Keywords telehealth - telemedicine - COVID-19 - opportunities - challenges
Background and Significance
Background and Significance
The severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) and the disease it
causes, that is, novel coronavirus disease 2019 (COVID-19), have made a tragic and
fundamental change in the world.[1 ] This pandemic may continue for at least several months. The health care setting
has experienced a significant change in this pandemic in two ways.[2 ] The first is the need to allocate limited medical and logistic resources to COVID-19-positive
patients,[3 ] and the second is protecting health care providers and patients from virus exposure.[4 ]
[5 ] In this context, health care organizations (HCOs) should also continue to provide
care in other fields.[6 ] However, the high rate of virus spread[7 ] has forced HCOs to take novel measures among which telehealth seems to be the most
effective and efficient one.[8 ]
According to the American Telemedicine Association (AMA), telehealth is defined as
“technology-enabled health and care management and delivery systems that extend capacity
and access”[9 ] and includes modalities such as “remote patient monitoring, telehealth, teleconsultation,
and the use of mobile application-based technology.”[10 ] It has developed rapidly in recent years, and the pandemic has accelerated its implementation
and usage.[11 ] Telehealth technologies have been implemented in almost all aspects of care, including
evaluation, diagnosis, treatment, therapy, follow-up, and monitoring.[12 ]
[13 ]
[14 ]
[15 ]
In the COVID-19 pandemic era, formal quarantine, social distancing, and the high probability
of nosocomial conditions have caused challenges in the continuity of care for patients
and HCOs.[16 ] In these circumstances, telehealth is a more feasible and cost-effective alternative
to face-to-face care.[11 ]
Several studies have investigated telehealth implementation in diverse health care
settings in the COVID-19 pandemic situation. Many studies illustrated the circumstances
and the steps taken to implement telehealth.[17 ]
[18 ] Some studies reported care delivery to patients in a specific field.[19 ]
[20 ]
[21 ] Others provided a specialty perspective on telehealth.[22 ]
[23 ]
[24 ] Moreover, several studies explained telehealth application in various uncommon cases,
including self-removing a drain,[25 ] home dialysis,[26 ] appraising drug efficacy,[27 ] and collecting samples for COVID-19.[28 ] Furthermore, some authors reported the opportunities of telehealth in the management
and monitoring of COVID-19-positive patients.[29 ]
[30 ] It can be concluded that although COVID-19 has masked the faces, it has unmasked
the face of telehealth.
Despite the numerous benefits, telehealth has confronted several challenges, including
technical issues (network connectivity and user interface), limited physical examination,
privacy issues, participants' literacy level, cost, reimbursement, and regulatory
barriers.[31 ]
[32 ]
[33 ] Recognizing the opportunities and challenges of using telehealth in this course
will help to take the necessary measures to use the capacities of the health system
more efficiently in future. To the best of the authors' knowledge, no study has reviewed
the opportunities and challenges of using the telehealth technology during the COVID-19
pandemic comprehensively.
Objective
This study was conducted to answer the following main questions: (1) what are the
opportunities of using telehealth for health care delivery during the COVID-19 era?
And (2) what are the challenges of using telehealth for health care delivery during
the pandemic?
Methods
This study was a comprehensive literature review of all publications related to telehealth
use and its subdomains during the COVID-19 pandemic to summarize the data about telehealth
subdomains, modalities, services, opportunities, and challenges in the period of the
ongoing COVID-19 pandemic. This study was conducted according to the Preferred Reporting
Items for Systematic Review and Meta-analysis (PRISMA) methodology suggested by Moher
et al[34 ] in five steps including literature review, control of inclusion and exclusion criteria,
selection of studies, quality assessment, and data extraction and synthesis.
Literature Review: Databases and Keywords
Four large databases including PubMed, Scopus, Web of Science, and Science Direct,
as well as the Google Scholar search engine were searched for articles about using
telehealth during the COVID-19 pandemic era published until November 4, 2020. Combinations
of the following keywords were used in the search: “eHealth” OR “Telehealth” OR “Telemedicine”
OR “Mobile Health” OR “mHealth” OR “teleconsultation” OR “telecare” OR virtual care,
OR online care, OR telemonitoring AND “novel coronavirus” OR “COVID-19” OR “SARS-CoV-2.”
The search for the keywords in the above databases was conducted on November 4, 2020.
The details of the search strategy in the databases are provided in [Supplementary Appendix A ] (available in the online version).
Inclusion and Exclusion Criteria
Inclusion Criteria
This study included (1) studies published in English language only, (2) studies whose
full texts were available based on access to published papers, (3) studies on telehealth
use and all its subdomains (telemedicine, mobile health, and telecare) during the
COVID-19 pandemic, and, (4) studies published until November 4, 2020.
Exclusion Criteria
The following studies were excluded: (1) studies whose full texts were impossible
to access, (2) review articles (but their reference lists were evaluated for completion
of search), and (3) studies suggesting models for using telehealth in the COVID-19
era not yet applied during the pandemic.
Studies Selection
A screening process by titles, abstracts, and full-text was conducted by two authors
independently. In case of disagreement, the authors reached consensus by discussion.
Quality Assessment
In this process, the quality of the studies was assessed using the Mixed Methods Appraisal
Tool (MMAT) version 2018 provided by Hong et al[35 ] which offers valid criteria for the assessment of qualitative, quantitative, and
mixed-method studies. Two authors independently assessed the quality of the studies
based on the MMAT tool criteria. The MMAT consists of two common screening questions
and five specific criteria per five categories of study designs (qualitative research,
randomized controlled trials, nonrandomized studies, quantitative descriptive studies,
and mixed methods studies) to appraise the methodological quality. For example, the
checklist for quality appraisal of quantitative descriptive studies consists of five
criteria including (1) is the sampling strategy relevant to address the research question?;
(2) is the sample representative of the target population?; (3) are the measurements
appropriate?; (4) is the risk of nonresponse bias low?; and (5) is the statistical
analysis appropriate to answer the research question?
Disagreements between the two authors were resolved through consultation with an out-of-study
methodologist. Afterward, studies that did not meet at least three of the MMAT criteria
were excluded. Furthermore, the authors conducted a manual search and checked the
reference lists for both research and review articles to find all eligible full-text
articles; however, none were added to the final articles for scrutiny.
Data Extraction and Synthesis
After the quality assessment process, the full text of each article was reviewed,
and the data were extracted from the studies using a predesigned form ([Supplementary Appendix B ], available in the online version). The form included basic characteristics of the
study such as the authors' names, location, design, and purpose, as well as specific
data, such as type of services provided through telehealth (consultation or treatment),
the specialty field used, and the opportunities and challenges associated with e-health
use in the COVID-19 era. In this study, we considered consultation as telecommunications
between patient caregivers or between caregivers to discuss health issues, while treatment
refer to the use of medicine, therapy, and others by health care providers to help
decrease the symptoms and effects of a disease. Also, medical specialties were coded
according the AMA classification and first author affiliation.[36 ]
Data extraction was done by two authors, and disagreement between the authors, if
any, was resolved by discussion. Thematic analysis was applied for the purpose of
this study[37 ] due to the heterogeneity of studies in terms of design, setting, and applications,
as well as opportunities and challenges. This analysis was conducted in three stages.[38 ] First, two authors independently coded the data of the articles. Disagreements in
coding were resolved through discussion between the authors in two meetings. Second,
similarities and differences between codes were determined, and codes were grouped
into initial themes. Finally, analytic themes were developed beyond the primary data
of the original articles to identify key messages. The extracted themes were first
reviewed independently and then discussed by two authors in one session to achieve
agreement. The findings regarding opportunities and challenges of telehealth application
during COVID-19 pandemic were synthesized according to the thematic approach. This
approach is applied to identify, extract, and summarize themes from included studies
in literature reviews.[38 ]
[39 ]
Results
The database search yielded 2,440 articles of which 1,492 duplicates were removed.
Titles, abstracts, and full texts of 948 unique articles were screened but 570 articles
did not meet the inclusion criteria. After the full-text screening of the remaining
articles (n = 198), 86 additional papers did not meet inclusion criteria and were therefore excluded
([Fig. 1 ]).
Fig. 1 Flow chart of the study selection process.
The COVID-19 pandemic dramatically accelerated the use of telehealth care for patients
across the world. In this study, 112 eligible articles were identified which offered
telehealth solutions to promote the delivery and access to health care services for
patients during the COVID-19 pandemic. In the majority of these studies, the telehealth
program was designed and implemented after the pandemic, indicating the potential
of telehealth for promoting access to care and social distancing.
Our literature search identified 112 initial concepts, 26 unique concepts, 12 initial
themes, and 4 final themes for opportunities along with 106 initial concepts, 37 unique
concepts, 16 initial themes, and 6 final themes for challenges ([Table 1 ]).
Table 1
Final themes, unique concepts, and initial themes in opportunities and challenges
domains extracted from studies applied telehealth for health care delivery in COVID-19
pandemic era
Final theme
Unique concept
Initial theme
Opportunities
Clinical (n = 80)
Improved patient safety (n = 36), improved physicians' safety (n = 7), infection control (n = 6), maintaining continuity of care (n = 32), improved patient-centered care (n = 6), better communication between patients and physicians (n = 7), improving care effectiveness (n = 23), improving care efficiency (n = 17), improving quality of diagnosis (n = 5), improving data quality (n = 1)
Improved safety (n = 40), maintaining continuity of care (n = 32), improved patient-centered care (n = 13), improved care quality (n = 35)
Organizational (n = 78)
Prevent hospitalization (n = 9), reducing patients' admission in health care organization (n = 7), improve patient and family satisfaction (n = 56), improve provider satisfaction (n = 18), cost reduction (n = 14), cost saving (n = 19), reduced travels expenses (n = 7), timesaving (n = 19), better management of institutional issues (n = 3), improved organizational performance (n = 5)
Reducing hospital workload (n = 14), patient and provider satisfaction (n = 52), cost saving (n = 32, time saving (n = 19), improved organizational performance (n = 8)
Technical (n = 38)
Acceptance by providers and patients (n = 21), usefulness (n = 5), feasibility of telehealth (n = 3), technology convenience (n = 6), system ease of use (n = 11)
Usefulness of telehealth (n = 27), ease of use (n = 17)
Social (n = 4)
Improving care equitability (n = 4)
Care equitability (n = 4)
Challenges
Legal (n = 17)
Privacy and confidentiality concerns (n = 8), security concerns (n = 1), accordance with institutional framework (n = 4), lack of a regulatory framework (n = 6)
Security, privacy and confidentiality concerns (n = 8), regulations concerns (n = 10)
Clinical (n = 46)
Inability physical examination (n = 30), patient evaluation concerns (n = 4), limited personal contact (n = 4), limited laboratory data (n = 9), worsening clinical status (n = 4), loss of care efficiency (n = 2), concerns about accuracy drug administration (n = 3), concern about diagnosis accuracy (n = 1)
Clinical decision-making concerns (n = 39), care efficiency concerns (n = 10)
Technical (n = 41)
Connecting to network issues (n = 29), initial set-up issues (n = 3), device requirement issues (n = 8), infrastructure issues (n = 6) software problems (n = 7), phone problems (n = 2)
Connecting to network issues (n = 30), technological problems (n = 21), phone problems (n = 2)
Organizational (n = 21)
Supporting issues (n = 5), administrative issues (n = 1), integration issues (n = 1), team working (n = 1), protocols and workflows (n = 2), reduced productivity (n = 2), time-consuming (n = 6), scheduling issue (n = 4), lack of knowledge/training (n = 8)
Structure (n = 6), Process (n = 3), Managerial issues (n = 15)
Socio/financial (n = 35)
Literacy gap (n = 6), lack of computer skill and knowledge (n = 5), social disparities (n = 16), lack of confidence(n = 8), patient concerns (n = 7), reimbursement concerns (n = 8), billing issues (n = 3)
Patient- related issues (n = 11), Social disparities (n = 16), confidence and concerns (n = 15), reimbursement concerns, billing issues (n = 11)
Data quality (n = 7)
Poor data quality (n = 4), poor documentation (n = 3)
Poor data quality (n = 7)
The majority of the included articles were original study with 85 cases (76%), followed
by case report (n = 5, 4.46%) and commentary each with five articles (4.46%); letter to the editor,
brief communication, and correspondence each with three articles (2.67%); case study
and notes from field each with two articles (1.78%); and finally editorial, case series,
clinical experience, and view point each with only one article.
Most of the studies used audiovisual media (n = 85, 76%) for communication between health care practitioners and patients, followed
by audio or phone call (n = 21, 18.7%). The type of media was not specified in six studies ([Supplementary Appendix B ], available in the online version).
The majority of the studies (n = 85, 76%) implemented and applied telehealth during COVID-19 pandemic, while less
than one-fourth of the studies (n = 27, 24%) used telehealth before the pandemic and only advanced or promoted its
use in this period ([Supplementary Appendix B ], available in the online version).
Distribution of Studies by Year and Country
Distribution of Studies by Year and Country
All studies were published in 2020. The included studies were conducted in 24 countries,
with almost half from the United States ([Fig. 2 ]).
Fig. 2 Country distribution of published articles.
Distribution of Studies by Database
Distribution of Studies by Database
According to [Fig. 3 ], 86 of the studies (76.7%) included were identified by Google Scholar (with or without
another search engine).
Fig. 3 Distribution of articles by database sources.
Distribution of Studies by Telehealth Application
Distribution of Studies by Telehealth Application
In these studies, telehealth technologies were mostly used for patient follow-up (n = 41, 36.6%) followed by consultation (n = 28, 25%), treatment (prescription or others; n = 23, 20.5%), and diagnosis (n = 18, 16%). Only two studies used telehealth for prevention purposes ([Fig. 4 ]).
Fig. 4 Distribution of articles by telehealth application.
Distribution of Studies by Medical Specialty Using Telehealth
Distribution of Studies by Medical Specialty Using Telehealth
The specialties of internal medicine, oncology, and infectious diseases had the highest
frequency of using telehealth technology during the COVID-19 pandemic ([Fig. 5 ]).
Fig. 5 Distribution of articles by medical specialty using telehealth synthesis of results.
OB-GYN, obstetrics-gynecologist; ENT, ear–nose–tongue.
Distribution of Opportunities and Challenges
Distribution of Opportunities and Challenges
The findings of the thematic analysis are presented in [Table 1 ]. The opportunities were classified into clinical, organizational, technical, and
social opportunities. The challenges were categorized into six groups including legal,
clinical, technical, organizational, socioeconomic, and data quality challenges. [Table 1 ] shows the initial and unique concepts in addition to initial and final themes.
Clinical themes dealt with factors directly related to care delivery and technical
ones included issues associated with any aspect of applying the technology. In addition,
organizational themes were related to items organized and managed by HCOs, and sociofinancial
themes included extraorganizational and human factors, as well as the factors affecting
the financial performance and revenue of HCOs and insurers. Legal themes referred
to challenges in dealing with regulation frameworks. Finally, data quality themes
indicated challenges about data entry and documentation (for more details refer to
[Supplementary Appendices C ] and [D ], available in the online version).
Discussion
Four themes are extracted for opportunities and six for challenges of using telehealth
in health care delivery during COVID-19 pandemic.
The clinical theme was most frequently identified across studies in both the opportunities
and challenges domains. Regarding the clinical opportunities theme, improvement in
patients' and health care workers' safety, care quality, pandemic management, and
patient-centered care comprised the most common clinical initial themes. The initial
themes were derived from concepts such as continuity of care, controlling pandemic,
reducing the mortality rate, observing social distancing, and minimizing the exposure
to COVID-19. Telehealth provides a basis for improving patient-centered care and enhancing
the care effectiveness through facilitating access to care and the communication between
patients and health care professionals, involving the patients in their own care process,
and controlling their self-care. Telehealth technology is an effective approach to
support a patient-centered care model which is highly encouraged due to improving
patient satisfaction, clinical outcomes, and social wellbeing.[40 ]
Numerous clinical challenges were reported in the reviewed studies, the most common
of which was limited physical examination. Thus, the ideal telehealth cases are those
where no examination or a limited examination (particularly visual or mental status
examination) is sufficient.
Another critical aspect of the clinical challenge was care effectiveness. Although
most of the studies have emphasized the effectiveness of care, four studies reported
worsening of the patients' clinical opportunities which two studies performed in a
similar environment. These studies were performed in neurology, urology, and adolescent
field requiring more careful planning and face-to-face interaction.[40 ]
[41 ]
[42 ]
[43 ]
[44 ] Moreover, three other studies reported a challenging situation regarding drug administration.[27 ]
[45 ]
[46 ] Sudden tendency to deliver drugs using telehealth after an epidemic requires proper
coordination and planning that in lack, drug administration will be problematic. It
can be concluded that these challenges are related to the study setting, context,
and monitoring of medication administration. Besides, designing appropriate electronic
forms and interfaces for timely and accurate recording of related data would increase
the data and documentation quality.
Regarding technical opportunities, the usefulness of telehealth from the patients
and providers' perspectives was the most common technological opportunities acknowledged
in the included articles, followed by ease of use and agility of technology. Perceived
convenience and time- or cost saving are key components in the usefulness of telehealth
technology. The intention to adopt telehealth technology is influenced by its perceived
usefulness and ease of use by users. Telehealth technology agility supports collaborative
organizations and plays a key role in facilitating collaborative care.[47 ] Collaborative care using telehealth modalities provides a safe solution to meet
the different needs of patients and help control the COVID-19 pandemic.[48 ]
Regarding technical challenges, the most important concept was the internet access
or data transmission, especially in video-based visits, which was mostly reported
by patients. This problem prevents visits from occurring or leads to incomplete visits
or changes from video to audio or phone.[44 ]
[49 ] Another challenge was the initial set up of the program due to the time pressure
caused by the critical situation, lack of previous experience, and lack of integrated
electronic medical records (EMRs). The concept of patient access to equipment and
experience required to use the system also included issues related to lack of infrastructure
and technology use which worsened the gap in telehealth acceptance and usage.
Users' and providers' satisfaction, as the most common organizational opportunity,
is a key indicator of the success of each modality of telehealth technology, indicating
that the users' expectations have been met.[50 ] Eliminating the need for travel and saving time and money, ease of access to telehealth
services,[51 ] and observance of social distancing during the COVID-19 pandemic can be the main
reasons for users' satisfaction. Telehealth could reduce hospital admission and workload
by providing necessary services for patients and reducing the time and costs. Furthermore,
telehealth can improve staff efficiency by automating tasks, saving staff's time,
and facilitating access to practitioners.
HCOs have faced numerous organizational challenges in implementing telehealth in the
current pandemic crisis. Many do not have a history of the widespread use of telehealth;
as a result, they use it without proper knowledge and training of the staff and patients,[52 ] imposing a host of organizational challenges. Resolving some of these challenges
requires structural changes to apply a new approach to care delivery and integration
with work patterns to decrease the staff load.[49 ]
[53 ]
[54 ] Managerial challenges also deal with spending more time, scheduling patients, and
providing the necessary training.
Social issues were the most challenging findings of this study. While four studies
reported an increase in equitability as a significant consequence of using telehealth,
other studies identified social differences (age, sex, race, ethnicity, and income)
as challenges in equitable access to the effective and widespread use of this modality.
On the one hand, telehealth has the potential to ensure access to health care in disadvantaged
areas by removing the barrier of distance and meeting the needs of diverse patients.
On the other hand, social challenges are related to the equitable access of all subpopulations
of the society to telehealth services. Different groups of people have large differences
in terms of technology literacy, language, income, and level of trust in technology
which affects their ability to use telehealth.[44 ]
[49 ] The importance of these factors is such that they lead to a dramatic increase in
inequities in access to care. Of course, with continued use, most users gain the knowledge
and experience needed to work with the system[27 ] and develop trust in the technology by understanding its benefits. However, reducing
or eliminating barriers, such as digital literacy gaps, access requirements, and regulation
amendments to the use of telehealth for providing care for different patient populations
could further improve equity in health care.
Economic issues were challenging for both providers and patients. While reimbursement
is one of the most vital factors in physicians' willingness to provide telehealth
services,[55 ] it does not exist or is negligible in many countries. However, in countries with
approved regulations, full reimbursement is calculated for video-based visits, and
only in the latest editions of the regulations have telephone visits been reimbursed
by some payers.[56 ] On the other hand, in the absence of reimbursement, paying the visit fee is a serious
concern of the patients[57 ] which is exacerbated by economic conditions resulting from the COVID-19 pandemic.
Legal issues mainly resulted from the special situation caused by the COVID-19 pandemic.
They have challenged many regulatory frameworks for the provision of care. It is always
essential to maintain a balance between security/privacy issues and access to care.
Free platforms were used in several included studies; however, although they improved
access to care, they raised serious regulatory concerns. In this regard, some countries
have reduced or facilitated the requirements for telehealth services.[22 ]
[58 ] These concerns are also observed in countries with no confirmed legal frameworks
for the use of telehealth.[52 ] The technical solutions include using compliant applications, applying corporate
accounts, and using the latest versions of the applications.[59 ] Furthermore, applying instructions related to the information exchange management,
such as using yes/no questions, is another solution to legal challenges.[60 ]
Limitations
The first limitation of this study was that it covered the opportunities and challenges
of using telehealth in the COVID-19 era reported in the included articles published
until November 4, 2020. As a result, the opportunities and challenges may not be comprehensive.
The second limitation was that this review was narrowed to English language studies,
and therefore some local or national opportunities and challenges could have been
missed. Therefore, national and regional studies should be conducted to identify the
opportunities and challenges regarding the use of telehealth technology for better
management and control of disasters and public health emergencies.
Conclusion
Clinical, organizational, technical, and social themes were the primary opportunities
of using telehealth during the pandemic. Furthermore, legal, clinical, organizational,
technical, and socioeconomic themes were the main challenges of applying telehealth
in the pandemic era. Telehealth has a great potential in providing collaborative and
patient-centered care, thus improving the satisfaction of patients and health care
providers. Despite the favorable results of using telehealth, attention should be
paid to the barriers to its successful use. This study provides valuable information
about the opportunities and challenges of implementing telehealth to policy makers
for offering safe, efficient, accessible health care delivery to diverse patient populations
during and after the COVID-19 pandemic era so that they can make more informed decisions
about implementing telehealth in response to the situation by addressing the barriers
ahead.
Clinical Relevance Statements
Clinical Relevance Statements
The novel coronavirus disease 2019 (COVID-19) pandemic has resulted in challenges
related to delivery of care in the health care industry.
Application of telehealth in the health care industry has improved the safety of the
patients and staff, care quality, pandemic management, and patient-centered care;
however, its use is associated with some challenges including inability to perform
physical examination, security issues, and legal and social challenges.
COVID-19 pandemic has significantly accelerated the use of telehealth across the world.
Knowledge of the practical opportunities and challenges associated with the use of
telehealth will improve effective policies regarding the use of telehealth in managing
this pandemic.
Multiple Choice Questions
Multiple Choice Questions
Which specialty has the highest frequency of using telehealth technology during the
COVID-19 pandemic?
internal medicine
infectious disease
oncology
ENT
Correct Answer: The correct answer is option a. According to [Fig. 5 ], in 13 studies, internal medicine specialists published the results of the use of
telehealth in COVID-19 pandemic.
What is the most important concept regarding the technical challenges?
internet access or data transmission
initial set up of the program
device requirement issues
infrastructure issues to lack of infrastructure
Correct Answer: The correct answer is option a. Regarding technical challenges, the most important
concept was the internet access or data transmission, especially in video-based visits,
which was mostly reported by patients.
What theme is the most challenging findings of this study?
social
technical
legal
clinical
Correct Answer: The correct answer is option a. Social issues were the most challenging findings
of this study. While four studies reported an increase in equitability as a significant
consequence of using telehealth, other studies identified social differences (age,
sex, race, ethnicity, and income) as challenges in equitable access to the effective
and widespread use of this modality.
