studies included covering 94 Internet based intervention is as psychotherapy Health, Percep- services. The overall mean weighted effect effective as face-to-face tion/satisfaction, size was 0.53, similar to the average effect intervention. Social size of traditional, face-to-face therapy. Comparison between face-to-face and i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771 Internet intervention across 14 studies showed no differences in effectiveness.Clark et al. [16] Cardio- All countries Remote Behavioural, Fourteen studies (RCTs) included. Four Programmes for chronic heart vascular monitoring, Cost/economic, evaluated telemonitoring, nine structured failure that include remote (CHF) telephone Health telephone support, and one both. Remote monitoring have a positive effect support monitoring programmes reduced the rates of on clinical outcomes in admission to hospital for chronic heart community dwelling patients with failure by 21% and all cause mortality by 20%. chronic heart failure. Three studies reported quality of life improvements and four, reduced cost, one found no gain in cost-effectiveness.Jaana et al. [17] Respiratory USA, Europe, Remote Behavioural, Twenty-three studies included. Good levels of Home telemonitoring of conditions Israel, Taiwan monitoring Cost/economic, data validity and reliability were reported. respiratory conditions results in Feasibility/pilot, However, little quantitative evidence exists early identification of Health, Percep- about the effect of remote monitoring on deteriorations in patient condition tion/satisfaction patient medical condition and utilization of and symptom control. Positive health services. Positive effects on patient patient attitude and receptiveness behaviour were consistently reported. Only of this approach are promising. two studies performed a detailed cost However, evidence on the analysis. magnitude of clinical and structural effects remains preliminary, with variations in study approaches and an absence of robust study designs and formal evaluations.Myung et al. Smoking Worldwide Web and Behavioural Twenty-two studies included (RCTs). In a The meta-analysis of RCTs [18] cessation computer-based random-effects meta-analysis of all 22 trials, indicates that there is sufficient programmes the intervention had a significant effect on clinical evidence to support the smoking cessation. Similar findings were use of Web- and computer-based observed in nine trials using a Web-based smoking cessation programs for intervention,(and in 13 trials using a adult smokers. computer-based intervention Subgroup analyses revealed similar findings for different levels of methodological rigor, stand-alone versus supplemental interventions, type of abstinence rates employed, and duration of follow-up period, but not for adolescent populations. 743
  9. 9. 744Table 1 (Continued)Reference Conditions Geographic Service/ Outcome Authors’ summary of results Authors’ conclusions included area interventionNeubeck et al. Cardio- USA (3 Communication Behavioural, Health, Eleven studies included (RCTs). Telehealth interventions provide [19] vascular studies), using ICT, psychosocial state, Telehealth interventions were associated effective risk factor reduction and (CHD) Norway (1), patient- quality of life with non-significant lower all-cause secondary prevention. Provision of Canada (3), professional mortality than controls. These telehealth models could help Australia (3), interventions showed a significantly increase uptake of a formal Germany (1) lower weighted mean difference at secondary prevention by those i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771 medium long-term follow-up than who do not access cardiac controls for total cholesterol, systolic rehabilitation and narrow the blood pressure, and fewer smokers. current evidence-practice gap. Significant favourable changes at follow-up were also found in high-density lipoprotein and low-density lipoprotein.Pineau et al. Psychiatric Focus on Telepsychiatry Cost/economic, ‘About 60’ studies included. The authors The review concludes that [20] conditions Canada and Ethical issues, Legal, argue that definition of clinical guidelines telepsychiatry should be (adult and USA Organizational, and technological standards aimed at implemented in Québec and paediatric) Technology related, standardising telepsychiatric practice will provides detailed clinical and clinical guidelines promote its large scale implementation. technical guidelines for and technical implementation. They add that standards taking into account human and organizational aspects plays a part in ensuring the success of this type of activity; that legal and ethical aspects must also be considered; and that a detailed economic analysis should be carried out prior to any large investment in telepsychiatry. Finally, implementation of psychiatry should be subjected to rigorous downstream assessment in order to improve management and performance.Powers and Anxiety Not stated Virtual reality Behavioural, Percep- Thirteen studies included. VRET (Virtual Given the advantages and the Emmelkamp (especially exposure tion/satisfaction, reality exposure therapy) is highly efficacy of VRET supported by this [21] phobias) therapy Psychophysiology, effective in treating phobias and more so meta-analysis a broader perceived control than inactive control conditions. VRET is application in clinical practice over phobias slightly, but significantly more effective seems justified. than exposure in vivo, the gold standard in the field. Advantages of VRET: can be conducted in the therapist’s office, rather than in vivo situations, the possibility of generating more gradual assignments and of creating idiosyncratic exposure. VRET is cost-effective.
  10. 10. Prange et al. Stroke USA Rehabilitation Health Eleven studies included. Robot-aided This systematic review indicates [22] (robots) therapy of the proximal upper limb that robot-aided therapy of the improves short and long-term motor proximal upper limb can improve control of the paretic shoulder and elbow: short and long-term motor control however, there is no consistent influence of the paretic shoulder and elbow. on functional abilities. Robot-aided therapy appears to improve motor control more than i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771 conventional therapy.Reger and Mental health Not stated Internet/computer- Behavioural, Health Ninteen studies included (RCTs). The results of this meta-analysis Gahm [23] problems based Meta-analysis showed that ICT was provide preliminary support for (anxiety) treatment superior to waitlist and placebo the use of Internet and assignment across outcome measures computer-based CBT for the The effects of ICT were equal to treatment of anxiety. therapist-delivered treatment across anxiety disorders. Conclusions were limited by small sample sizes, the rare use of placebo controls, and other methodological problems. The number of available studies limited the opportunity to conduct analyses by diagnostic group.Spek et al. [24] Mental health Global CBT via internet Health Twelve studies included (RCTs). Authors Despite study limitations, eCBT (depression concluded that eCBT was effective, but seemed to be effective. and anxiety) noted that there was only a small number of studies and significant heterogeneity.Tran et al. [25] Diabetes, heart Canada Home telehealth Cost/economic, Seventy-nine studies included. Of the Conclusions relate to the potential failure, COPD focused, but Health, Percep- included studies, 26 pertained to for home telehealth in Canada and other international tion/satisfaction diabetes, 35 to CHF, nine to COPD, and which is seen as positive. However, chronic publications eight to mixed chronic diseases. The more research, such as multicentre diseases included comparator “no care” was not identified RCTs, is warranted to accurately in any of the included studies, so usual measure the clinical and economic care was used as the comparator impact of home telehealth for throughout the clinical review. Home chronic disease management to telehealth appeared generally clinically support Canadian policy makers in effective and no patient adverse effects making informed decisions. were reported. Evidence on health service utilization was more limited, but promising The economic review suggested cost-effectiveness, but the quality of studies was low.van den Berg et Internet based Not Physical activity Behavioural, Health Ten studies included. The analysis There is indicative evidence that al. [26] physical mentioned focused on the methodological quality of internet based physical activity activity other than the studies, which showed variation in interventions are more effective interventions language study populations and interventions than a waiting list strategy. limitations making generalization difficult. 745
  11. 11. 746Table 1 (Continued)Reference Conditions Geographic Service/ Outcome Authors’ summary of results Authors’ conclusions included area interventionHyler et al. [27] Mental health France, Telepsychiatry Feasibility/pilot, Per- Fourteen studies included. Telepsychiatry Only a handful studies have Australia, ception/satisfaction, was found to be similar to In person for attempted to compare Canada, Quality of different studies using objective assessments. telepsychiatry with in-person Japan, UK instruments used Bandwidth was a moderator. psychiatry (IP) directly, using and US for consultations Heterogeneous effect sizes for different standardised assessment moderators (bandwidth) High bandwidth instruments to permit meaningful was slightly superior for assessments comparison. According to the i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771 requiring detailed observation of patients. meta-analysis, there was no difference in accuracy or satisfaction between the two modalities. Telepsychiatry is expected to replace IP in certain research and clinical situations.Barlow et al. Elderly people, Worldwide Home telecare Behavioural, Health, Sixty-eight RCTs and 30 observational Having identified where there is [28] chronic Organisational, studies with 80 or more participants evidence of effectiveness, and diseases Safety included. Results show that the most where it is lacking, the authors effective telecare interventions appear to conclude that insufficient be automated vital signs monitoring (for evidence does not amount to lack reducing health service use) and of effectiveness: more research is telephone follow-up by nurses (for needed. improving clinical indicators and reducing health service use). Evidence on cost-effectiveness is less clear, and on safety and security alert systems insufficient.Bussey-Smith Asthma USA, Hawaii, Computer-based Behavioural, Nine studies included. One study each Although interactive CAPEPs may and Rossen Sweden patient Cost/economic, showed reduced hospitalizations, acute improve patient asthma [29] education Health, Percep- care visits, or rescue inhaler use. Two knowledge and symptoms, their programmes tion/satisfaction, reported lung function improvements. effect on objective clinical (CAPEPs) Social Four showed improved asthma outcomes is less consistent knowledge, and five showed improvements in symptoms.Jaana et al.[30] Diabetes North Remote Behavioural, Health, Seventeen studies included. Most studies Positive effects are reported, but America, monitoring Technology related, reported overall positive results in there is variation in patient Europe and Structural Diabetes mellitus type 2, and found that characteristics (background, Asia IT based interventions improved health ability, medical condition) sample care utilisation, behaviour attitudes and selection and approach for skills. treatment of control groups.Azarmina and All All countries Remote Cost/economic, Nine studies included. Results showed The review suggests that remote Wallace [31] interpretation in Feasibility/pilot, that time between encounters was interpretation is an acceptable and medical Health, reduced, but evidence on consultation accurate alternative to traditional encounters Organisational, Per- length was not consistent. Good client methods, despite the higher ception/satisfaction, and doctor satisfaction was shown, but associated costs. Safety those interpreting data preferred to do so face to face. Costs of these interventions are high, but efficiency gains are possible.
  12. 12. Demiris and Older people, Europe, USA, Smart home Behavioural, Health, Twenty-one projects included (drawing Most of the studies demonstrated Hensel [32] people with Asia Safety, Social, on 114 publications). A table is presented the feasibility of the technological disabilities Physiological and with their technologies, target audience, solution. Technical, ethical, legal, i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771 functional technologies and different outcome. A clinical, economical and lack of evidence on clinical outcomes is organisational implications and identified. challenges need to be studied in-depth for the field to grow further.Martinez et al. Heart failure All countries Remote Behavioural, Forty-two studies included. (1) Remote Evaluating the articles showed [33] monitoring Cost/economic, monitoring for cardiac heart failure that home monitoring in patients (home) Feasibility/pilot, appears to be technically effective for with heart failure is viable. Health, Legal, following the patient remotely; (2) it Organizational, Per- appears to be easy to use, and it is widely ception/satisfaction, accepted by patients and health Safety, Social, professionals; and (3) it appears to be Technology related economically viable.Gaikwad and Chronic Not stated Home based ICT Behavioural, Twenty-seven studies included. These Telecare, telehealth etc. have Warren [34] disease interventions Cost/economic, systems can improve functional and positive clinical and cost outcomes Health, Percep- cognitive patient outcomes in chronic – although studies are few in tion/satisfaction disease and reduce costs. However, the number and heterogeneous. Better research is not yet sufficiently robust. evidence-based outcome measures are needed, especially regarding costs and physician perspectives. 747

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