Telehealth “is the means by which technologies and related services concerned with health and well-being are accessed by people or provided for them irrespective of location” (Doughty 2018). This amends the original definition set out by the Telehealth Quality Group which referred to access or provision “at a distance” rather than “irrespective of location” and may have inadvertently and incorrectly signaled a lesser relevance of telehealth in urban center areas (Fisk 2014; Paraciani et al. 2017). As with telemedicine, telehealth products are used or services operated in contexts where the provider and the consumer are physically separated; therefore, a communication link is needed to connect them.
The Telehealth Quality Group definition fits with those offered by Darkins and Cary (2000) and the World Health Organization (2010), where both of the latter see telehealth and telemedicine as, in part, synonymous. The distinction that they recognized was that telemedicine may be restricted to services where physicians and health professionals are involved and, in some cases, to exchanges of information (for purposes of diagnoses and treatment) which did not involve the patient. Telehealth, by contrast, will always involve the patient and can include its use by people who have no current or specific need for diagnoses or health-related treatments.
It follows from the definition that telemedicine is a subset of telehealth. There are, however, multiple subsets of telehealth that include mHealth (mobile health) accessed via smartphones (Lynch and Fisk 2017); health and clinical disciplines and roles such as telepsychiatry, teledermatology, and telenursing (Schlachta-Fairchild et al. 2008); and social care including social alarms and telecare (Fisk 2003).
Telehealth services can be accessed by people through the simplest of telephones (for social alarms, personal emergency response services or information, and advice); through smarter, including mobile devices (with greater functionality and access to apps); or through communications networks with video and audio connections which can carry substantial data, including images, relating to their activities and/or vital signs (whether to help with self-management or to facilitate diagnoses, treatments, or other interventions).
The most appropriate point to begin any overview of telehealth and its meaning is the work of Darkins and Cary (2000). They noted in the opening sentence of their book that “telecommunications technologies are changing ways of thinking, acting and communicating.” They set out to explore how these changing ways were impacting or could impact on established health-care systems that, they affirmed, “until comparatively recently” had been “the exclusive preserve of the health professions.” Their work focused on the United States and the United Kingdom, but the issues they attempted to address have global resonance.
Advances in communications technologies in the ensuing two decades have been substantial. Dineson et al. (2016), in another transatlantic review (United States and the European Union), pointed to the “greatest strides in the use of remote monitoring technologies” having occurred – these now underpinning what we recognize as telehealth. Most notable are the increased capacity of communications networks; and the increased intelligence embedded within smart and often portable devices by which information or services can be accessed and/or remote monitoring can take place. Some of the wide range of technologies has been noted by McGee Lennon et al. (2012), including TV, personal computers, mobile phones, and (normally wrist-worn) “wearables.”
With issues relating to broader well-being in mind, telehealth includes aspects of social care. This means that part of telehealth is closely positioned with regard to communities and people’s homes, rather than institutional settings such as the hospital, clinic, or nursing home. It creates a context where its role can be seen as concerned both with clinical and preventative health – carrying the potential to influence and support people (with, where needed, the involvement of social care and community nursing staff), not just in relation to their health but also their behaviors and lifestyles. This is also a pointer to telehealth’s potential benefits within the most remote rural and island communities – where clinic- and hospital-based services may be scarce or unavailable. The same applies for areas that experience conflict or natural disasters.
Telehealth developments, in addition, relate to a wide and changing context in terms of disciplines and service types. And it is important to recognize that the driver for the changes is, in part, people’s aspiration to have control over their health, with this being enabled through advances in communication technologies. Health care (including that element of which may carry the telehealth label), as a consequence, becomes a matter within wider service “menus” – ready to be accessed and used in ways that people themselves choose as well as something that may be necessitated on account of a clinical need.
Dineson et al. (2016) posed three questions: (1) How will the market players (designers, manufacturers, service providers) respond to the changing technological context? (2) To what extent will they recognize the inevitable shift away from established models of clinically (and institutionally) driven health-care delivery? (3) How rapidly (and in what way) will the demand for services change as more people access and use new technologies in ways that fit with their lifestyles, behaviors, and needs?
Key Research Findings
Although a distinction between the two has been made, the development of telehealth rests with telemedicine (See “Telemedicine”). While published sources report on the use of the “telegraph” for medical care in the American Civil War (1861–1865), the origins of telemedicine are generally attributed to Willem Einthoven who, in 1905, transmitted via telephony what he called “telecardiograms” from his hospital in Leiden (The Netherlands) to his laboratory 1500 m away (Dumanskyy et al. 2013). Much, of course, has happened in the ensuing century that changed and improved the essential core of telemedicine and telehealth that comprises both the networks and the linked devices that attach to or communicate through them.
Given the shared origins of telemedicine and telehealth and their use of technologies to facilitate communication over a distance, it is unsurprising that there has been a preoccupation with those technologies and the extent to which they could enable clinicians to ply their trades in a different, perhaps more convenient and less costly, way. It follows that the technologies were regarded as and are seen, at least by clinicians, as “tools” for health care. This perspective on the technologies is reflected in the work of Christensen et al. (2009) who, while being emphatic about the “disruptive” effect of new technologies, saw them as enabling a “virtual decentralization” of clinical services. But, as argued by Lynch and Fisk (2017) in a study of mHealth, they failed to extend the logic of their argument to points of care that were beyond the local clinic. According to Lynch and Fisk, Christenson et al. did not see that understandings of telehealth are changing – responding to different expectations and the way that people are harnessing increasingly affordable, accessible, ubiquitous, and portable new technologies. Hence while expert clinical knowledge must still be highly valued in the world of health, the boundaries around the clinical domain are becoming increasingly blurred as a direct consequence of people wanting both to engage with health professionals and access services and information in new ways.
It follows that the three questions posed by Dinesen et al. (2016) loom large. They help point to themes that are, in part, concerned with the efficacy of telehealth technologies and services but are also to do with the telehealth imperative that is about responding to people’s changing needs, choices, and aspirations.
Key Research Themes
The imperative that underpins some of the developments around telehealth arises through the disruptive impact of communication technologies, people’s access to and adoption of the technologies (and use of related services), and what appears to be the increasing unsustainability of current health-care service frameworks. To these can be added fears around increasing numbers of (often older) people with long-term conditions and the likely consequent costs to health-care services. Budgetary projections for the countries of the European Union, including the factors of health care and long-term care, point to the “fiscal impact of ageing” being “projected to be a significant challenge in almost all member states” (European Commission 2018). These factors can, however, be countered or mitigated through policy and practice initiatives that establish social norms to promote higher levels of health (and digital) literacy in order for people to adopt and maintain better lifestyles and be equipped (supported by clinicians as appropriate) to self-manage in relation to aspects of their health.
Telehealth clearly has a part to play in this – subject to products and services being configured in order to be accessible, usable, and nonintrusive, with people able to build and make best use of their health literacy (including being able to exercise choice and control when using telehealth services). Telehealth can also enable more (older) people to stay longer in or return to the workforce – thus promoting health gains, reducing dependency, and increasing the tax take – whereby health and social support services can become more affordable.
Making Sense of the Research
The extent to which products and services will change in relation to the telehealth imperative about responding to people’s changing needs, choices, and aspirations is uncertain. That there will be change, however, is indisputable. It is a consequence of rapid technological developments, changing social norms, and the growing accessibility of the technologies to people of all ages. The rapidity of change means, however, that much research pertaining to telehealth is problematic and/or quickly out of date. The ambivalent outcomes of or methodological shortcomings in much of the research to date are one reason for the limited extent of service developments.
Greenhalgh et al. (2017) explored such research in the context of heart failure (a condition for which substantial attention has been given in telehealth interventions). They noted that “randomised trials have be slow to recruit [patients] and produced conflicting findings; real-world roll-out has been slow.” They affirmed that the results of randomized trials “demonstrated no statistically significant impact from comparable telehealth interventions and patient groups”; and they noted that a Cochrane review (of multiple studies) showed “no overall benefit.” Remarkable, in addition, is Greenhalgh et al.’s listing of 37 factors that account for the poor uptake of telehealth in heart failure. Many or all of these have resonance and relevance for the wider application of telehealth. Dinesen et al. (2016), in contrast, reported that multiple studies demonstrate “clear benefits for patients with chronic disease” with “remote patient monitoring” programs associated with “decreased hospital utilization, improved patient compliance, improved patient satisfaction with health services, and improved quality of life.”
Doughty (2018) noted, for what were known as the Whole System Demonstrators (WSDs), telehealth pilots with some 3000 patients in England, that outcomes of the evaluative research were positive in terms of, e.g., reduced emergency admissions but that there was a high cost for the technologies. The WSDs were implemented in 2010 for patients with diabetes, coronary heart disease or chronic obstructive pulmonary disease (COPD). Telehealth did not, therefore, “seem to be a cost-effective addition to standard support and treatment.” Doughty (2018) pointed out, however, that a reduced cost of the technologies combined with changes in operational frameworks would have changed the equation. Steventon and Bardsley (2012) pointed to the WSDs finding a 20% reduction in hospital emergency admissions and fewer deaths but noted that “the impact of telehealth depends on the type of technology and how it is used, as well as the nature of care that is subsequently provided.”
The WSDs in England were followed by a similar initiative in Northern Ireland. This focused on just under 4000 patients with the target conditions of diabetes, heart failure, COPD, and hypertension. The evaluation found (as for the WSDs) “no evidence within the dataset of any marked impact of telehealth services on hospitalisations and hospital based service usage” (McElnay et al. 2016). Poor targeting was seen as a primary factor, hence their affirmation that any program of telehealth service development “should include strict protocols for patient selection so that only those who are likely to gain benefit … receive the service.”
With regard to more qualitatively oriented studies, Vassilev et al. (2015) reviewed 15 papers that related to telehealth “interventions.” These were concerned with patients with COPD, heart failure, diabetes, and “behaviours and complications associated with these conditions.” This review helps to shift the telehealth research agenda toward patients or, rather, “people” and signals the need to consider outcomes of telehealth interventions at least in part in relation to felt well-being gains (of patients or service users) as opposed to measures of service usage and related costs.
Vassilev et al. (2015) identified three concepts concerned with relationships, fit, and visibility. The first (relationships) was important in pointing to the simple fact that people (recognized as “patients, peer groups, and/or lay and professional carers”) are a “necessary” component of telehealth interventions. The second (fit) relates to the extent to which telehealth interventions can be “integrated within everyday life” (again, suggestive of a home and community context) as well as within “health care routines.” The third (visibility) is concerned with the way in which people view and exercise choices in adopting or rejecting telehealth interventions (linked with the “visibility” of their health circumstances to themselves or others). These concepts provide a pointer to some of the associated design and ethical issues that need to be considered as people access telehealth services where there are greater choices (requiring, therefore, careful consideration by potential providers and users) and potential threats to users on account of the “capture” and usage of personal data (i.e., health and, potentially, lifestyle data).
To make sense of the research, it is necessary to reaffirm telehealth’s position as an “umbrella” concept, facilitated in the definition provided at the outset of this discussion. That umbrella covers products and services concerned with broader well-being, as well as both clinical and preventative health. Its position is important in view of the locus of health care being increasingly decentralized and where telehealth more emphatically revolves around people (patients), their homes, and communities, rather than clinicians. In fact, a wider view is considered as necessary where people are more informed (health literate), have access to and use technologies in new ways (technology literate), and are motivated in ways that enable them, with the support and guidance of clinicians where necessary, to take greater responsibility (including self-managing) in relation to their health.
Future Directions of Research
With changes in the technologies, it becomes necessary for health and social care services to either “accommodate” them or harness their potential. It follows that, for the researcher, telehealth is something of a “moving target.” The establishment of an evidence base regarding its merits is difficult, and it appears from this discussion that narrowly quantitative research methods used for some evaluations have shortcomings. Further research is, therefore, required that considers telehealth in a context that recognizes health from both clinical and broader perspectives with attention being given to the facts around people’s technology adoption and broader well-being gains that could ensue or is ensuing from telehealth’s positioning in relation to the same.
Greenhalgh et al. (2017) pointed to the need for more research that makes greater use of theoretically informed qualitative methods in this “complex area.” Certainly there is a need to avoid narrow quantification that fails to do justice to that complexity and/or overlooks the rapidity of change, not just in communications technologies but also in the way that people are using them. This is not, it needs to be added, just a consequence of what health and related services offer to patients; it is also a consequence of people’s changing aspirations and expectations. Regarding mHealth, in the words of Lynch and Fisk (2017), the technologies “are disrupters, because their increasing pervasiveness and lower cost open up part of the world of medicine to a wider public – this, in turn, undermining the long-held hegemony of the clinicians who saw themselves as having mastery over technologies in healthcare.”
It follows that the research requiring to be undertaken must acknowledge the potential that is being indicated for telehealth, recognizing that the mixed messages about its benefits within the research to date are at least, in part, a result of narrow conceptions of what telehealth is and the inadequacy of methodological approaches that have been often used to evaluate telehealth interventions.
Telehealth has been placed in a broad context that recognizes its common origins with, but divergence from, telemedicine. That divergence may be considered as increasing as telehealth’s relevance to health and well-being agendas is recognized; and the associated communications technologies are increasingly used by people to access services in new ways. A “telehealth imperative” has been posited that requires that telehealth products and services increasingly respond to people’s changing needs, choices, and aspirations.
Importantly, the three questions posed by Dineson et al. (2016) have begun to be answered. In summary, there is a need for greater recognition of how the demand for and relevance of telehealth services is changing. Within this there is a “shift away” from established models of clinically and institutionally driven health care. This is reflected in people’s choices and the extent of their control over the technologies in question, a matter that impacts on design considerations for telehealth products and services. Designers, manufacturers, and service providers should recognize the inevitability of such change.
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