Telemedicine is a service that is rapidly evolving to provide increased access to high-quality healthcare that is efficient and cost-effective, especially in the midst of the current COVID-19 pandemic. According to the Centers for Medicare and Medicaid Services (CMS), telemedicine is ‘a service that seeks to improve a patient’s health by permitting two-way, real-time interactive communication between the patient and the physician at a distant site’. Although similar, the terms ‘telehealth’ and ‘telemedicine’ should not be used interchangeably. Telehealth refers to ‘the use of telecommunications and information technology (IT) to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance’. Therefore, telehealth can be considered a broader concept of telemedicine that includes technology used to collect and transmit patient data such as telephones, email and remote patient monitoring (RPM) devices for the purposes of providing health education or ancillary healthcare services.
Telemedicine has been recently deployed in many countries both developed and developing ones. Like other system applications, several challenges have been arisen and they are outlined in this section. In total 5 key issues based upon economic, technological and social sides together with some existing studies are described.
- System Development Cost – Apart from the required medical issues, enabling the population especially those dwells in remote or developing areas to benefit from the information and communication technologies generates additional costs. Such requirement can be considered as a key policy in the 21st century3 and it needs to be driven by the government.11 Both technologies are core infrastructure and a large amount of budget is required to invest in necessary computer equipment and developing tools.8 Hardware and software installation and maintenance together with qualified manpower and knowledge transfer demonstrate one-time and periodic investment.
- System Implementation – Several parties within and across institutes are involved in an implementation of telemedicine services.11 Like other domains, telemedicine implementation is not only technological but also managerial prospects. Prior to implementing a telemedicine project, several issues including technological and societal aspects have to be carefully considered.8 As telemedicine services are built upon existing digital technologies, developing teams are normally required to understand the underlying infrastructure and the users’ requirements. Advancement in digital technologies including hardware and software has been occurring and they are utilized for transformation in several domains in order to yield better solutions and competitive advantages. Developing tools and devices have been created and continuously improved to conform to the latest advancement. The system developers are always expected to properly select and use the tools and the devices in order to develop the next generation of telemedicine solutions which conform to the requirements.4 Moreover, obtaining precise requirements are challenging as they need proper communication and collaboration skills between groups of people with different expertise and background.
- Digital Literacy – This issue mostly affects the elderly as they were born before the “digital disruption” age where most systems or services are integrated with the digital technology. Unlike the following generations that digital technology has become one of the major parts of their lives, the elderly has to learn how to use some devices such as smartphone and interact with applications such as health technology-based applications. Results show that the users aged over 65 years old produce lower success rate and higher error on assigned computer-based tasks compared to the younger ones.8 Several studies on technology acceptance by the elderly including stakeholders’ perspectives, factors influencing technology and dynamics in technology have been conducted.15 250 Volume 71, No.3: 2019 Siriraj Medical Journal www.smj.si.mahidol.ac.th According to survey on digital technology usage, 71 percent of the elderly aged over 65 years access the Internet every day or almost every day.16 Moreover, 27 and 18 percent of them own tablet or e-book reader and smartphone, respectively. Telemedicine service may build upon some existing applications or has its own applications. Therefore, the user uses its services via several devices.
- Digital Technology Acceptance – Even digital technology has been integrated to many activities in our daily lives, some people including the elderly still do not accept it regarding several issues such as privacy and security.8,11 A large number of firms such as banks are developing their own financial services on web or mobile applications in order to decrease operation costs. Several campaigns or privileges are offered to persuade their customers to go online. However, different realization may be observed in the healthcare domain. First, health-related personal data is required to be securely transmitted over digital networks and accurately destined to predefined receivers. Second, additional devices such as wearable devices capable of measuring heart rate or blood pressure are deployed to sense and transmitted the measurements to the receiving nodes.
- Diagnostic Accuracy – Accuracy of the diagnosis is one of the key concerns especially when the physicians and the patients are at different locations. Face-to-face medical care usually brings confidence to patients, especially the elderly.8 However, a short period of medical interrogation and vital sign measurement performed at a hospital may not reflect current symptoms due to the white coat syndrome.18 Physicians may obtain more accurate results by applying continuous health monitoring based upon electronic healthcare approach. Several studies have been undertaken in order to investigate the diagnostic accuracy of the telemedicine applied to the emergency department and ophthalmology.19,20 The results demonstrate telemedicine as a viable alternative to the in-person and a valuable tool where medical service is in high demand.
Most countries have been experiencing deficiency of physicians and aging society transformation. Population dwelling in remote or developing areas tends to have lower opportunities of decent medical care than those residing in an urban or developed areas. Such limitations worsen the situations especially in an emergency where urgent help is needed. Telemedicine can be used to deliver medical services regardless of distance and time via information and communication technologies. Several studies and reviews of applying telemedicine in developing countries have been undertaken.21-24 This section outlines feasible opportunities of telemedicine.
- Cost Reduction – One of the main objectives of digital technology integration is to provide better services at lower cost. In case of telemedicine, several operation costs such as traveling can be reduced as the patients are able to get medical services online. Several results indicate cost effectiveness of telemedicine compared to other methods.25-27 Telemedicine can thus be considered as an alternative diagnosis and treatment methods in several cases. For example, it can be used for the first diagnosis or an emergency to provide an urgent help. Moreover, hospitals benefit from applying telemedicine. Hospital bed or space occupancy and resource utilization can be improved as patients receive medical cares at any places and anytime.
- Healthcare Equality – Limitations of distance and time are tackled by the information and communication technologies. Telemedicine is built on top of such technologies in order to provide medical services. People around the world can therefore access the services as soon as they are connected to the Internet. Medical services are not only delivered by local physicians. Professionals residing at other areas can provide diagnoses and treatments. Local or novice physicians are capable of learning from medical specialists. In order to achieve healthcare equality, collaboration, regulation and standardization are required. Governmental agencies and private institutes have to cooperate and agree upon a set of requirements. Regarding the digital technologies related issues, several predefined standards such as communication protocols can be adopted.
- Service Diversity – With an advancement of recent digital technology, data delivery and processing are considerably improved. Instead of basic data type, multimedia streaming over the Internet is now more efficient. Processing power is also remarkably increased while the hardware price is continually decreased. Such improvements support a variety of medical services and enable real-time applications. A variety of telemedicine services such as tele-pathology, tele-dermatology, tele-nursing and tele-surgery and their performance acceptance are addressed.32 The key consideration on offering new service is to select a set of suitable tools and technologies.
Two major indices reflecting good quality of life are healthiness and access to decent medical services. Lack of medical personnel, demographical and geographical problems are significant barriers of medical service improvement. Telemedicine can be applied to aging society transformation which causes higher demand of remote medical care and treatment. Telemedicine is officially defined by the World Health Organization (WHO) as the delivery of health care services where distance is a critical factor. Major challenges of telemedicine utilization include system development cost, system implementation, digital literacy, digital technology acceptance and diagnostic accuracy. Building a telemedicine service requires information and communication technologies as the underlying infrastructure. System integration needs some specialists who can address users’ requirements and develop the required system. Users’ acceptance of technology is crucial to acquiring the advantages of telemedicine