INTRODUCTION:

As defined by the World Health Organisation (WHO), telemedicine refers to any electronic and telecommunication technologies and services used to provide healthcare services at a distance for the purpose of treatment diagnosis, disease and injury prevention, research and evaluation, as well as education of health care providers¹. Telemedicine is commonly confused with telehealth, but there are some subtle differences between these two terms. Telehealth broadly refers to any electronic and telecommunication technologies and services used to provide healthcare services remotely and includes any remote non-clinical services. Telemedicine, on the other hand, specifically refers to only remote clinical services.

Before the start of the Covid-19 pandemic, telemedicine was still in development; it wasn’t widely utilised until after the pandemic had occurred. The rise of telemedicine stemmed from a demand for safe, contactless healthcare delivery to patients as a part of the global effort to minimise unnecessary face-to-face interactions². This review aims to identify how telemedicine benefits both healthcare providers and patients, to understand how much telemedicine has advanced in the midst of a global pandemic, as well as to explore potential developments of telemedicine in the near future. Through this review, we hope to increase awareness of the importance of telemedicine, especially during the Covid-19 pandemic.

METHODS:

A literature review was performed on a general topic of telemedicine using search engines like PubMed, Google Scholar, SpringerLink, ClinicalKey and ScienceDirect to search for articles published between 2006 to 2022. Websites of several professional organisations were also reviewed to obtain information and data relevant to our topic. The keywords used include “telemedicine”, “advantages'', “limitations'', “applications'', “Covid-19”, “development” and “future”. For article selection and review, a total of 4 reviewers were involved. In the end, the number of articles were narrowed down to 33, based on the inclusion criteria consisting of systemic reviews and research studies, all published within 16 years (from 2006 to 2022) and written in English. Unpublished, non-English and non-telemedicine-related articles as well as abstracts and duplicates were excluded from our literature review.

INTEGRATION OF TECHNOLOGY IN HEALTHCARE (ADVANTAGES AND LIMITATIONS):

A variety of electronic methods have been incorporated into healthcare systems over time to manage patient information and their health. Healthcare information technology has made it easier and more efficient for healthcare practitioners to manage patient care more effectively. Medical practitioners can store patient information in secure and private platforms electronically hence improving healthcare quality by far and making it more Cost-effective.

The advantages of health information technology include facilitating effective communication between the healthcare team including the doctors, nurses, and pharmacists in maintaining safe medication dispensing, tracking and adherence. With the development of healthcare Information technology, healthcare providers can have access to complete and precise information about a patient’s health history easily during routine visits or even during a medical emergency. Moreover, with information technology incorporated in health systems, the medical team can coordinate efficiently among themselves the care given to the patient, especially patients with chronic illness who have a long medical history. Storing information electronically has also enabled sharing and reporting of patient information securely with the family or caregivers through the internet making communication easier and faster. Medication efficacy has increased by a top-notch in public health disease surveillance and reporting^3-7.

Health IT have also improved patient safety using medication alerts and reminders which provide better tracking of consultations and monitor closely diagnostic testing and complete patient data. The efficacy of therapeutic interventions can be evaluated through data obtained by the health IT systems hence improving medicine practice and patient handling. Alerts help in monitoring adherence to guidelines of treatment. This reduces practice variations and optimises evidence-based care for common patient conditions⁸.

Nonetheless, major improvements are needed in all health IT, especially in implementation, design and integration between platforms used in the health environment. A very strong interoperability has been a very elusive concept yet very essential for safe patient care. Patient safety and quality are the key focus that are highlighted in any developing information technology platform in healthcare. There are several safety concerns with health information technology. In a 2013 list of hazards by the Emergency Care Research Institute (ECRI), four among the top 10 hazards were directly involving health Information Technology. Technology systems may have several errors such as those of omission or commission which may lead to poor patient care and even cause adverse effects due to wrong treatments. These accidental adverse effects usually crop up from faulty device systems or human-machine interfaces³.

The use of alerts to signal the healthcare teams have proven to be a very dangerous tool rather than helpful. Alerts have been on top of the ECRI list of 2013 health IT hazards. It has been shown that the Alerts cause fatigue to the healthcare professionals. The only way to solve this is by individualization within each health facility to reduce the volume of alerts directed to one healthcare personnel at a time. A system that manages these alerts needs to be developed that can establish priority levels for each alert which will make them unambiguous hence will reduce alert fatigue to the healthcare professionals which is a critical aspect in maintaining patient safety.

Moreover, there are several barriers that concern health IT systems in addressing patient care and safety. There is no mandatory reporting for medical errors caused by IT health systems. Many health IT vendors are competing in developing such software that the medical workers are afraid of providing errors directly to the IT system out of fear of violating non-disclosure clauses.

APPLICATION OF TELEMEDICINE AND THE APPROACHES AVAILABLE:

Teleradiology:

The application of telemedicine in radiology practices is known as teleradiology. It involves the digital transmission of radiological images and reports such as X-rays, computed tomography (CT), magnetic resonance imaging (MRI), from the site of acquisition to a remote radiologist for the purpose of reviewing and interpretation, followed by diagnosis and consultation^9,10. This is particularly useful in radiologists' limited settings as radiology plays a crucial role in the diagnosis and treatment of diseases, especially in cardiology, pulmonology, neurology and orthopaedics. Teleradiology is one of the most widely implemented telemedicine services, which contributed to more than half of all telemedicine applications in the US in 2014⁹. The evidence available to date suggests that the availability and prevalence of teleradiology have been rising throughout the years.

A review established the feasibility of teleradiology practices over the two decades, as well as its positive treatment and patient outcomes¹¹. In addition, a study conducted in an area with resource shortages showed the clinical value of teleradiology to modern radiology practices¹². On top of that, the European Society of Radiology (ESR) and American College of Radiology (ACR) conducted surveys on teleradiology practice, where findings revealed a wide utilisation of insourcing and outsourcing teleradiology in Europe as well as the widespread implementation of teleradiology throughout the continent respectively^13,14.

Despite the benefits of reduced turnover time and workload, concerns about quality assurance and regulatory matters were raised^13,14. Technical limitations have also been thought to impede the optimal integration of teleradiology practices¹⁰. For instance, conversion of DICOM images to JPEG format can cause low resolution of images, which may lead to misinterpretation and diagnostic error¹⁵. Hence, attention to these issues should be warranted to ensure high quality and easy accessibility of teleradiology.

Telepsychiatry:

Telemedicine has been implemented in the field of psychiatry, known as telepsychiatry. It involves the delivery of mental health care, including virtual assessment, patient education and therapy from a remote mental health professional primarily via videoconference¹⁶. It is currently one of the most practised telemedicine applications after teleradiology, whereby the practice has been increasingly adopted and expanded in recent years owing to the COVID-19 pandemic^17,18. With the current shortage of psychiatrists, researchers have proposed that implementation of telepsychiatry can be a promising alternative to the traditional practice and a possible solution to current issues faced¹⁹.

Over the decades, there is an increasing number of research and reviews on telepsychiatry, where earlier evidence was mainly on its feasibility and acceptability while the later ones are more outcome focused. A review in 2015 established the clinical value of Videoconference-based telepsychiatry, in which the findings showed equivalent or even superior outcomes in mental disorders as compared to the conventional method²⁰. Moreover, a study demonstrated that cognitive behavioural therapy (CBT) via videoconference was equally effective as that in person²¹.

Telemonitoring in chronic diseases:

Chronic diseases are long-term conditions that impose a significant financial burden on patients. The high prevalence of chronic diseases presents a major challenge to the health system worldwide in providing sufficient care²¹. Telemedicine, in the form of remote monitoring, can be implemented in the management of chronic conditions to help reduce treatment cost, improve patients care and minimise disease progression^21-23. Studies and literature for the use of telemedicine in chronic disease management are emerging, where most of them are outcome focused. The majority of the applications share common functionalities, which require physicians to monitor condition progression remotely and patients to be equipped with devices for self-measurement while all the medical data generated from the devices are inputted either manually or through an automated transmission system to a platform accessible by the healthcare team. An alerting system is also incorporated to automatically detect any self-measurement that surpasses the thresholds defined for each patient, generating an alert that helps to indicate a much needed follow up or action to be taken in an emergency case^22,23.

Orozco-Beltran et al. conducted a study to assess the impact of telemedicine, in the form of telemonitoring, on patients who are at risk of hospital readmission or emergency visit and are suffering from chronic diseases or comorbidities, particularly diabetes, hypertension, cardiac failure and chronic obstructive pulmonary disease (COPD)²². The patients’ chronic conditions were monitored based on self-measured vital signs, including weight, blood pressure, heart rate, oxygen saturation and capillary blood glucose, as well as remote symptoms questionnaires. The study showed positive outcomes of the telemonitoring program on disease control, as well as a reduced frequency of readmission and emergency department visits^22.

Besides, telemonitoring has also been integrated in the management of chronic liver disease like cirrhosis to prevent decompensation and hospital readmission through remote monitoring of vital signs and symptoms of disease progression, along with daily sodium intake²⁴. Similarly, this approach has been implemented as follow-up of post liver transplantation in both adult and paediatric populations^24,25. The application of telemedicine is also seen in chronic kidney diseases management where it is used to remotely monitor dialysis parameters and physiological data following peritoneal dialysis²³.

TELEMEDICINE DURING COVID-19 AND ITS IMPORTANCE:

Telemedicine enables health care workers to offer safe care by lowering the risk of potential exposure to both the provider and the patient, maintaining personal protective equipment, and reducing patient loads at hospitals and facilities. Following the rapid spread of the SARS-CoV-2 virus, the World Health Organisation (WHO) proclaimed a coronavirus 2019 illness (COVID-19) pandemic on March 11, 2020. The COVID-19 outbreak has sparked a worldwide lockdown, severely disrupting daily living as well as most health-care systems, which have been tasked with managing both infected patients and ordinary non-COVID-19 patient care²⁶. As a result of favourable data from earlier pandemics and technology improvements, the use of telemedicine has expanded throughout this critical moment, particularly in industrialised countries, particularly the United States, the United Kingdom and China²⁶.

Much more cutting-edge digital technology has supplemented traditional phone interviews. Both national and international guidelines should examine the incorporation of e-health, or telemedicine technology, into their revisions, while clearly distinguishing between advice for general use and recommendations for emergency situations. In fact, the lack of vaccines or effective treatments as a result of social boundaries and lockdown as primary preventive measures makes telemedicine the safer connection mechanism between patients and clinicians. The widespread nature of this epidemic has also spurred a narrowing of the gap associated with poor adherence to the use of digital technologies. Based on earlier research and models, social distance has generated three potential e-health applications during the COVID-19 pandemic. On the one hand, patients at increased risk of infection, particularly those with chronic, autoimmune, or immunosuppressive conditions, can avoid exposure to risk factors by virtually conversing with their primary care physician and/or specialist. Referral to clinical facilities is consequently restricted to the most severe cases²⁶.

Furthermore, unequivocal positive cases, whether asymptomatic or minimally symptomatic, are not prioritised for hospitalisation; however, they are closely monitored through dedicated channels with both COVID-19 centres, general practitioners, and local health authorities. Furthermore, e-health communication has allowed minimally infected professionals to continue their usual practice by allowing them to conduct their duties remotely²⁷. The viability of this novel medicinal method is currently being debated. Furthermore, the cost-to-benefit ratio of these technologies should be maximised for better worldwide utilisation of telemedicine beyond the current emergency context in the future, with a greater emphasis on chronic disease care.

During the COVID-19 epidemic, strict social isolation and a lack of viable therapies rendered telemedicine the most secure interactive system between infected and uninfected patients and clinicians. A few possible evidence-based scenarios for the use of telemedicine have been proposed²⁶. Because of the significant risk of poor prognosis, its usage in diabetes for instance and complication monitoring has increased dramatically. New evidence and technology advancements in telemedicine use in diabetic retinopathy (DR) screening have proved efficacy and utility²⁶.

On the contrary, despite evidence of the effectiveness of virtual ambulatory care for older persons, some studies have noted difficulties in implementing telemedicine in this population due to hurdles such as disability or a lack of devices, adequate internet access, and technological experience. This is the foundation of a rural area²⁸. However, around the globe a study found that telemedicine use increased dramatically among older adult patients throughout the Covid times. This was most likely due to the new COVID-19 billing codes, which allowed for the reimbursement of phone visits, as phone calls may be easier for older persons to obtain than videoconferencing. Furthermore, through improving social distance, telemedicine services can aid in public health mitigation tactics during this epidemic. By decreasing potential infectious exposures, these services can be a safer option for HCPs and patients²⁹. They can alleviate the load on healthcare systems by reducing the spike of patient demand on facilities and the usage of PPE by healthcare providers. When an in-person visit is not realistic or feasible, remote access can assist sustain the patient-provider relationship.

It is encouraging to see greater proof of telemedicine's usefulness; nevertheless, additional study on telemedicine's influence on cost, quality, access, and patient experience is required²⁹. There is no doubt that telemedicine will become more mainstream. However, inadequate research has been conducted to determine if inequities in telemedicine receipt across age, race, ethnicity, socioeconomic position, and rurality extend into this current phase of unplanned telemedicine expansion³⁰. Telemedicine is not only the future of medical practice; it is also a primary means of providing care to those who have restricted access to physicians³¹. Requiring patients to visit a physical facility for treatment is becoming increasingly unrealistic and unsustainable.

Future Developments For Telemedicine:

Due to the current pandemic, the utilisation of telemedicine has indeed risen significantly and is currently without a doubt at its peak. However, it is not definite that telemedicine will continue to strive, especially post-pandemic. The fate of telemedicine in the post-pandemic world will depend on various factors, particularly the availability of reimbursements as cost is one of the greatest obstacles in implementing telemedicine programs and necessary devices^32,33. The chances of telemedicine or telehealth being implemented by various health care organisations will be limited to only if there is an absence of associated cost increase upon implementation as well as an associated cost reduction in the long run after implementation³⁴. However, current evidence suggested that despite the overwhelming benefits that telehealth brings, it does not reduce the cost of delivering healthcare services^34.

Other than financial factors, patient-related and physician-related factors also play pivotal roles in telemedicine development in the post-pandemic world². Out of necessity, the patients involved were “forced” to accept telemedicine as a new means of receiving healthcare, which in turn contributed to the rise of telemedicine. However, it is uncertain whether patients would continue to utilise telemedicine even after the end of the pandemic. The potential reasons are limited access to computers or smartphones, low technological literacy, and inconsistent internet connection³⁵. Besides patient demand, the willingness of physicians and other healthcare professionals to continue implementing telemedicine is also important². A study found out that physicians viewed telemedicine as only a temporary solution for healthcare delivery during Covid-19 lockdown while expecting the level of utilisation to decline after the pandemic^36,37-39. In fact, the number of virtual health visits had indeed spiked during the lockdown, but the numbers declined as clinics were reopened for physical practice³⁵.

For now, the fate of telemedicine in the post-pandemic world remains unclear. As much as healthcare providers and patients are accustomed to this new norm, its sustainability comes down to reimbursements in the end^32,34. Further advancements may be anticipated provided that financial assistance is granted. It is important for the barriers mentioned above to be overcome in order to benefit fully from telemedicine in the future as well as to be prepared for any future pandemics to come^29,40-46.

CONCLUSION:

The unprecedented breadth of telemedicine adoption among independent members most likely sped up the adoption of such an innovative care model by several decades. Relieving pre-pandemic technical specifications for telemedicine visits has crafted telemedicine extra accessible to the public who are less tech-savvy. Furthermore, during the COVID-19 pandemic, telemedicine expanded rapidly across a wide range of clinical conditions and demographics. Aside from that, hundreds and thousands of patients of all ages and backgrounds have now had clinician visits without the transportation costs and wait time associated with traditional in-person visits. However, E-Health literacy was linked to higher levels of satisfaction with telemedicine. Rural residents, on the other hand, encountered difficulties with telemedicine significant exposure because of unreliable/unstable internet and found the service impersonal. The lack of technological infrastructure is a persistent concern for rural communities seeking healthcare equity on par with their urban counterparts. If telemedicine is to be used during and after COVID-19, it is critical that rural residents have the support they need to engage in this type of remote care. Future telemedicine use may well not represent the existing surge, but reversion to earlier low levels of adoption is highly improbable, as evidenced by the present state of telemedicine use. As the future of telemedicine unfolds, more research into adoption trends, health results, and patient and provider fulfilment will be required to establish policy and guidelines for safer and more effective use of this technology.

CONFLICT OF INTEREST:

The author has no relevant conflict of interest to disclose.

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Received on 12.04.2023 Modified on 03.08.2023

Research J. Pharm. and Tech 2024; 17(4):1895-1901.

DOI: 10.52711/0974-360X.2024.00301