Telemedicine (also referred to as telehealth) is defined as the delivery of health care services through the use of telecommunications technologies. This can include preventive care, diagnostics, treatment, and education [1]. Telemedicine is not limited to a narrow scope of practice or discipline but can apply to an array of fields, such as mental and behavioral health, obstetrics and gynecology, child wellness and pediatric, cardiology, nutrition, neurology, diabetes management, oncology, and other specialties. For a telemedicine session to be conducted, patients need to have access to the appropriate technologies, usually a computer, smartphone, or tablet with video/audio capabilities, a secure internet connection, and peripheral equipment such as a thermometer, otoscope, or spirometer, depending on the specialty. In most cases, the patient’s primary care physician acts as a facilitator in the telemedicine process. For each system, the patient must be registered with an account user ID and password. There should be an identification verification of the patient before entering into a video/audio chat session with the physician. The patient’s basic demographics are gathered and documented upon registration. A patient history form is typically required, which outlines prior services or treatments for the patient. Pre-registration questions on current health conditions are also collected. Upon provider assignment, a patient is taken into a first discussion room where she is directed to a questions/answers component. The component guides patient questions and concerns that should be considered before moving into the actual service [2]. The patient is then placed into a video session with a medical assistant or nurse practitioner. The nurse is there to ask the patient additional medical history questions not covered in the patient history document. Finally, the patient is placed into the video/audio conference room with the physician. In this room, the patient is able to discuss her health issues confidentially with the physician without the presence of other staff. Prior to the telemedicine session, the patient is asked to consent to the telemedicine consultation. After obtaining consent, the telemedicine session begins with a verbal account of the telemedicine consultation procedures. The telemedicine session accounts for 25 to 30 minutes for a physical health consultation or 45 to 60 minutes for a mental health consultation. After the telemedicine session, the patient completes a computerized survey that evaluates the overall telemedicine experience.
1. Definition and Scope
The evolving techniques of information delivery and retrieval in medicine are termed telemedicine. Telemedicine encompasses remote health care delivery between patients and providers. Traditionally, the singular provider-centric model was employed. But with changing scenarios, patients are now empowered with information of their own. Telemedicine may be found as a disruptor to the provider-centric model either directly challenging it or augmenting it [2]. With changes in the western healthcare scenario, now, patients have access to consultations over the web. Providers now have to upskill themselves to provide appropriate continuity of care after obtaining information over the web. If they fail to adapt to these changes, they risk losing control over the information and the doctor-patient relationship to large health care corporations. Given the significance of telemedicine in the changing healthcare scenario, there is a need for awareness regarding what entails at the provider level.
A fair understanding of how WebMD, Microsoft health vault, and similar initiatives impact the traditional provider-centric model is essential. Telemedicine may offer an opportunity for providers to utilize advanced technology and large databases to continue caring for patients and to provide better health care access to disadvantaged populations [3]. On the other hand, emerging consumer-centric initiatives may be detrimental to the traditional patient-and-provider relationship. There is a lack of awareness regarding these innovations and their impact within the healthcare professionals. Some of the recent developments in telemedicine include remote ICD monitoring, Internet-based home care services, and the viability of 24/7 hotlines and telephone triage services.
1.2. Historical Context
Telemedicine is the ability to provide medical assistance across distance. It encompasses a wide variety of modalities, including telegraphy, telephony, and television. The largest and most successful telemedicine program in the United States is the Federal Bureau of Prisons, which uses videoconferencing for psychiatry, medication maintenance, dermatology, and primary care for 10 facilities housing 9,700 patients and consuming 320 hours of videoconferencing time per month. The Veterans Administration, which already evaluates medical conditions through videoconferencing, is contemplating expansion with a $50 million budget [2].
In 1968, West Virginia School of Medicine faculty created the first formal telemedicine program to extend medical services across the state. The 1990s were years of expansion and creativity (with over 350 U.S telehealth programs), validation studies of cost-effectiveness, and a nationwide focus on regional telehealth networks. With the endorsement of the Governors, the National Telecommunication and Information Administration implemented a $573 million, five-year Grant for the Rural Health Care Program. The 2000s are anticipated to hold consolidation and an expanded emphasis on applications in public health, education, and monitoring emerging infectious diseases. The National Institutes of Health’s Human Genome project and electronic health records will almost certainly require changes in telemedicine and telehealth programs and new training of health care personnel [3].
2. Technological Foundations
Telemedicine encompasses the delivery of health-related services with real-time bidirectional communication between patients and providers via telecommunications. Telemedicine services have been broadly classified into three types: synchronous, asynchronous, and remote monitoring. Telemedicine enables rural and far locations to access health care resources that are lacking locally. Telemedicine can be seen as a means of bridging the gap between the need for health services and their availability pertaining to geographic, financial, and non-geographic barriers. Ongoing developments in healthcare informatics have influenced the evolution of telemedicine [4].
Artificial Intelligence (AI) generally is a term used to signify the development of computer systems that can execute tasks that normally necessitate human intelligence. These activities include knowledge perceiving, speech recognition, problem-solving, etc. Artificial intelligence has become ubiquitous in everyday life and is also being increasingly integrated into the field of medicine. Artificial intelligence in medicine can generally be classified into three categories: logistic AI, analytical AI, and human-interactive AI. The main applications of artificial intelligence in telemedicine include diagnostic systems, therapy advisory systems, predictive analysis, knowledge-based systems, and data analysis systems [5].
2.1. Key Technologies in Telemedicine
Telemedicine relies on various types of technology- internet, devices, applications, platforms and software. Broadly, it consists of six main technologies: digital communication technologies, digital patient monitoring devices, digital imaging and tele radiology technologies, telecommunication technologies, electronic medical record (EMR) technologies and clinical decision support systems. Digital imaging and tele radiology technologies comprise picture archiving and communication systems (PACS). Tele radiology and digital imaging technologies together facilitate the visualisation of body parts, tissues and organs by an outside observer allowing remote health care services through tele radiology. Overall, these technologies enable digital capture, storage, communication and presentation of imaging data involved in telemedicine. Image compressed and transmitted may be in formats such as JPEG, MPEG-2, MPEG-4, and H.261-265 coded [6]. Telecommunication devices either conduct or provide facility to conduct tele conferences. Patients can be connected with doctors telephonically or through video conferencing or web cam technologies such as mobile phones, desktop phones, internet and video conferencing systems. EMR technologies comprise different hardware, software and network devices designed for recording and storing patients’ health information as EMRs to facilitate primary fulfilment of routine clinical tasks, secondary storage and data mining of EMRs for varied health care system analyses, programme evaluations and research activities [4].
Clinical decision support systems combine computerized data banks of clinical knowledge with large health care database to generate patient-specific advice and recommendations to clinicians for preventive, diagnostic and therapeutic interventions. Davis et al. passionately advocate the integration of high quality clinical decision support systems with EMR technologies to bolster the efficiency of telemedicine applications and services. Systems thereby integrate state-of-the art clinical knowledge with patients’ EMRs, thereby providing computer-generated advice and recommendations for executing evidence-based treatment options.
2.2. Role of Artificial Intelligence
Artificial Intelligence (AI) is at the forefront of emerging technologies that continue to shape the healthcare and telemedicine landscape. As a facilitator for telemedicine, AI has been integrated into various applications in healthcare systems, including the evaluation of patient health concerns, patient triaging, diagnosis, and prescription medication. Patient interactions with telemedicine are limited by the capabilities of the origination provider. Conversely, AI has the potential to overcome limitations. For instance, AI algorithms can evaluate and prioritize patient health concerns before interaction with a provider [7]. Most telemedicine services do not routinely capture clinical data, allowing for little quality assessment. AI algorithms could function in the background, automatically collecting data for metric analyses, thus guiding quality improvement measures to help meet the outlined guidelines. AI-assisted data collection could also mitigate obstacles to ongoing physician education and training. The evidence base for a given physician’s performance is difficult to compile, being fragmented, disparate, and requiring careful scrutiny, which can create uncertainty regarding quality of care and culpability regarding adverse events or complications. These complexities necessitate physician education and training on a case-by-case basis.
Telemedicine is a time-sensitive intervention involving multistep processes of information transfer and actions between multiple stakeholders and information sources, including hospitals, physicians, technicians, nurses, emergency medical service crews, and patients themselves. AI algorithms can take various approaches to enhance data collection and better integrate telemetry into health systems, accomplishing this while considering the needs of local health systems, patients, and telemedicine providers. Currently, most telemedicine programs lack the required infrastructure for effective integration. External data sources, such as clinical lab data or prehospital telemetry evaluations, are not routinely captured for quality assessment. Integration must first begin by ensuring that information from prehospital patients are received. Once data is received and accessible, information technologies can be designed to automatically compile, process, and analyze collected data. AI algorithms can enhance data compilation and organization to be useful for quality assessment and improvement [8].
3. Benefits of Telemedicine
Telemedicine holds substantial promise in enhancing health care delivery, boosting access to services, and improving overall service quality. Telemedicine improves access to healthcare services for both rural and urban populations [9]. With the advent of mobile telecommunication, wireless internet, compact mobile medical equipment, and ECG monitoring gadgets, telemedicine and e-health systems are gaining prominence. During the COVID outbreak, telemedicine garnered attention for its pivotal role in curbing the spread of the virus. There is now consensus among the international community regarding using telemedicine to reach underserved populations. The predominant telemedicine formats include video consultations, telephone consultations, telephone triage, and online messaging. Telemedicine adds value by allowing physicians to collect information before the patient visits the clinic and staff to sign off administrative tasks and prescription refills before the consultation. In scenarios where patients cannot visit in person, telemedicine offers a second-best option. The efficacy of telemedicine varies significantly in practice depending on the medical specialty, urgency, visit type, reimbursement model, and experience with virtual care.
Telemedicine is a cost-effective alternative to in-person visits, as clinic and hospital visits often incur costs for health care providers, ranging from three to fifty dollars per visit. Access to telemedicine services can also reduce costs associated with travel and transportation. In contrast to in-person visits, most patient and provider surveys indicate overall satisfaction with telemedicine visits. The immediate advantages of telemedicine visits include shorter waiting times and the possibility of enjoying care from home or another familiar environment. It allows individuals to receive specialized attention routinely or follow up on pre-existing problems, interact with difficult-to-reach practitioners, and care for dependents with few additional demands. In rural communities, telemedicine services can help reduce isolation by ensuring smooth communication between patients and care providers, thereby lessening insecurity and anxiety. Telemedicine also enables practitioners to monitor their patients on a routine and longer-term basis and prevents the ‘doctor-shopping’ phenomenon often related to patients with mental health disorders. Instituted clearly defined telemedicine policies enhance the potential advantages and limit the possible risks.
3.1. Improved Access to Healthcare Services
Telemedicine is the exchange of medical information from one site to another via electronic communications. The American Telemedicine Association outlined telemedicine as the appropriate application of telecommunications technology to health care. Advancements in telecommunications technology and significant system utilization have bolstered the convenience and quality of telemedicine. Telemedicine holds the potential to impact the delivery of health services and the health status of consumers. Implementation within a health service delivery system is required to realize such benefits. Such implementation can affect social structures on an organizational scale and the very nature of health services in a community [1].
As an implementation model, telemedicine encompasses health information and telecommunications technology applied to remote health service delivery. Thus far, disability dictates preference of service delivery via telecommunication, whereas latency and prudency will take precedence in all others. With the anticipated results of improved quality and cost savings, service delivery via telemedicine would be sought after where feasible. An implementation model and accompanying method of inquiry are proposed for analysis and evaluation. Implications for the telemedicine system are provided, followed by a discussion of the questions to be considered and the approach. The emphasis on these questions goal is to probe the mind and stimulate discussion and thought as a telemedicine system is prepared [10].
3.2. Cost-Efficiency
Telemedicine has the potential to yield substantial economic savings and optimize the use of the available resources [9]. On average, patients opt for a physician located in another city to avail consultations. As they are not physically available, the only way is televaluation (teleconsultation, telehealth etc.) by means of fixed broadband connections which is of lower-cost in terms of long-distance call charges. In addition, most of the patients approach their doctor by consulting other members of the family, friend, or acquaintance in a network rather than approaching the doctors directly. This involves social costs and is likely for the young professional who has little credibility or knowledge of hospital functioning. Surprisingly, the hospital’s telehealth activities have not yet been independently evaluated or studied in terms of costs and benefits associated with patients.
In this era of globalization, cities, organizations, and enterprises seek to share both information and facilities. Therefore, a large volume of private sector investment, particularly in economically developing countries, is expected to render the establishment of telemedicine therefore implement sunshine strategies. Nonetheless, the above plans might fall short of proper screening, anatomical and physiological investigation, and interpretation or misinterpretation of clinical signs; hence, complications may pave the way for negligence suits for both doctors and the treating hospitals. There is a necessity to devise and compute a standardized format in India so that the rights of doctors and patients can be ensured. This would be a benchmark for all the hospitals intending to provide telemedicine services.
4. Challenges and Limitations
Telemedicine has advantages, however, this technology is not extensively accepted by many health centers due to a number of obstacles and constraints. Specifically, the challenges are examined in five levels: regulatory and legal issues, technical and infrastructure issues, cultural issues, implementation issues, and costs issues. The telemedicine system is still a growing technology and there are many problems related to it.
Regulations and legal issues are among the challenges and barriers to telemedicine technology. The challenges include licensure, limitations on where the provider can treat the patient, limits on the medium of care, no malpractice standard for telemedicine, laws regarding the enforcement of clinical standards and guidelines, laws that require follow-up visits, and limitations on prescription medications. One legal consideration often raised in connection with telemedicine is the issue of physicians providing care in jurisdictions where they are not licensed. Most state medical boards consider telephone and other forms of remote health care to be the practice of medicine. This involves a tele-expert and gives rise to medical legal liability if the physician is not licensed in the state where the patient seeks care. However, “tele-physician” statutes have been passed providing exceptions for long-distance care. Compliance with state and federal laws as telemedicine technologies evolve will be an ongoing challenge. As regulations are generally reactionary, telemedicine efforts will continue to outpace regulation. Nonetheless, clarity and uniformity are desired within the telemedicine community and are essential for the growth of the telemedicine industry.
4.1. Regulatory and Legal Barriers
In 2018, researchers from the Texas A&M University and the University of North Texas studied the state of telemedicine laws in the United States and reported their findings on the scope of practice, regulatory barriers and licensure, prescriptive authority and controlled substances, and reimbursement and payment for telemedicine services [6]. Similar research in India would yield much-needed comparative data on telemedicine practice in developing countries. Patients rely on providers of acute care, chronic care, and allied health services, who often belong to different universities in various parts of the country. This causes malice and complexity as at least one party in any tele-consultation or tele-procedure must be out of state, or outside the provider’s jurisdiction. The complex inter-state regulation should be addressed at the national or federal level to avoid a plethora of conflicting laws hampering the already scarce and critically needed telemedicine services.
The licensing of each healthcare professional, be it allied health processor, doctor, or paramedic in each state is another major barrier. The simplest solution is uniform telemedicine licensing for each category of health professions for the nation. Meanwhile, new applicants should be granted reciprocal licensing to practice in a new state if they have previously obtained a similar license in another state. Providers from a different state with an existing license could be allowed to start practice with a permanent telemedicine practice license if they have been in good standing for at least three years in that state. In 2017, the Federation of State Medical Boards mandated for the first time that states with telemedicine laws adopt a Model policy to help streamline licensing and practice issues similar to the Model Practice Act for Physicians [11].
4.2. Technological Limitations
Telemedicine is defined as the use of technology to provide healthcare services at a distance. While telemedicine holds great potential, certain yield limitations and constraints can hinder its delivery and use. The potential technological limitations of telemedicine at various levels of delivery and use are outlined below.
Technological limitations concerning telemedicine delivery can vary at the personal, societal, and application levels. Regarding telemedicine delivery at the personal level, some providers and patients may choose not to adopt telemedicine due to the concern that technology is too difficult to use. Poor transmission quality of the equipment can be a problem, including bandwidth shortages, controlling video quality, poor video and audio synchronization, blurry images, jerky images, delays in transmitting, and disabling of equipment. Furthermore, unavailability of equipment can hinder telemedicine delivery [12].
Telemedicine software applications can also yield limitations. There is no single telemedicine application to meet the needs of all telemedicine situations, such as having multiple telemedicine applications from different vendors that architecture differently. Consequently, needed applications can be unavailable. Compatibility problems can prevent using multiple telemedicine applications from different vendors such as video codecs and compression/decompression algorithms. Telemedicine unless supported by all components, store-and-forward, combined audio and video telephony, and interactivity’s concerning image enrichment are telemedicine application shortcomings. Deadly silence due to telecommunication failure, misinterpretation of GP referral letters, and a disservice to patients are some of the shortcoming consequences [5].
5. Telemedicine in Specialized Fields
Telemedicine is often thought to be mostly for remote consultations, but it’s being utilized in many other ways too. This section specifically explores how telemedicine is being used in specialized fields of healthcare, including mental health and rural healthcare, but is not limited to these examples. For those that do not know, telemedicine combines mobile technology, telecommunications, and clinical information to allow remote medical diagnosis, treatment, and instruction. In the early 1950’s, an experimental telemedicine system was built to wire the patients of the Norfolk State Hospital, a state-owned facility in Virginia, to the University of Virginia. This system was modified to link the hospital to the university’s psychiatric department to aid in the delivery of neurological examinations and consultations of psychiatric patients. The early institutional uses of the technologies that would evolve into telemedicine involved linking hospitals, universities, and research institutions, and had a clinical focus on the monitoring of patients with chronic medical conditions such as hypertension and diabetes. Since then many advances in both technology and methodology occurred, including the findings of a longitudinal, large-scale study performed at the University of Miami, Jackson Memorial Hospital, and 14 community hospitals concerning cardiac evaluations, extrapolating points made by researchers involved in telemedicine studies in 1981, and the Transportation Act of 1992 which provided funds for technological advancements in rural areas. With regards to mental health, there is a wide disparity in the availability of care in the United States. Unlike many other fields of care, telemedicine’s applications in psychiatry are both wide and relatively well established [10].
5.1. Mental Health
Telemedicine is the remote provision of health care using technology. Specialists can video conference patients out of the office or inpatients can use a tablet to connect with providers from their rooms. Although telehealth has been primarily utilized for physical health issues within large health systems, the delivery of mental health treatment through telemedicine, referred to as telepsychiatry or cyber psychiatry, has seen popularity lately. Some research exists about telepsychiatry, but much of it focuses on practitioner acceptance or utilization and efficacy rather than costs and benefits or increasing access to effective care [13]. However, telepsychiatry has been applied to many populations, including veterans, the elderly, students, rural residents, the disabled, and underserved minorities. All have seen increased access to mental health care as a result, and in some cases, significantly decreased costs. Telemedicine has a long history in mental health care, and the potential and impact of such technology are still being understood. Telepsychiatry has constraints as well. There are many concerns surrounding this technology that must be addressed before providers can fully embrace it. Some such concerns include reimbursement issues, licensure and interstate practice, privacy and security, patient safety and quality of care, and interoperability. These concerns must be resolved if telepsychiatry is to be accepted in the mental health care community.
5.2. Rural Healthcare
The application of telemedicine in rural healthcare settings is of utmost significance in addressing healthcare accessibility challenges in remote or underserved areas. Telemedicine serves as an innovative healthcare delivery approach that utilizes telecommunications technologies to provide healthcare services at a distance. As a vital component of ensuring healthcare access, especially during challenging times like the COVID-19 pandemic, telemedicine is expected to multiply its footprint in the post-pandemic era [4]. Nevertheless, concerns surrounding the equitable adoption of telemedicine persist, particularly among vulnerable populations, such as the medically underserved.
Telemedicine holds great promise in improving healthcare delivery in rural regions. Rurality presents numerous barriers to care access, often resulting in unfavorable health outcomes and high healthcare costs. There has been a nationwide effort for the past several decades to find ways to overcome these barriers. Community Health Center systems, Medicare Rural Health Clinics, and other bundled services have been heavily invested in as solutions to the problem of access. Recent advances in telecommunications technologies with the rapid proliferation of broadband access have spurred interest in telemedicine as a means to enhance the quality, efficiency, and accessibility of healthcare in rural regions [14].
6. Ethical Considerations
A “telemedicine” implementation or “tele-medicine” incorporation (TMI) is examined as a new treatment plan for patients in the home environment using a multi-antenna tele-robot (mTR) to respond to patient activities in the home setting, allowing a general physician at a healthcare center to observe the health status of patients while accepting video consultations with patients [6]. This design enables patients to receive attention despite potentially being unable to access the clinic, being bedridden, or being late in treatment by consolidating a variety of healthcare sensors to monitor the patients’ health. A set of ethics procedures is introduced to facilitate research and debate in social circles from the design stage through field deployment.
Telemedicine can be considered to have both popularity and sceptical designers based on the use of artificial systems like robots. Telemedicine incorporates social implications on the home and patient side, with the home seen as a technology place for remote observation/moderation by a healthcare center. Ethics consideration is essential in this implementation; implementation and ethics design on telemedicine within the purpose of assisting bedridden patients are explored [15]. Ethics robots or telemedicine systems where decisions with certain social implications are concerned is one moral concern. Privacy and data security are with fundamental ethical concerns on the side of the social implement people. Privacy and data attribution issues are examined for effective and robust TMI, with reasonable coding and power assignment designs.
6.1. Privacy and Data Security
Telemedicine is the electronic exchange of medical information. Telemedicine includes patient monitoring, diagnostics, treatment, education, and consultation. Telemedicine has various benefits and challenges such as security threats, legal challenges, technology, reimbursement, privacy and ethical issues [6]. Privacy and data security within the context of telemedicine have raised concerns. Telemedicine is the practice of providing patient care remotely using technology. Even though it has been an asset in providing healthcare to people across various geographical boundaries, there are concerns regarding data privacy and security. The healthcare sector accumulated sensitive information such as Health Insurance Portability and Accountability Act (HIPAA). Safeguarding patient information, upholding privacy, and preventing unauthorized access to personal and medical records is crucial.
In telemedicine, computerized devices should access information as they democratized access to sensitive information (i.e., increased risk of privacy invasion). Studies stated there are security risks associated in networks especially in shared public network [16]. Hackers breach glaring vulnerabilities in firewall or with access control in information systems. Blocking the access of outside individuals with anonymous identity and involuntary penetration of firewalls is difficult in public networks.
7. Patient Experience and Satisfaction
Research on the patient care experience and satisfaction before and after telemedicine visits helps understand the user perspective of this service. Countries and regions, including the United States, East Africa, Canada, Saudi Arabia, Kuwait, Turkey, and Bangladesh, are using telemedicine services of various types, such as teleconsultations, telepsychiatry, telecardiology, and teledermatology. More than 568 participants aged 18 years or older, with previous experience of healthcare services using telemedicine, were included.
The studies included in this review assessed the usability and satisfaction of telemedicine services at the overall level. This approach provides important knowledge that relates to the usability and satisfaction of telemedicine services rather than focusing on specific problems. Most studies shared descriptive data about telemedicine services, including the service type, communication technology used, diagnoses, referral sources, service duration, and number of visits. Eight studies before the COVID-19 pandemic mainly focused on specific diagnoses. After the outbreak of the pandemic, studies naturally focused on the use and evaluation of telemedicine services for various medical specialties to control its spread. Most services were funded by the government or non-government organizations. Services were delivered via platforms accessed via phones, tablets, and computers. Only one study also investigated the usability of telemedicine services from the provider perspective. Remembering past and actual visits was considered the most complex task in both studies [17] [18].
8. Future Trends in Telemedicine
Telemedicine has become a hot topic of discussion across the healthcare landscape, and what was once a buzzword is being implemented with growing interest. Telemedicine encompasses a wide range of medical services and treatments that are delivered remotely through technology, and it is gaining traction with patients and providers [3]. During this time of great change, the trends in telemedicine’s past, present, and future can offer insight into its evolution and survival.
Although telemedicine is being adopted at a rapid pace, some trends that will shape its future have been seen in past and current behavioral and social economic examples [4]. The term “telemedicine” dates back to the 1950s, when it literally meant medicine at a distance. The world’s health technology chain is controlled by a few multi-national companies, and a good share of telemedicine networks is donor-funded or large-scale government financed. Since the shift from public to privately financed healthcare resources, the technology-centered setting of telemedicine has been threatening the development of health information technology infrastructures. While developments in telemedicine technology are important and need to be continued, it is more important that the technology is in accordance with its users and their needs. These past and current trends help clarify important developments that are likely to shape telemedicine’s growth in the future.
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