Background

Telemedicine is used today as an umbrella term encompassing the delivery of health-care services and the exchange of health-care information across distances, with the help of a wide variety of technology [1, 2]. The word telemedicine has been supplemented by terms such as telehealth, online health, and more recently, e-Health [1]. It is widely recognized that there is no single, definitive definition of telemedicine [3]. However, the World Health Organization describes telemedicine as: “the delivery of healthcare services by healthcare professionals over a distance involving the exchange of information related to diagnosis, treatment and prevention of diseases and injuries, research and evaluation, and for continuing the education of healthcare providers, all with the goal of advancing health and the healthcare system” [4].

While technology continues to advance, infrastructure and legal barriers remain within the field of telemedicine [5]. Despite these barriers, the implementation of telemedicine measures remains promising with the potential to significantly reduce healthcare expenditures, especially in rural or remote areas such as Northern Canada where the cost of healthcare prevails [6]. Past research has found that telemedicine can also play a role in enhancing complementary, alternative, and integrative medicine (CAIM), allowing the maintenance of cultural values and ancestral knowledge [7]. However, more research is warranted to understand the use and impacts of telemedicine for CAIM.

CAIM is typically described as therapies used together (complementary), in replacement (alternative) of conventional Western medicine, or as the combining of both conventional and unconventional therapies in a coordinated way (integrative) [8, 9]. CAIMs encompass a broad range of approaches that commonly include natural products (e.g., vitamins, herbs, probiotics), mind and body practices (e.g., yoga), and traditional forms of medicine (e.g., traditional Chinese medicine) [9]. The use of telemedicine for the delivery of CAIM holds unique potential to increase access to CAIM practices for those living in remote areas or with accessibility challenges. Greater accessibility to CAIMs through telemedicine may potentially improve clinical outcomes, decrease patient healthcare utilisation, and enhance patient satisfaction with mental health and chronic disease management [10, 11]. The continued use of CAIM in treatment plans, and the growing use of telemedicine as an avenue to extend healthcare, particularly for remote and rural communities, justifies the need to investigate how telemedicine is used in the context of CAIM. Thus, the purpose of this scoping review is to understand the breadth of the literature regarding telemedicine used in the context of CAIM, to inform future areas of investigation and practice.

Methods

This review was conducted to understand how telemedicine is used in the context of CAIM. Arksey and O’Malley’s five-stage scoping review framework [12] was utilised and also supplemented with additional scoping review guides [13,14,15]. The five steps were as follows: 1) identify the research question, 2) identify the relevant studies, 3) select relevant studies, 4) chart data, and 5) collate, summarise, and report the results.

Step 1: Identify the research question

The research question for this scoping review was as follows: “How is telemedicine used in the context of CAIM?” For the purposes of this review, telemedicine was defined based on recent, well-cited review articles, as the application of any online or digital service such as Facebook live groups, Twitter, phone, mobile application, and websites, to enhance health-care management [16,17,18]. CAIM was defined using the operational definition provided by the Cochrane Complementary Medicine group, which included a list of therapies that were classified as complementary, alternative, or integrative medicines [19, 20]. All CAIMs discussed met the Cochrane Complementary Medicine group’s definition. In this review, all included studies contained at least one type of telemedicine being used for at least one type of CAIM.

Step 2: Finding relevant studies

A preliminary scan of the literature indicated that academic literature on this subject area was sparse. We devised a systematic search strategy as shown in Table 1. CINAHL, PsycINFO, MEDLINE, EMBASE and AMED databases were searched on October 12, 2020. The CADTH website was used to search for grey literature, and was also searched on the same day [21]. Primary research articles were considered, and relevant reviews were used to source additional eligible primary research articles.

Table 1 MEDLINE search strategy for studies investigating how telemedicine is used in the context of CAIM, executed October 12, 2020
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Step 3: Selecting the studies

Records were included if they mentioned CAIM and telemedicine, with no restrictions placed on the type of telemedicine strategy. Records were excluded if they were 1) non-academic or non-scholarly sources (e.g., websites, blogs, news articles), 2) found outside of bibliographic database searches (e.g., unpublished theses and dissertations), or 3) conference abstracts. Only articles published in English were included. Three authors (NN, AM, CH) first pilot-screened titles and abstracts independently and in duplicate, and then met to verify the appropriateness of the inclusion criteria. Next, the three authors completed independent screening of articles for eligibility by title and abstract, and full text. Disagreements were resolved with discussion with the senior author (JYN) and in the case that consensus was not reached, eligibility was determined based on majority vote.

Step 4: Charting the data

Articles that met inclusion criteria were critically reviewed using Arksey and O’Malley’s descriptive-analytical narrative method [12]. The following information was extracted by three authors (NN, AM, CH): title, author, year, country, study setting, study design, population type and sample size, type of CAIM used, type of telemedicine used, primary and secondary outcomes and how they were measured, main findings, challenges encountered, and conclusions. Authors then met to resolve any data discrepancies. Later, four authors (AQS, NR, RCS, ZK) reviewed the data extraction as a quality measure.

Step 5: Collating, summarising and reporting results

Charted data was summarized in table format, and thematic and descriptive data was analysed (NN, AM, CH). A thematic analysis was conducted to present a narrative related to the research question and highlight knowledge gaps in the current literature (AQS, NR, RCS, ZK). Themes were discussed in consultation with NN and JYN, who have prior experience in conducting thematic analyses.

Results

Search results

Searches identified a total of 1797 records, of which 1602 were unique. A total of 1402 titles and abstracts were eliminated, leaving 200 full-text articles to be considered. Of these, 138 were ineligible for the following reasons: did not include a CAIM (n = 58) or did not include telemedicine (n = 15), review (n = 44), research protocol (n = 9), conference abstract (n = 5), case study (n = 5), commentary (n = 1), or letter to editor (n = 1), leaving a total of 62 eligible studies which are included in this scoping review. A breakdown of study filtration through the inclusion exclusion process can be found in Fig. 1.

Fig. 1
figure 1

PRISMA diagram displaying the search strategy and selection process [22]

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Eligible article characteristics

Eligible articles were published from 1999 to 2020, and originated from the United States (n = 34), Italy (n = 4), the United Kingdom (n = 3), South Korea (n = 3), Canada (n = 2), China (n = 2), Norway (n = 2), Taiwan (n = 2), Australia (n = 2), France (n = 1), Germany (n = 2), Iceland (n = 1), Israel (n = 1), and Switzerland (n = 1). One article included participants from both the US and the UK [23], and another study included collaboration between Austria and China [24]. Of the 62 articles included, all were primary research articles focused on, development of a telemedicine technology or processes for CAIM (n = 11), analysis of the data collected by a telemedicine technology for CAIM (n = 26) and/or, analysis of usability, acceptability, or feasibility of existing telemedicine software (n = 25). The characteristics of all eligible articles can be found in Tables 2, 3, and 4.

Table 2 General characteristics of the included studies investigating the use of telemedicine in the context of CAIM (n = 62)
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Table 3 Participant characteristics of the included interventional studies investing CAIMs delivered via telemedicine (n = 56)
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Table 4 Major telemedicine findings and type of research in the included studies investigating CAIMs used in the context of telemedicine
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CAIM characteristics

Of the 62 articles included, the distribution of CAIMs discussed were as follows: mindfulness training (n = 11), mind–body exercise (n = 7), yoga (n = 7), biofeedback (n = 4), music therapy (n = 4), spiritual care (n = 4), dance therapy (n = 3), cannabis (n = 3), chiropractic manipulation (n = 2), guided imagery (n = 2), hypnosis (n = 2), ketogenic diet (n = 2), acupuncture (n = 1), auricular acupressure (n = 1), Chinese medicine (n = 1), exercise (n = 1), qigong (n = 1), herbal medicine (n = 1), meditation (n = 1), Mediterranean diet (n = 1), play-based therapy (n = 1), and vitamin B weight loss (n = 1).

Telemedicine characteristics

Of the 62 articles included, the telemedicine tools used were as follows: videoconferencing (n = 16), mobile application (n = 7), web- or mobile-based application (n = 2), videos (n = 10), websites (n = 7), telephone (n = 7), database/cloud system (n = 1), telemedicine centre (n = 1), teleconference (n = 1), telephone and video (n = 1), e-mail (n = 1), remote tele-biofeedback (n = 1), social media platform (n = 1), telephone and portable electromyograph (n = 1), videos and chat group (n = 1), text messaging (n = 1), telephone and videoconferencing (n = 1), telephone and mp3 audio (n = 1), and website and videoconferencing (n = 1).

Findings from thematic analysis

In total, three main themes emerged from our analysis and are described below.

Theme 1: Practitioner view of CAIM telemedicine

Feasibility of CAIM telemedicine interventions

Overall, practitioners found it feasible to deliver traditionally in-person CAIM interventions through a telemedicine approach (n = 26) [24, 25, 27, 31,32,33,34,35, 38,39,40, 42, 43, 51, 52, 54, 55, 58,59,60, 63, 68, 69, 71, 72, 74, 76, 80, 83, 85]. Sufficient technology exists to meet the delivery needs of a great number of heterogeneous CAIM interventions. For example, Skype as a videoconferencing platform could be effectively used for hypnotherapy [42], but also for mind–body therapy [80]. Other technologies such as telephones, internet websites, smartphone applications, virtual-reality technology, and even specialized cloud platforms were successfully tailored to the goals of particular CAIM interventions and targeted towards a diverse range of patient populations including older adults [27]. Practitioners found it feasible to implement physical activities such as dance and yoga virtually [25, 59, 68], but also found it was possible to administer more complex CAIM interventions such as hypnosis therapy, or the virtual management and treatment of patients with COVID-19 [51, 71].

The feasibility of the intervention itself was comparable, and in some cases, superior to in-person delivery. One study found that interest in participation and feasibility of a Skype mind–body therapy was superior compared to an in-person pilot test of the same intervention [43], while another study found increased scheduling flexibility and subsequently, greater participation in the telemedicine intervention compared to in-person care delivery [80]. Telemedicine approaches to CAIM were also more inclusive for participants who would usually have been unable to participate due to cost barriers, or travel difficulties such as urinary incontinence [42].

High acceptability and satisfaction of CAIM telemedicine interventions

Practitioners readily accepted and reported favourable attitudes towards telemedicine approaches to CAIM (n = 21) [23, 39, 41, 45, 46, 50,51,52,53,54,55,56,57, 61, 63,64,65,66, 68, 70, 73]. Practitioners did not have major concerns regarding ease of use, appeal to target population, or efficacy of telemedicine CAIM interventions. This held true across the various populations included in this review. For example, clinicians in a cannabis reduction intervention did not have concerns about confidentiality, or application of mobile device technology [70]. Another telephone-adapted delivery format for a mindfulness-based stress reduction was perceived by practitioners as “very positive” [63]. In a dance-therapy session for older adults, student nurse leaders expressed high interest and enjoyment in intervention delivery among study participants [52]. Moreover, practitioners involved with a study by Green et al. [39] found that telehealth enabled continuity of care with patients and was therefore a “valuable” tool.

A common view was that telemedicine is valuable to improve the efficiency of medical resource use, through reducing wait times for patients [51], improving hospital-bed shortage problems [51], and reducing the workload burden of healthcare staff [45, 46, 50, 73]. Practitioners were also satisfied with the potential to lower healthcare delivery costs [46, 55, 57, 63, 66, 73], in one case by up to 75% [63]. Practitioners believed telemedicine delivery of CAIM had a high potential for wider scalability in the healthcare system [63, 64, 66, 73]. Although, some studies expressed barriers such as a lack of a tailored approach to goal setting in an internet-based workplace intervention promoting a Mediterranean diet [61], and poor software and hardware usability of an electromyographic audio biofeedback program for telerehabilitation [65].

Health and well-being improvements

Practitioners found that CAIM interventions delivered using telemedicine resulted in health and well-being improvements across a variety of patient populations, comparable to improvements observed in in-person delivery modes (n = 35) [23, 24, 27,28,29, 31, 33, 36,37,38, 40, 41, 43, 45, 47,48,49,50, 55, 58, 64, 66,67,68,69, 72, 74,75,76,77,78, 80,81,82, 84]. This applied not only to physical patient health [77], but also to quality of life [76], mental [31, 40, 43, 75] and spiritual [64] health, and aspects of personality such as self-concept and self-esteem [64]. The improvement in health was observed across all age groups, from children and adolescents [64], to older adults [67]. Moreover, the improvements to health manifested across a diverse range of patient groups, including veterans, cancer patients, and individuals with chronic illness. Many of these changes were clinically meaningful, having positively impacted the course of the illness or resulted in visible improvements from the perspective of both patients and clinicians [64, 66, 67]. Positive health changes often persisted longitudinally at various follow-up periods, indicating that telemedicine interventions can produce persistent health benefits [28, 43, 48,49,50, 57, 58, 62, 64, 68, 74, 75, 80, 81]. In some cases, health benefits did not remain at follow-up [29], or longitudinal assessment was not reported.

Theme 2: Patient view of CAIM telemedicine

The patient-practitioner relationship

Patients felt it was challenging to form meaningful connections with CAIM practitioners employing telemedicine alternatives (n = 10) [23, 25, 26, 32, 33, 44, 47, 52, 71, 78, 79]. Study participants reported a lack of understanding of the role of the practitioner, difficulty following along with remote-based interventions, and lack of sufficient feedback on their performance from practitioners. For example, participants involved in yoga interventions through video-conferencing technologies identified challenges such as having to continuously “readjust screens,” difficulty “learning and doing poses simultaneously,” a lack of instructor feedback in real-time, and an inability to “bond” with the instructor [25, 47, 78]. In telephone-based coaching interventions, participants seemed to be unclear of the role of coaches, and found it “difficult to develop a relationship with or trust a stranger on the phone” [26, 44]. Furthermore, according to participants, CAIM interventionists may misinterpret their needs particularly when employing audio-visual or phone-based telemedicine technology [25, 26, 29, 41, 47, 67, 71, 78, 85], for reasons such as being unable to perceive “subtle expressions” of interest, emotion, or physical comfort [25], or as a consequence of ineffective communication between practitioners and participants through digital platforms [47, 78].

The impact of existing chronic health conditions and morbidities on intervention outcomes

Complex or chronic conditions, as well as multimorbidity, was found to negatively impact participation, patient safety, or retention of patients in CAIM interventions delivered through telemedicine (n = 12) [23, 25, 32,33,34, 37, 43, 47, 52, 55, 63, 69]. In particular, the presence of these types of health conditions were associated with various functional and mobility limitations such as breathing problems and fatigue, which served as a barrier to participation [23, 47, 63]. For example, some individuals with cancer found it difficult to participate in virtual yoga training due to “[cancer] treatment-related fatigue,” and cancer-related overwhelmingness and forgetfulness [25]. Individuals with chronic pain found that their condition interfered with their ability to attend virtual mindfulness-based classes as part of an intervention [37]. However, this issue was acknowledged and the program was lengthened to suit their needs [37]. Other studies noted that attrition was often due to deteriorating health, or health-related responsibilities (e.g., surgery) [33, 43, 55, 63].

The benefit of telemedicine delivery of CAIM for traditionally underserved populations

Participants most frequently cited CAIM interventions administered through a telemedicine approach as an accessible alternative to in-person care, that leads to improved health outcomes without any salient consequences (n = 21) [25, 27, 28, 30, 32, 37,38,39, 42, 45,46,47, 51, 55, 57, 63, 69,70,71, 74, 76]. Virtual care delivery appeared to expand access to care particularly for rural populations [74], or those with chronic health conditions that prevented them from travelling long distances. Many of the included studies also engaged populations that are often neglected such as racial or ethnic minorities [26, 60], or women veterans [74]. Evaluations and feedback were overwhelmingly positive and in support of these health interventions, noting improved accessibility in receiving CAIM in the comfort of their own homes [32, 43]. Previously identified barriers to participation such as high travel costs [28, 32, 42, 45, 63], inability to travel [28, 42, 63, 69], time conflicts [28, 30, 63], and reluctance to participate in a group or associate with other frail individuals [27], among others, were overcome.

Theme 3: The technological impacts of CAIM via telemedicine

Overall, technological issues did not appear to impede the success of CAIM delivered via telemedicine. However, some participants did believe that technological difficulties were a hindrance. Broadly, issues included degradation of audio and visual quality, limited access to the necessary devices, complex user interface in applications, and troubles with downloading CAIM intervention content, which are all necessary components in successful telecommunication delivery of CAIM (n = 14) [23, 25,26,27, 29, 30, 32, 33, 42, 43, 46, 47, 54, 72]. For example, an unstable internet connection, especially in rural areas, made it difficult to attend or follow along during CAIM sessions [23, 72]. Even when participants did connect to the telemedicine platform being used, freezing of the video stream or inconsistent audio made it difficult to engage and maximally benefit from the intervention [23, 32, 54]. Consequently, some participants believed the technological difficulties prevented them from gaining the “full benefit of the teacher’s feedback and interaction” [33]. In some cases, the technological difficulty meant that the therapeutic session had to be rescheduled [32]. Other types of technological barriers included font and video screen sizes in a mobile app study [30]. In contrast, practitioners did not generally find that technological difficulties were a significant barrier to the feasibility of intervention delivery, reporting that issues were infrequent [29, 32, 63, 74], and quickly and easily resolved when they did occur [25].

Discussion

The purpose of this review was to synthesize the literature on telemedicine utilised in the context of CAIM. To our knowledge, this is the first study to explore this field using a systematic search of peer-reviewed and grey literature to inform practice and future areas of research. Overall, CAIM interventions offered through telemedicine approaches are comparable to face-to-face interventions across dimensions of feasibility, clinical efficacy, and patient and provider satisfaction. The presence of complex or chronic health conditions such as cancer, as well as technological difficulties were reported as barriers to patient participation and satisfaction.

The results of our study reveal that telemedicine strategies to deliver CAIM are diverse, including videoconferencing, telephone, mobile applications, email, and cloud platforms. There is also great heterogeneity in the target populations of these interventions. This aligns with previous findings that telemedicine approaches can be effective for populations with diverse physical, mental, and emotional health-care needs [86,87,88].

Both practitioners and patients overwhelmingly found that telemedicine delivery of CAIM was feasible and acceptable. Practitioners perceived telemedicine as a valuable, cost-effective tool with potential for wider scalability [31, 43, 47, 55]. Furthermore, statistically significant, and clinically meaningful improvements in health outcomes were noted by both patients and practitioners. This reflects evidence telemedicine is found to comparable to face-to-face care in terms of feasibility and clinical-effectiveness [85, 89,90,91,92]. Practitioners also cite time savings after implementing telemedicine, due to a reduction in “downtime and inefficiencies” [93]. For many families, telemedicine delivery reduced cost and transportation barriers, increasing access to care. A recent review indicates that telemedicine advancements have improved access to care for a wide range of clinical conditions, and has addressed geographical barriers to care, although social barriers still lack attention [94].

Both patients and providers appear to be highly satisfied with telemedicine delivery of CAIM, citing that technical difficulties that arose in the intervention delivery were quickly and easily resolved. However, more patients noted technological difficulties that interfered with their participation and satisfaction with the intervention relative to providers delivering the intervention. This is in contrast to the literature where patients typically report high satisfaction with telemedicine approaches [95, 96]. One aspect of technological difficulties included a lack of access to the internet or telecommunication devices. This necessitates education to guide patients that may be unfamiliar about the use of various internet and mobile technologies (e.g., videoconferencing platforms, mobile applications), and its benefits in promoting health and well-being [97]. Patients in areas with unstable internet connections such as rural and remote regions also faced additional barriers to participation in telemedicine delivery of CAIM interventions [97, 98]. This may require government action to enhance internet network bandwidth and deploy advanced generations of network technologies to provide the necessary support as telemedicine continues to expand [97]. On the other hand, provider satisfaction with telemedicine has been studied less frequently as there was a lack of evidence found in this review. This is despite provider perspectives being crucial to the expansion of telemedicine [96].

An important barrier identified by patients is that it was more difficult to establish valuable, meaningful connections with care providers virtually compared to face-to-face. Sharing difficult diagnoses and end-of-life conversations are examples of situations where it is challenging to facilitate via telemedicine, and the telemedicine approach cannot replace human connections formed with a face-to-face conversation [99]. This underscores the importance of ensuring that medical practitioners delivering care using telemedicine modes consider the limitations of these approaches. Both patients and providers reflecting on using telemedicine for chronic disease management recommended that the initial patient-provider interaction should be face-to-face, and that patients should see the same provider at follow-up visits [100].

It is also important to consider that participants with chronic health conditions such as cardiovascular disease, cancer, or diabetes may experience condition-specific barriers such as “chemo fatigue,” [25] or functional limitations [101]. Older adults with chronic illness may face additional challenges relating to frailty, vision and hearing loss, and cognitive limitations that have relevance in non-face-to-face interventions [102]. Moreover, elderly patients may not be able to handle large volumes of online information and some older adults may become anxious or annoyed when adding technology to their regular routine [102]. This is supported by past studies, which identified that special populations such as older adults, patients with disabilities (e.g., vision or hearing difficulties), limited mobility, and/or racial and ethnic minorities may face additional barriers in telemedicine delivery of care [97, 98]. Accordingly, training both care providers and patients is paramount for effective delivery of CAIM via telemedicine [97].

Implications and future directions

Telemedicine models of care have been used for many years, particularly in the United States, but its use has expanded globally during the COVID-19 pandemic [103]. The reviewed literature highlights the potential to deliver CAIM via telemedicine. This study has generated several areas for future research on CAIM delivered using telemedicine.

Further research is required to identify groups that would realize the greatest impact from telemedicine delivery of CAIM. For patients with chronic conditions such as diabetes or cancer, or for older adults, it is important to consider physical or cognitive limitations that may be barriers to successful completion of these interventions. There is also a need to investigate the impact of a more personalized or tailored approach for these high-needs groups with existing illnesses and morbidities [104].

CAIM interventions delivered via telemedicine would benefit from a more holistic evaluation beyond biomedical outcomes. Currently there is a lack of reporting in the literature on how CAIM therapies delivered via telemedicine compare to face-to-face approaches with respect to provider and staff burden, and the experiences of family and friend caregivers [102]. There is also a lack of incorporation of social determinants of health such as socioeconomic status, and race in telemedicine interventions. Evidence indicates that social determinants affect access to telemedicine for groups already suffering from inequities in healthcare access [105]. Accordingly, future telemedicine policy and research should go beyond technological dimensions, and consider social determinants of health [106]. Further, assessment of outcomes at longer follow-up periods is needed to determine whether telemedicine delivery of CAIM is capable of producing sustainable effects [43, 49, 81].

Finally, future work at the intersection of CAIM and telemedicine should identify and evaluate the (in)appropriate use of telemedicine across various CAIM practices. In line with this, more work is needed to examine the facilitators and barriers that providers face in employing telemedicine delivery of CAIM.

Strengths and limitations

Strengths of this study include adherence to Arksey and O’Malley’s five-stage scoping review framework [12], and the use of a comprehensive systematic search strategy across several bibliographic databases to identify eligible articles. Interpretation of the findings was strengthened by the fact that three authors independently screened, and a total of seven authors extracted, and summarised the findings. There are some limitations to this scoping review. By including studies only written in English, we could be missing important international work. This is especially relevant because CAIM may be practiced more frequently in non-English speaking regions of the world, such as traditional Chinese medicine in China.

Another limitation is that despite the use of a comprehensive search strategy, CAIM is an umbrella term encompassing a broad range of practices and as such, it is possible that not all CAIM therapies were captured in the search. Finally, records outside of those found via bibliographic database searches (e.g., unpublished theses and dissertations) were considered outside of the scope of this review, although we acknowledge that this may have contributed to some relevant literature being missed.

Conclusions

The present scoping review explored the breadth of the literature on telemedicine used in the context of CAIM. Three main themes were identified: 1) the practitioner view of CAIM telemedicine, 2) the patient view of CAIM telemedicine, and 3) the technological impacts of CAIM telemedicine. These themes highlight the feasibility, acceptability, and satisfaction of CAIM delivered via telemedicine from both a practitioner and patient point of view. Telemedicine approaches increase access to CAIM, and there is high potential for scalability. Patient barriers include chronic illness and morbidities, low technical proficiency, and an inability to form meaningful connections with care providers. Further research is required to mitigate barriers to telemedicine uptake and increase the knowledge of clinicians on topics of CAIM and telemedicine. We recognize that this may take the form of changes to training, management techniques, and health-care policies.