1 Introduction
Telehealth – the use of technology to deliver healthcare services across the spectrum
of care over distance, has globally improved access to healthcare services. Telehealth
services can include assessment, diagnosis, and management of patients [[1]]. Telehealth has been particularly beneficial for remote populations or those who
cannot easily access healthcare services, such as the elderly with chronic diseases,
and those in geographically isolated locations with limited access to specialist and
generalist care [[2], [3]].
The COVID-19 pandemic was the “nudge” for enabling and “fast-tracking” technological
innovation and adoption in several fields including retail and commerce, education,
and healthcare [[4]]. COVID-19 resulted in a substantial increase in telehealth delivery worldwide as
patients and providers sought to maintain continuity of care to overcome effects of
lockdowns, and service delivery and supply chain issues [[5]
[6]
[7]]. Aside from support for clinical care, telehealth also supported a broader range
of health system tasks including patient education and supply chain management. Preliminary
studies have been favorable for the role that telemedicine played in pandemic response
including supporting care delivery through video and audio visits [[8], [9]].
Evaluation of telehealth service delivery during the pandemic has also highlighted
unintended consequences (UICs) including equity, literacy, and other issues [[10]
[11]
[12]]. We use the term UIC, drawing on previous medical informatics literature that specifies
that UICs are outcomes that have not been anticipated, and that these outcomes can
be desirable or undesirable and positive or negative [[13]]. For this paper, we focus on negative undesirable UICs. Several types of these
UICs have been reported during the COVID-19 pandemic. Racial and ethnic minorities
and social socially disadvantaged groups have experienced more UICs related to access
to care (including access to digital care), and also experienced poorer health outcomes
during the COVID-19 pandemic [[14], [15]]. Some UICs are clinical in nature, an example being healthcare processes not transitioning
well to digital format, other UICs are financial or regulatory, while others are due
to the complexity of patient conditions such as patients with comorbid conditions
[[16]]. A widening of the digital divide has been a significant UIC from virtual care
delivery during the COVID-19 pandemic [[17], [18]].
UICs from telehealth delivery could be expected as they are known to occur while implementing
complex technology into complex and diverse settings and processes [[13], [19]]. However, we often manage UICs in a way that is reactive rather than proactive.
Proactive management requires us to consider the broader system where health information
technology (HIT) is used. UICs that arose from COVID-19 mediated telehealth usage
were not a direct result of the pandemic itself, but rather they were a consequence
of telehealth interacting with various health system concepts where the various telehealth
tools were used [[20]]. Accepting that one cannot completely eliminate the occurrence of UICs from HIT
implementation, we propose instead that we must better understand the context in which
UICs occur so that we can purposely design health systems that allow us to better
manage UICs [[19], [21]]. Technology alone cannot transform healthcare delivery into a resilient and equitable
system and it is myopic to focus on technology without considering other system concepts
that influence healthcare delivery [[5], [22]]. Systems function as designed, and health or social systems are no different in
that regard. Coiera [[23]] argued that policies and innovations have political, social, cultural, and other
implications and because of this, addressing UICs such as system inequity cannot happen
by addressing individual parts of a system, but require a systems-based approach that
supports proactive solutions to UICs and other system issues.
We believe that health systems designers where telehealth is used must address system
inequity that poses as a “ghost in the machine”. To do so, they must address two core
issues. First, we need to proactively manage UICs as part of system planning and design
using systems thinking approaches to account for the range of factors that can impact
HIT implementation [[24], [25]]. Second, they need to account for how technology such as telehealth influences
and is influenced by the broader underpinnings of an equitable healthcare system,
including consideration of the social determinants of health that will influence how
an individual agent interacts with a health system and the tools, services, and resources
within it.
This paper provides initial insight into the design of an equitable telehealth system.
The IMIA-Telehealth WG members conducted a two-step approach to understand the role
of telehealth in enabling health equity. We first conducted a consensus review on
the topic followed by a modified Delphi technique to respond to four questions related
to the role telehealth can play in developing a resilient and equitable health system.
2 Methods
We conducted a modified Delphi process to capture consensus across a subset of the
IMIA-Telehealth WG members on how to reduce unintended consequences of telehealth
implementation as part of developing resilient and equitable health systems. Fifteen
WG members from 8 countries participated in the study. The Delphi method is an iterative
process that allows a group of stakeholders to reach a structured consensus on a topic
or question [[26]
[27]]. It is a suitable method for this study as the evidence base on the role telehealth
can play in developing resilient and equitable health systems is very limited. It
was also a suitable method given the geographic dispersion of our WG members.
Our method also incorporates our previous IMIA Yearbook article [[28]] that identified the need for telehealth usage to balance multiple health system
concepts including patient centered connected health needs and privacy and data standard
requirements. We expand on our earlier work by conducting a multi-country comparison
of how telehealth evolved before and during the COVID-19 pandemic to understand the
telehealth implementation issues facing practitioners, policy makers and researchers.
Our analysis provides insight on (a) unintended consequences and (b) inequities fostered
and mitigated by implementation of global telehealth services. The detailed steps
we followed are as follows:
2.1 Step One: Develop a Consensus Review on Telehealth as a Means of Enabling Health
Equity
In the first step, we developed a set of consensus statements from a representative
group of our international telehealth WG members. We convened an online discussion
of WG members and invited everyone to freely contribute to a body of text that would
enable a “systems thinking” approach to the questions of how telehealth field experience
translates to address issues of equitable access to healthcare and resilient health
systems. In initiating this discussion, our starting point were the three telehealth
patterns we defined in our 2018 IMIA Yearbook paper [[28]] and a summary of negative unintended consequences from telehealth delivery [[20], [29]]. [Fig. 1] shows the analytical framework used for the consensus review.
Fig. 1 Integrated framework for system resilience and equity in telehealth services.
2.2 Step Two: Use a Modified Delphi Process to Develop Consensus Themes from Different
Countries
Following the development of the consensus statements, the members of the telehealth
WG electronically convened a discussion to formalize the findings from the consensus
review. With the overarching question, “How can telehealth help design resilient and equitable global health systems?”, we organized the discussion into four thematic questions derived from the consensus
review:
-
What is the role of telehealth delivery in enabling health equity?
-
Which factors in a health system influence access to telehealth services?
-
What is the potential of standards/guidelines for promoting telehealth services?
-
What are negative unintended consequences of telehealth delivery and how can they
be addressed?
For the discussion, we used a modified Delphi process to accommodate diverse opinions,
experiences, and insights of the experts and their field notes. The experts in the
IMIA-Telehealth WG were from different countries, dispersed across time zones and
thus much of the data collection was asynchronous. Data collection took place over
one month between October and November 2021.
We then analyzed the narratives to generate themes related to each question. The names
of the respondents are referred to here by their initials with abbreviations of their
country names in parentheses. This was a consultation in a public domain document
and all data is from co-authors of the paper. No human participants were involved,
and ethics approval was not needed. The responses are paraphrased for brevity.
3 Results
WG member responses to the four questions are provided below. Each response is labeled
with the initial and country of the WG member.
1 What is the Role of Telehealth Delivery in Enabling Health Equity?
While there was broad agreement that telehealth services enable better access to care
delivery and other healthcare services, several concerns were raised about inequity
in the access to telehealth services. On one hand, telehealth plays a significant
role in providing access to healthcare care services for those without direct access
to them. This access is particularly important for people in remote or rural settings.
SJ (India) noted that teleophthalmology provides comprehensive eye care and reduces
the need for travel for patients from rural villages. VR (UK) cited a UK NHS technology
enabled care program where telehealth technologies are transforming the way people
control and engage with their own healthcare data and results, empowering people to
manage their care in a way that is appropriate for their context. IH (NZ) also cited
evidence from New Zealand on access to, and use of healthcare services, during the
COVID-19 lockdown when telehealth was the first and main point of contact with health
services.
CK (Can) provided an example from Canada that also described how telehealth played
a key role in enabling care access across different patient groups, disease types
and neighborhood income groups [[30]]. MI (Brazil) noted that telehealth could increase communication and facilitation
of coordination between patients with chronic conditions and their caregivers to support
collaboration between them. JGU (India) stated that digital telepsychiatry services
are appropriate for patients during and potentially post-pandemic as it can decrease
the inflow of regular outpatient consultations, minimizing exposure to COVID-19 and
eliminating transportation and logistics costs for patients and caregivers [[31]]. The consensus of the WG was that Telehealth enables communication and coordination
between stakeholders across time and space because it is possible to interact with
everyone at any time, bringing more equity by providing appropriate timely patient-centered
care to everyone.
However, WG members provided several examples of UICs where telehealth access was
not equitable for everyone. VR (UK) noted that inequitable access can result in groups
receiving less care relative to their needs, or inappropriate or sub-optimal care,
than others, leading to poorer experiences, outcomes, and health status. SBG (India)
cited a publication by the IMIA-Telehealth WG published in 2016 that described telehealth
as a “cause of health inequity”. To establish the argument about how telehealth can
be an impeding factor to equity, SBG referred to an example of telecare from the city
of Chennai in India which experienced floods in 2015. Following the flood, those citizens
who had better access to smart mobile phones managed to get help earlier than those
without. They stated that the discrepancy in access to help was due to penetration
of the Internet through cell-phones and broadband access. People who lived remotely
were more likely to be poor and most affected by the digital divide. It was “ironic”
that the areas that needed help most were those who struggled the most to get access
to help in the initial response phase after the floods.
JGU (India) noted that people with inadequate access to Information Communication
& Technology (ICT) tools, and unfamiliarity or discomfort in using them may be disadvantaged
in benefitting from telehealth services. Planners and providers of telehealth services
need to proactively ensure that certain population groups such as migrants, refugees,
senior citizens, people with disabilities and rural populations who may not be sufficiently
equipped with technical devices or skills are not “left behind”” in accessing the
telehealth services.
AT (Australia) noted that available community infrastructure can pose challenges to
equity of access to telehealth services. In rural and remote locations, digital bandwidth
and connectivity infrastructure in general are less robust compared to urban locations.
Investments of governments and local communities for types of business also exert
influence here. IH (NZ) noted that in general underserved, also known as under-resourced,
communities experience greater health inequities and greater barriers to access healthcare
than the general population and provided insights in the context of New Zealand where
such communities include rural communities and Maori (NZ indigenous population).
2 Which Factors in a Health System Influence Access to Telehealth Services?
AT (Australia) listed social determinants of health as a key health system influence
on access to telehealth services stating that where a person is born, grows, lives
and works can influence their access to healthcare services. AT also noted the role
of community infrastructure and geographical variables (e.g., urban versus rural)
as factors influencing equity. VR (UK) noted that adoption of telehealth reveals opportunities
for identifying gaps to address health equity such as challenges to effective mobile
working by community nurses in patient's homes due to poor internet connectivity.
As a result, when the nurse would be working in a patient's home that has poor connectivity
to the Internet, the health provider cannot access digital documents such as electronic
records. Other limitations identified by VR were: limited or no training to use devices,
mobile device not being compatible with other software, and uploading data into systems
that do not talk to each other leading to interoperability issues.
IH (NZ) cited evidence from the seminal work by Piggot and Orkin [[32]] that the root cause of health inequity is system failures in health care delivery.
IH noted that telehealth offers a way to remove some of these barriers to access by
using digital technologies delivering “healthcare at a distance”. IH noted several
ways in which telehealth can be deemed to improve access to healthcare including reduction
of waiting times, improve access to early treatment, reduction in travel time, travel
expenses, less time off work, and development of culturally appropriate services.
IH cited the NZ Ministry of Health (MoH) telehealth website stating that telehealth
provides benefits for patients, district health boards, aged care workers/nurses,
general practice and allied health providers and that telehealth provides overall
a “fairer health system”.
OJ (India) shared experiences of telehealth supported continuum of care for persons
with noncommunicable diseases during the COVID-19 pandemic among a rural population
in Andhra Pradesh, India. A key factor identified by the patients was health systems
responsiveness using automated call back for follow up by specialists where care escalation
was recommended during the first contact. OJ also gave examples of doorstep delivery
of medicines and facilitation of diagnostics at home through frontline healthcare
workers as examples of providing appropriate healthcare services to a rural population
[[33]].
AT (Aust) observed that telehealth services are dependent on information and communications
technology and mobile medical apps (‘software as a medical device’) and that they
must fully align or comply with medical device standards. AT noted that mobile medical
apps provide less guarantees for patient safety compared with other medical device
standards and such lack of alignment across ISO/IEC standards makes it confusing for
app developers and users of mobile medical devices alike, which in turn impedes compliance-based
confidence in telehealth.
KA (Brazil) noted that people in the high vulnerability spectrum of society, like
people who are homeless and people in overcrowded prisons are historically exposed
to difficulties in accessing health services. During the pandemic, these populations,
in addition to the usual challenges, had to deal with difficulties in maintaining
social isolation and lacked equal offers of solutions for psychological and health
support due to the lack of meaningful universal healthcare access in their locations.
A member of the group from India noted the need to consider the costs of setting up
a telepresence and to compare such costs with actual care delivery, given that costs
rise exponentially when the type of care provisions rises from preventive to tertiary
levels. According to this participant, telehealth costs would rise to support more
complex care delivery patterns and health systems must ensure they have the financial
and other resources to sustain telehealth delivery beyond pilot stages of telehealth
delivery offerings.
3 What is the Potential of Standards/Guidelines for Enabling Equitable Telehealth
Services?
JGU (India) noted that the planners and providers of telehealth services need to consider
measures that ensure certain population groups such as migrants, refugees, elderly
people, and those in rural areas who may not be sufficiently equipped with devices
or skills and those with disabilities are not “left behind”” in accessing the telehealth
services.
VR (UK) noted that a strategic approach to digital health delivery has the potential
to enable health equity; citing the context of the UK National Health Services “The
Technology Enabled Care Services (TECS)” where they developed resources named “Resource
for Commissioners” with a focus on delivering set of practical tools and resources
to address the demand from health and social care professionals for support and guidance
on how to commission, procure, implement and evaluate so as to maximize the value
of these types of solutions and services. The tools include a “TECS evidence database”
showing the impact of telehealth on patient outcomes and cost effectiveness such as
diabetes and chronic obstructive pulmonary disease (COPD).
MN (Brazil) observed that tele-homecare applications would be expected to expand in
developing countries with limited accessibility and availability of traditional healthcare
services and high hospital acquired infections. MN noted the importance and necessity
of clear guidelines and protocols for training of care providers to ensure quality
of care, where tele-homecare would be deemed as an alternative or supplement to care
delivered face to face (“traditional care”).
AT (Aust) observed that a barrier to telehealth implementation is reluctance of physicians
to adopt telehealth, due to concerns about quality of care and privacy issues WM and
AT noted that this can be alleviated by demonstrating compliance with globally accepted
international standards ISO/IEC-standards where these standards govern telehealth
services and aspects of technology including information management. They further
observed that quality of telehealth services is covered by ISO 13131:2021 and that
experts from the Telehealth WG have contributed to this recent version of the standard.
The standard describes quality requirements for a wide variety of use cases, including
scenarios of (home-based) telehealth services in remote areas and consumer engagement
with telehealth.
WM and AT argued that two circumstances confound the widespread and flexible delivery
of telehealth services: lack of standards supporting integration of data collection
components in a broader system, and lack of a universal framework for development
of the underlying analytic and logic software, in a critical system setting.
4 What are Unintended Negative Consequences of Telehealth Delivery and How can we
Address Them?
CK (Can) noted that while telehealth has improved care delivery, it has introduced
UICs in the form of the digital divide. One significant challenge in Canada was that
once COVID-19 induced lockdowns began to be lifted, some practitioners continued providing
virtual care delivery rather than providing any in-person care delivery (https://www.cbc.ca/news/canada/toronto/patients-frustrated-concerned-as-some-ontario-doctors-slow-to-return-to-in-person-appointments-1.6160171). Telehealth delivery is not meant to be a direct replacement for in-person care
delivery but rather a patient's specific context and needs must determine the modality
of care delivery.
In overcoming UICs such as the digital divide, AT (Aust) identified health and digital
literacy as early challenges that telehealth must overcome. AT noted, as did JGU (India),
that telehealth's potential for providing equitable access for everyone requires content
to be adapted or tailored to the target audience. AT observed that artificial intelligence
could play a role in overcoming UICs by allowing health professionals to understand
the behavior and way of communication of diverse user groups to develop content and
meet their needs in a specialized and personalized way.
AT also observed that the fact that telehealth care access and utilization allows
for acceptance to the digital divide in healthcare is an unintentional consequence
of telehealth, revealing income-based and regional health disparities. Those living
in more affluent and urban areas where ICT infrastructure is common were more likely
to have accessed telehealth during the pandemic than those in low-income or rural
areas. AT noted because of these system factors that telehealth could ultimately worsen
access to health services and thus increase health inequity.
JGU (India) noted that a virtual, indirect, and screen-mediated consultation, unlike
a face-to-face meeting between a doctor and patient, makes relationship building a
challenge. JGU noted that for new cases where the patients/caregivers are in contact
with a stranger on a small screen, they may not like disclosing everything about their
life, which could impact relationship building and the care provided to the patient
[[31]].
4 Discussion
In this paper we build on earlier work by our international working group (WG) by
conducting a consensus review and then using a modified Delphi approach to study the
question “How can telehealth help design resilient and equitable global health systems?”
Inclusive digital health and a resilient health system for all is a broad outcome
and getting there requires a systems-based approach that develops telehealth capacity
over time. This paper presents a global perspective on telehealth design and service
delivery to support inclusive and resilient health systems.
The WG reached broad agreement that telehealth services before and during the COVID-19
pandemic have enhanced the delivery of and access to healthcare services. The group
also emphasized that global telehealth delivery has not been equitable. Technology,
financing, access to medical supplies and equipment, and governance capacity will
all impact the delivery of telehealth services. While technology is a key part of
telehealth delivery, it alone cannot create a resilient telehealth system, nor will
it enable equitable access to the system. The challenges to developing resilient and
equitable health systems are multifactorial. In this study, we have identified several
areas we need to focus on including health and digital literacy, how to digitally
build meaningful patient-provider relationships, and ensuring that the social determinants
of health such as someone's socioeconomic status or geographic location (e.g., rural
settings) does not impact their ability to efficiently access any needed healthcare
services.
While it is critical to identify barriers and UICs to developing resilient and equitable
health systems it is equally important that we be proactive in generating evidence
on solutions to reduce system wide barriers for access to telehealth so that underserved
populations can take advantage of telehealth to improve access to healthcare services.
The IMIA-Telehealth WG has already initiated efforts to address several of the shortcomings
identified in this paper. For example, we have started developing telehealth guidelines,
including implementation of telehealth standards, with a focus on ISO 13131:2021.
Our WG also continues to leverage the breadth of our international experience to understand
telehealth delivery in different global health systems. Overall, as part of developing
resilient and equitable health systems we will strive to develop strategies for the
design and evaluation of telehealth services that incorporate systems thinking [[5]].
As we continue to grow and expand telehealth delivery, a distinction needs to be made
between a pattern of telehealth usage where a patient is just pulling information
from sources (e.g,. one way access/exchange) and a pattern of two-way communication
between a patient and providers that occurs over time [[26]]. The former telehealth pattern is easier to implement and deliver but it provides
a less substantial care delivery service than a pattern that involves ongoing two-way
communication between a patient and a care delivery team. Scalability of telehealth
tools and approaches is another area where future work is needed.
5 Conclusion
Globally, telehealth continues to be a key enabler of health system transformation.
That said, an individual's ability to access the level of telehealth services needed
for their specific context should not depend on socioeconomic factors such as income,
education, or place of residence. At the same time, global digital health systems
should not lead to inequity where some populations have access to more robust or substantial
telehealth delivery compared to others.
The COVID-19 pandemic has further made the case that we need a resilient and sustainable
digital health system that can deliver efficient, effective, and equitable care during
events like a global pandemic. Telehealth provides the means for a health system to
be disrupted and rebuilt around the care needs of individuals and populations, empowering
them to drive the delivery of their own health care independent of broader health
system factors such as socioeconomic status.
