Case Study A Framework for Telehealth Program Evaluation

Surya Nepal, PhD, Jane Li, MD, MSc, Julian Jang-Jaccard, PhD, and Leila Alem, PhD Computational Informatics, Commonwealth Scientific and Industrial Research Organization, Marsfield, New South Wales, Australia.

Abstract Evaluating telehealth programs is a challenging task, yet it is the most sensible first step when embarking on a telehealth study. How can we frame and report on telehealth studies? What are the health services elements to select based on the application needs? What are the appropriate terms to use to refer to such elements? Various frameworks have been proposed in the literature to answer these questions, and each framework is defined by a set of properties covering different aspects of telehealth systems. The most common properties include application, technology, and functionality. With the proliferation of telehealth, it is important not only to understand these properties, but also to define new properties to account for a wider range of context of use and evaluation outcomes. This article presents a comprehensive framework for delivery design, implementation, and evaluation of telehealth services. We first survey existing frameworks proposed in the literature and then present our proposed comprehensive multidimensional framework for telehealth. Six key dimensions of the proposed framework include health domains, health services, delivery technologies, communication infrastructure, environment setting, and socioeconomic analysis. We define a set of example properties for each dimension. We then demonstrate how we have used our framework to evaluate telehealth programs in rural and remote Australia. A few major international studies have been also mapped to demonstrate the feasibility of the framework. The key characteristics of the framework are as follows: (a) loosely coupled and hence easy to use, (b) provides a basis for describing a wide range of telehealth programs, and (c) extensible to future developments and needs. Key words: telehealth, telehealth implementation, telehealth evaluation, telehealth framework

Telehealth Framework

A

lthough telehealth frameworks have been evolving with the development and emergence of new technologies, it is not expected that there will be a consensus framework for the design, implementation, and evaluation of telehealth (trial or pilot) programs. However, a comprehensive framework is needed to evaluate such programs.1 Lack of consensus has not

DOI: 10.1089/tmj.2013.0093

deterred telehealth technology developers and evaluators from using different dimensions and components of telehealth. As a result, different frameworks have been used in the literature to describe different dimensions of telehealth such as telehealth technologies, health service provisioning processes, and modes of service delivery. These frameworks appear in the literature in different forms ranging from taxonomy to technology. Bashshur et al.2 defined a three-dimensional model for telemedicine based on functionality, technology, and applications. Functionality is further divided into consultation, diagnosis, monitoring, and mentoring. Technology covers the communication aspect of telemedicine, which includes modes of communication (synchronous or asynchronous), network design (virtual private network, open Internet, or social network), and connectivity (wired or wireless). Applications include processes of care including treatment modalities, medical specialty, different types of diseases, and sites of care. Many other models/frameworks in literature have focused in only one dimension. For example, Edwards et al.3 defined a onedimensional view based on the healthcare processes, which is similar to functionality dimension in the three-dimensional model of Bashshur et al.2 Five healthcare processes considered by Edwards et al.3 are monitoring, diagnosis, triage, consultation, and procedure. Similarly, the Centre for Information Technology (CITL) focused only on the bandwidth and technology dimension and defined six levels of technology.4 The first two levels are classified as pretelehealth technology: the first level includes postal mail and telephone service, and the second level covers simple electronic communications such as e-mail and fax. The last four levels are driven by technologies; they are store and forward, real-time video, hybrid, and advanced telehealth. However, several telehealth pilot programs are still using technologies that fall under the first two categories. Furthermore, this classification does not cover the technologies required to healthcare processes, termed as procedure in the report of Edwards et al.,3 such as telesurgery and healthcare assistive robotics. National Information and Communication Technology Australia1 classified telehealth into four functional groups: teleconsultation, store and forward, telehomecare, and tele-education. This model chooses elements from all three dimensions: technology, functionality, and modes of communication.2 For example, store and forward belongs to technology, teleconsultation and tele-education belong to functionality, whereas telehomecare is a mix of both functionality (monitoring) and application (sites of care). The rationale behind this classification is not clearly articulated in the report. Maeder5 defined a model using two dimensions: tele and health. Unlike other models, this model uses low-level functions. The tele dimension consists of five functions: capture, storage, transmission,

ª M A R Y A N N L I E B E R T , I NC .  VOL. 20

NO. 4  APRIL 2014

TELEMEDICINE and e-HEALTH 393

NEPAL ET AL.

processing, and quality of display. They cover the scientific and engineering characteristics (e.g., data, connectivity, human factors, etc.). The application contains five functions: assessment, diagnosis, treatment, management, and monitoring. This is similar to functionality as defined by Bashshur et al.2 The technical dimension is described at the lower level in comparison with the application dimension. All functions in technical dimension are necessary to realize the technology dimension.2 For example, all five functions are needed to realize store-and-forward technology. In this model, all functions are implemented using software components. Tulu et al.6 proposed a three-dimensional model for telemedicine evaluation. In addition to synchronous (real-time video) and asynchronous (store-and-forward), the technology dimension contains bandwidth and peripherals. This is the first model that introduces these additional two aspects in the model. The application dimension in this model is similar to the functionality dimension in Bashsur et al.2 However, unlike the model of Bashshur et al.,2 which only considers four clinical aspects, the model of Tulu et al.6 considers two nonclinical aspects: education and public health. The perspective dimension covers the end-users. The site element in the model of Bashshur et al.2 partially covers the perspective dimension in the model of Tulu et al.6 While analyzing these two three-dimensional models, it is clear that even the term application has completely different meanings. Tulu et al.7 have presented an evaluation of a set of relevant literature. In addition to these generic models, Doughty et al.8 have developed two different models for telehealth and telecare. The difference between these two models lies in the location and people involved in the care. They argued that a new telecare umbrella model covers a broader spectrum of applications from alarms through monitoring of vital signs through to medical consultation from home to institute. The focus of this model is on the use of assistive technologies from the perspective of clients (or patients). The CITL has also recognized the lack of a comprehensive model that reflects not only the technologies used, but also the variety of remote interactions and personnel involved. Vincent et al.9 have proposed a three-dimensional model that includes the type of telehealth interactions, the location of the controlling medical authority, and the urgency of care. Telehealth is a complex multidimensional system involving different aspects of technology, human, and health practices in different social settings. It is very difficult to summarize these different frameworks as each of them focuses on different aspects of telehealth, and these different dimensions are often entangled with each other. Table 1 aims to summarize the different types of telehealth frameworks reported in the literature to the best of our understanding. From this review, we confirmed that there is a lack of a comprehensive framework to evaluate telehealth programs. We noticed that the socioeconomic dimension is missing from all the frameworks we have reviewed. This dimension is a key to successful program design, implementation, and evaluation. We also noticed that the health services dimension is mixed in the functionality dimension. An explicit separation of the function and the health services is needed. We next describe a telehealth framework we have developed at the

394 TELEMEDICINE and e-HEALTH A P R I L 2 0 1 4

Commonwealth Scientific and Industrial Research Organization (CSIRO), based on these findings.

PROPOSED TELEHEALTH FRAMEWORK Our aim is to design a comprehensive telehealth framework that explicitly introduces the socioeconomic evaluation, the health services dimension, and the health services, discipline area of health, and context in which the services are being delivered. The frameworks reported in the literature focus on a particular set of functionalities, technologies, or applications. They do not consider economic and social aspects of the telehealth trials and programs. In order to address this shortcoming, this article defines a multidimensional CSIRO framework as shown in Figure 1. Our framework is used to evaluate the telehealth programs. Our framework covers socioeconomic aspect of telehealth under four different categories: costs, benefits, barriers, and outcomes (this includes clinical outcomes). In the following sections, detailed descriptions on each dimension of our framework along with a review of telehealth programs are presented. These dimensions include the health domain, telehealth services, telehealth technologies, communication technologies, environment settings, and socioeconomics.

Materials and Methods An extensive literature search was conducted by four researchers (co-authors of this article) with a PhD degree. We searched peerreviewed journal articles, conference articles, and white papers published by both government agencies and industries. We used the Google search engine to search the relevant articles. Combinations of the following search terms were used: ‘‘telehealth,’’ ‘‘telemedicine,’’ ‘‘telecare,’’ ‘‘framework,’’ ‘‘remote,’’ ‘‘Australia,’’ ‘‘ehealth,’’ ‘‘trials,’’ ‘‘programs,’’ ‘‘evaluation,’’ ‘‘implementation,’’ ‘‘rural,’’ and ‘‘regional.’’ We limited the review to English language articles from 2002 to 2012. The cutoff date was set during the classification process with the focus on programs that have used broadband technologies. The search was conducted independently by the four researchers, and then the search results were discussed. Discussions of the results led to a filtering process. Articles that described and/or discussed at least one of the following aspects of telehealth were selected for further analysis: . . . .

Telehealth taxonomy and framework Australian telehealth programs in regional and remote areas Satellite telehealth applications Major international telehealth programs or initiatives

This filtering process resulted in 86 articles. Out of these, 9 articles1–5,7–10 were found very relevant to telehealth frameworks, 15 articles10–24 were found relevant to Australian telehealth trials and programs, and 11 articles25–35 were picked up as major international initiatives (note that we discarded minor programs outside Australia). This article is based on these 36 main articles and 13 supporting articles. The main articles are used to review existing telehealth frameworks and mapping to the CSIRO telehealth framework, whereas the supporting articles are used to design and describe the CSIRO telehealth framework.

ª M A R Y A N N L I E B E R T , I N C .  VOL. 20

NO. 4  APRIL 2014

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

V

MONITORING

O

O

MENTORING

FUNCTIONALITY

O

O

V

TRIAGE

O

O

PROCEDURE

CITL, Centre for Information Technology; EHR, electronic health record; NICTA, National Information and Communication Technology Australia.

Vincent et al.9 (2007)

Doughty et al.8 (2007)

Maeder5 (2009)

Tulu et al.6,7 (2005, 2007)

O

O

DIAGNOSIS

O

DIMENSION

CONSULTATION

O

O

O

ASSISTIVE TECHNOLOGY

O

O

HYBRID

TELEHEALTH AND EHR

Bashshur et al.2 (2011)

O

REAL TIME VIDEO

O

O

STORE AND FORWARD

O

O

E-MAIL AND FAX

NICTA1 (2010)

CITL4 (2007)

Edwards et al.3 (2009)

FRAMEWORK

POSTAL MAIL AND TELEPHONE

TECHNOLOGY

Table 1. Summary of Different Frameworks

O

O

O

TRAINING/ EDUCATION

O

O

TREATMENT MODALITIES

O

O

MEDICAL SPECIALITY

O

O

TYPES OF DISEASES

APPLICATIONS

O

O

O

O

O

SITES OF CARE

A FRAMEWORK FOR TELEHEALTH

TELEMEDICINE and e-HEALTH 395

NEPAL ET AL.

domain-specific telehealth application is performed under different settings and socioeconomic backgrounds and thus requires different health services and telehealth technologies as well as communication technologies.

HEALTH SERVICES There is no single consensus definition for health services. In our evaluation framework, we adapted the definition recommended by Australian Privacy Law and Practice (ALRC Report 108; Recommendation 62-2):

Fig. 1. Commonwealth Scientific and Industrial Research Organization framework of evaluating telehealth trials or programs.

HEALTH DOMAIN The core part of the framework is the health domain that refers to the domain in medical field (or application area). We consider health domain as one of the core parts of our framework, as different domains require different kinds of information and different underlying telehealth and communication technologies to meet those requirements. Example health domains include oncology, neurology, dermatology, pathology, and pediatrics. Begg et al.36 have identified eight prominent health domains in the context of Australia: cancer, cardiovascular, neurology, mental, chronic respiratory, diabetes, injuries, and musculoskeletal. Each health

Fig. 2. Health services classification.

396 TELEMEDICINE and e-HEALTH A P R I L 2 0 1 4

Health services means— a. an activity performed in relation to an individual that is intended or claimed (expressly or otherwise) by the individual or the service provider to (i) assess, predict, maintain or improve the individual’s physical, mental or psychological health or status; (ii) diagnose the individual’s illness, injury or disability; or (iii) prevent or treat the individual’s illness, injury or disability or suspected illness, injury or disability; b. a health-related disability, palliative care or aged care service; c. a surgical or related service; or d. the dispensing on prescription of a drug or medicinal preparation by a pharmacist. Under the umbrella term of telehealth, there is a range of specific applications. As mentioned before, one of the problems in understanding and using telehealth is a lack of consensus regarding terminologies and a tendency to use terms interchangeably. Our descriptions and examples below are used in this article and are suggestions only. Telehealth services generally include clinical and nonclinical applications (Fig. 2). Clincal application is the use of technology to facilitate healthrelated communications between practitioners or between practitioners and patients. Note that this is just an example to explain the framework, and the given list is not exhaustive. Examples of clinical use of telehealth include diagnosis, consultation, case review, monitoring, triage, and treatment. Examples of nonclinical use include medical training, consumer education, administration, and supervision. These telehealth services draw on the healthcare processes of Edwards et al.3 and the five functions area of Maeder.5

A FRAMEWORK FOR TELEHEALTH

Table 2. Summary of Different Communication Technologies COMMUNICATION TECHNOLOGIES

COMMUNICATION INFRASTRUCTURE

BANDWIDTH

LATENCY

POTENTIAL PROBLEMS

300 ms or more Physical damage in copper wire

COST OF CONNECTIONa

Dial up

Telephone lines

40–50 kbps

$12.95 (80 MB data)

ISDN

Telephone lines

128 kbps–1.5 Mbps

15–30 ms

Physical damage in copper wire

Not available

Cable/HFC

Television cable (copper + fiber optic)

30–40 Mbps

10–20 ms

Contention (due to shared medium)

Not available

ADSL, ADSL2, ADSL2 +

Copper wires

256 kbps–24 Mbps

10–20 ms

Far distance (attenuation)

ADSL2 + $39.95 (20 GB data, 24/1 Mbps)

Wireless 3G/4G

Radio Antenna

1.5–100 Mbps

30–50 ms

Walls/mountains (blocking), CBD, far distance (attenuation)

3G mobile $59.95 (10 GB data)

NBN fiber

Fibre optics cable

100 Mbps symmetric

< 5 ms

Physical damage in fiber optic

$69.95 p/m (20 GB data, 100/40 Mbps)

NBN fixed wireless

Radio antenna

12 Mbps (download) 1 Mbps (upload)

30–50 ms

Walls/mountains (blocking), CBD, far distance (attenuation)

$49.95 p/m (20 GB data, 12/1 Mbps)

NBN satellite (interim)

Satellite dish

6 Mbps (download) 1Mbps (upload)

> 500 ms

Rain fade (moisture, rain, snow)

$49.95 p/m (20 GB data, 6/1 Mbps)

NBN satellite broadband

Satellite dish

12 Mbps

> 500 ms

Rain fade (moisture, rain, snow)

a

Based on westnet (www.westnet.com.au/) retail price (indicative only). Prices vary depending on the service provider and the location of the service being provided.

kbps, kilobits per second; Mbps, megabits per second; NBN, National Broadband Network; p/m, per month; CBD, Central Business District.

TELEHEALTH TECHNOLOGIES Traditionally telehealth applications can be classified into two basic types: store-and-forward/asynchronous and real-time/synchronous, according to the timing of the information transmitted and the interaction between the individuals involved. In order to capture the full breadth of telehealth, we suggest that considerations need to be given to both these timing categorizations and a wide range of

technologies involved, particularly the new and emerging ones. Technologies involved in telehealth include: . Communication technologies. Key attributes of communication technologies include bandwidth, latency, and reliability (Table 2). . Interaction technologies, such as videoconferencing and other interaction devices and techniques (e.g., multitouch mobile devices, three-dimensional visualization, etc.) . Assistive technologies or diagnostics technologies, such as physiological monitoring devices and sensors . Other e-health technologies, such as an electronic health record These are the bases for our telehealth technology levels (Fig. 3), which are adapted from CITL’s taxonomy. Advanced telehealth systems require broadband connections. The first three levels (Levels 0, I, and II in Fig. 3) are already widely covered in the literature. We briefly describe the latter three levels (Levels III, IV, and V in Fig. 3) here: .

.

Fig. 3. Telehealth technologies.

Level III: Advanced telehealth systems support simultaneously multiple channels of high-quality video communications for data sharing and interactions (e.g., Wilson et al.23). They can also integrate with electronic health record systems. These systems enable a sense of presence and richness of data to be shared. Level VI: Integrated home telehealth systems are the convergence of diagnostic, communication technologies, and health record systems. These systems integrate

ª M A R Y A N N L I E B E R T , I N C .  VOL. 20

NO. 4  APRIL 2014

TELEMEDICINE and e-HEALTH 397

NEPAL ET AL.

.

advanced assistive and diagnostic technologies such as pointof-care testing, micro-electromechanical systems, and biosensors.37 Wireless mobile technologies can be expected to become very important in these systems.38 The availability of broadband enables high-quality real-time videoconferencing with clinicians.8 The growth of the patient control electronic health record system will coincide with increased broadband usage and become an important component at this level.39 Level V: Advances in technologies, such as three-dimensional visualization, immersive environment, virtual reality, remotely operated robotics, haptic feedback devices, and other new interaction techniques supported by high-speed computers and broadband links, open up an opportunity for the use of advanced interactive systems in telehealth.40

COMMUNICATION TECHNOLOGIES The communication technologies range from traditional telephone lines to the high-speed broadband network. Table 2 provides a summary of communication technologies that could be used for deploying telehealth in the context of Australia. This dimension of the framework is important when designing a telehealth program. It helps determine what can be done based on the available communication technology.

ENVIRONMENT SETTING The environment setting captures the health services context. The choice of the telehealth technologies for delivering health services depends on the environment settings. The environment settings refer to the typical environments that the medical staff or patient will be using during the telehealth-based services delivery. Figure 4 shows four basic elements that describe the environment. There are a set of specific characteristics with regard to videoconferencing such as privacy of the room, room size, and room lighting. These low-level details should be captured within the different types of communication modes. Examples of location include hospitals, outreach clinics, health centers, home, and mobile. Examples of people include the patient, medical professional, and carer. In addition to different form of computing devices, examples of devices include environment sensors, body sensors, and audiovisual devices. The communication among people, providing and receiving health services, at different locations occurs

Fig. 4. Elements in environment setting.

398 TELEMEDICINE and e-HEALTH A P R I L 2 0 1 4

using various devices via a different mode of communication such as text, image, audio, video, and multimodal (i.e., exchanging and sharing a mixture of text, images, audio, and video through different channels). For example, in a case review, medical doctors between a city hospital and a rural hospital may use a collaborative platform where they can do videoconferencing as well as share patients’ personal records and medical images in independent workspaces shared among the parties using different communication channels.

SOCIOECONOMICS EVALUATION The socioeconomic dimension captures the telehealth implementation issues. Advancement in information and communication technologies is a critical factor in the success of telehealth. The uptake of telehealth inevitability also depends on the socioeconomic relationships. The optimistic vision of telehealth is to provide an even distribution of healthcare services to rural and remote communities. However, there has been a counterargument that telehealth may work contrary to its vision and in fact deepen the existing inequalities between major cities and remote communities.41 Therefore, it is important to study the socioeconomic analysis of telehealth as part of the evaluation framework. We observed that existing frameworks do not consider socioeconomic analysis as a dimension within telehealth. We argue that socioeconomic analysis should be an integral part of the framework. In most of the literature, socioeconomic analysis of telehealth is buried under the technology discussion. Jennett et al.42 have reviewed the socioeconomic impact of telehealth using 306 different sources. Their main finding was that telehealth studies have not used socioeconomic indicators consistently. This reinforces our argument of socioeconomic analysis being an integral part of the framework. In our framework we analyze the socioeconomic aspect of telehealth in four different dimensions: costs, benefits, barriers, and outcomes, as shown in Figure 5. We are not advocating limiting the socioeconomic analysis within these four dimensions. However, based on the survey of the literature, we believe that these four dimensions may not be exhaustive but are comprehensive enough to cover most of the socioeconomic aspects discussed in the literature. Barriers. The uptake of telehealth has several social, economic, and technology barriers. These barriers are more significant in the regional and rural areas in comparison with their city counterparts.

Fig. 5. Socioeconomic factors in telehealth.

A FRAMEWORK FOR TELEHEALTH

Barriers include regulatory, financial, cultural, technological, and workforce. An example of cultural barriers is that patients and communities in regional and remote areas often have very limited time and motivation to seek medical help. They are often not aware that they have health problems. Furthermore, seeking help sometimes seen as a personal weakness and is not encouraged by family members. Costs. The obvious cost that comes to mind with regard to telehealth is the cost of establishing computing infrastructure such as access to the Internet and computers. We often forget to include not so obvious costs such as time spent by medical professionals learning the new technology (i.e., workforce training) and cost associated with patients’ travels. Traveling to cities for treatment not only has financial costs, but also has social cost, as the treatment is provided outside the patient’s own community. Benefits. The benefits include financial benefits as well as social benefits such as peer support, knowledge-sharing, public health awareness, and interhospital relationships. Through peer support, the telehealth system can reduce the social isolation of medical professionals working in remote and regional areas. Patients may also derive a greater satisfaction by accessing the experts in the field in their own community setting or at their own home. For example, providing quality care at home increases the quality of life of patients (being in their own surroundings), which in turn increases the quality of care.43 These social benefits are equally important as economic benefits. Telehealth systems thus should not be evaluated on both dimensions.

part of the telehealth model. Integrating those components, we have developed a CSIRO five-layered telehealth model (Fig. 6). The bottom layer is the environment settings. The top three layers are health domains (or application areas), telehealth services, and telehealth technologies (described previously). The second bottom layer is the communication infrastructure, whereas the socioeconomic component crosses vertically across all five layers. We have proposed an integrated and comprehensive telehealth framework. This section reports on our evaluation of the framework. We are interested in assessing the utility and usability of our framework. To do so, we have mapped the telehealth trials and programs that we have reviewed and reported on our experience. The full mapping of other trials and programs that we have reviewed onto our model is given in Table 3. It is important to note that (a) we have excluded some parameters (e.g., costs, barriers, and benefits in socioeconomic analysis) from the mappings as the purpose of the mapping is to show the feasibility of the proposed framework and (b) the mapping only shows the evaluation aspect of the framework. We plan to use the framework for the design and implementation in future telehealth service delivery programs, which is beyond the scope of this article. On reflection, mapping the trials to our telehealth framework was reasonably easy. Using the framework helps with the ontological problem. The trials can be compared on a subset of the dimensions of the framework. This facilitates the comparison. The health services and context dimensions help us to think beyond the technology

Outcomes. The outcomes include the results of the deployment of telehealth applications such as early diagnosis, improved information flow, reduced delay in treatment, and safe, feasible, and improved patient care.

Integrated Framework and Mappings In earlier sections, we reviewed the telehealth taxonomy and classification tools reported in the literature. Our analysis resulted in six major components: health domain, telehealth services, telehealth technologies, communication technologies, environment settings, and socioeconomics. We define a CSIRO telehealth evaluation framework consisting of these six components. In this section, we use the framework to review a few major trials and programs in remote and regional Australia with a particular focus on National Broadband Network (NBN) (i.e., communication technologies) and socioeconomic analysis. It is important to note that we have used 9 articles1– 5,7–10 to develop the telehealth frameworks and 26 different articles10–35 for mapping. The socioeconomic aspect of telehealth is important in measuring telehealth’s feasibility and success. It is a driver for the implementation and deployment and an instrument for measuring the outcomes. Therefore, this component cuts across all the other five components and becomes an integral

Fig. 6. Commonwealth Scientific and Industrial Research Organization telehealth model. EHR, electronic health record; NBN, National Broadband Network.

ª M A R Y A N N L I E B E R T , I N C .  VOL. 20

NO. 4  APRIL 2014

TELEMEDICINE and e-HEALTH 399

NEPAL ET AL.

Table 3. Full Mappings of Other Trials and Programs That We Have Reviewed onto Our Model STUDY NUMBER

REFERENCE (YEAR)

HEALTH DOMAIN

TELEHEALTH TELEHEALTH TELEHEALTH COMMUNICATION APPLICATION TECHNOLOGIES SERVICES TECHNOLOGY

ENVIRONMENT SETTING (LOCATION)

SOCIOECONOMIC (OUTCOMES)

Australian 1

Buist et al.13 (2000)

Mental health

Telepsychiatric

Real-time video

Diagnosis

ISDN

Victoria

Telepsychiatry had enabled the rural services to increase access to specialist services.

2

Barry et al.12 (2006)

Diabetes

Teleophthalmology

Hybrid

Monitoring Diagnosis

NA

Perth

Visiting ophthalmologists have greatly improved the attendance for treatment and are cost effective.

3

Barrett et al.11 (2009)

Wound care

Wound imaging system

Store and forward

NA

Western Australia

Informed and willing staffs are critical to the successful implementation of a telehealth program.

4

Miguel et al.19 (2010)

Respiratory diseases

Home-based self-monitoring

Advanced telehealth with sensors

Monitoring

ASDL broadband

Perth metropolitan area

Self-monitoring increased self-confidence, control, and awareness in managing their condition, as well as an improved sense of security and reduced anxiety.

5

Masek et al.22 (2009)

Obstetrics and gynecology

Tele-obstetrics

Hybrid

Consultation Monitoring Mentoring Education

ADSL +

NA

6

Griffiths et al.16 (2006)

Mental health

Cognitive behavior therapy

Real-time video

Consultation Monitoring Mentoring Training

ISDN

North Queensland

CBT delivered via videoconference was as effective as CBT delivered face-toface.

7

Cregan et al.15 (2005)

Emergency care

Virtual critical care unit

Real-time video

Consultation Monitoring

Leased fiber 70 MB

Nepean Region, New South Wales

Use of near broadcastquality audio and video streams has been an important factor in the system’s rapid acceptance by users.

8

Wilson et al.23 (2010)

Emergency/intensive care

Virtual critical care unit, teleultrasound

Real-time video

Consultation Monitoring Mentoring

Broadband 1 GB

Nepean Region, New South WalesBernie, Tasmania

High bandwidth helped the feeling of strong physical presence, and ease of use was vitally important in point-of-care applications.

9

Hutchins et al.18 (2006)

NA

Collaborative virtual reality surgical training

Real-time video and visual aids

Mentoring Training

Broadband 1 GB

Melbourne

Supported a rich dialogue between an instructor and a student

10

Harris et al.17 (2007)

Pediatric

Telepediatric

Real-time video

Monitoring Mentoring Training/ education

NA

Mount Isa, Queensland

Clinicians gained confidence in the use of the system, and relationships were fostered between regional staff and specialists in the metropolitan area.

11

Mathews et al.20 (2008)

NA

Telemedicine aids to aeromedical retrieval

Real-time video

Monitoring

384 KB

Flying Doctors Australia

Prescreening via telemedicine helped unnecessary aeromedical retrievals.

12

Smith and Gray21 (2009)

Pediatric Geriatric

Telepediatric Telegeriatric

Real-time video

Monitoring Mentoring

NA

NA

Discuss eight key points for successful adoption of telemedicine

continued /

400 TELEMEDICINE and e-HEALTH A P R I L 2 0 1 4

A FRAMEWORK FOR TELEHEALTH

Table 3. Full Mappings of Other Trials and Programs That We Have Reviewed onto Our Model continued TELEHEALTH TELEHEALTH TELEHEALTH COMMUNICATION APPLICATION TECHNOLOGIES SERVICES TECHNOLOGY

ENVIRONMENT SETTING (LOCATION)

NA

Telenursing

Telephone

Triage

Telephone

NA

Sufi et al.10 (2009)

Cardiovascular diseases

Telecardiology

Hybrid

Monitoring Diagnosis

Less than 5 MB (mobile broadband)

NA

Chan14 (2007)

Obstetrics and gynecology

Tele-ultrasound Telesurgery

Hybrid

Diagnosis Consultation Monitoring Mentoring Education

384 KB1 MB

Brisbane

Real-time fetal ultrasound consultation is not only technically feasible, but also welcomed by the clinicians and patients involved.

STUDY NUMBER

REFERENCE (YEAR)

13

St George et al.24 (2008)

14

15

HEALTH DOMAIN

SOCIOECONOMIC (OUTCOMES) Telephone triage projects in Australia and New Zealand to acquaint Australian general practitioners with nurse-led telephone triage services.

Major overseas programs 1

VHA, United States: Darkins et al.26 (2008), Kobb et al.30 (2008), Godleski et al.28 (2012)

Mental health Diabetes Hypertension Congestive heart failure COPD

Telehomecare

Hybrid

Monitoring Consultation

Landline telephone line

United States

Large-scale long-term telehomecare has demonstrated positive clinical, quality, and financial outcomes for patients.

2

WSD Programme, 27 United Kingdom: Sanders et al.31 (2012)

Diabetes COPD Coronary heart disease

Tele-homecare Telecare

NA

Monitoring

Telephone

Newham, Kent, and Cornwall, United Kingdom

Demonstrate a 45% reduction in mortality rates

3

OTN, Canada: OTN34 (2012)

Mental health Internal medicine Oncology Rehabilitation

Telemedicine

Real-time video

Consultation Monitoring Training/education

High bandwidth dedicated network

Ontario, Canada

Importance of high-quality, reliable, compatible, farreaching network able to serve a remote section of the country 24 h/day

4

Shimizu et al.32 (2009)

NA

Tele-education

Real-time video

Education

Fiber 300 MB

Asian counties (Korea, China)

Telehealth application involving live demonstration of images/videos requires cutting-edge technologies.

5

Van Der Heijden et al.33 (2011)

Dermatology

Teledermatology

Store and forward

Consultation

Internet (Web-based)

The Netherlands

Teledermatology consultations between the GP and the regional dermatologist performed in daily GP practice improved quality and efficiency of the service.

6

Healthware: Healthware29 (2012)

France:emergency rescue, ambulatory treatment of psychiatric patient, GP-to-nursing home United Kingdom: oncology Czech Republic: education/training in oncology (students and remote doctors) Cyprus: emergency (injury) Greece: education (remote doctors) Poland: radiology Italy: home monitoring and consultation

Teleconsultation

Real-time video

Consultation

Satellite (2 MB returned)

Europe (Czech Republic, Poland, Cyprus, Italy, Greece, United Kingdom, France)

Satellite communications provide a unique added value regarding telemedicine in terms of performance, security, and flexibility.

continued /

ª M A R Y A N N L I E B E R T , I N C .  VOL. 20

NO. 4  APRIL 2014

TELEMEDICINE and e-HEALTH 401

NEPAL ET AL.

Table 3. Full Mappings of Other Trials and Programs That We Have Reviewed onto Our Model continued REFERENCE (YEAR)

7

European Space Agency35 (2008)

Radiology Education

E-care in the clinic E-care in the village E-learning

Store and forward

Diagnostic Education

Satellite (LEO): E-care in the clinicMobile network: E-care in the village E-learning: terrestrial technology

Sub-Saharan Africa

Satellite-enhanced telemedicine and e-health services could generate significant public health benefits, which are reflected in substantial socioeconomic benefits.

8

Anvari25 (2005)

Laparoscopic surgical care

Robotic surgery

Real-time with robotic

Assisting

15 Mbps fiber network (transmission delay was 140 ms)

Canada

Despite tolerable latency, a reliable connection is still essential.

HEALTH DOMAIN

TELEHEALTH TELEHEALTH TELEHEALTH COMMUNICATION APPLICATION TECHNOLOGIES SERVICES TECHNOLOGY

ENVIRONMENT SETTING (LOCATION)

STUDY NUMBER

SOCIOECONOMIC (OUTCOMES)

CBT, Cognitive Behavior Therapy; COPD, chronic obstructive pulmonary disease; GP, general practitioner; LEO, Low Earth Orbit; Mbps, megabits per second; NA, not available; OTN, Ontario Telemedicine Network; VHA, Veterans Health Administration; WSD, Whole System Demonstration.

element of the intervention of a telehealth trial. This in turn provides a more sociotechnical view of telehealth trials.

Discussion Telehealth is a complex multidimensional sociotechnical system involving a wide range of applications, domains, technologies, human capital, and health practices in different sociotechnical settings. The evaluation of any telehealth program requires a comprehensive framework. We have reviewed several telehealth frameworks and pointed to some of the issues underpinning them. We have then proposed a comprehensive telehealth framework with a focus on six dimensions: health domains, health services, technologies, communication infrastructure, environment setting, and socioeconomic evaluation. The benefits of the proposed framework in relation to exiting frameworks reported in the literature are as follows: .

.

.

Loose coupling: Unlike existing frameworks, different dimensions of the proposed framework are loosely coupled, allowing a more flexible use of the dimensions; they can be used independently or in conjunction with other dimensions. Extensible: The framework is extensible. It provides six different dimensions and presents example elements within each dimension. It is possible to extend each element on a specific dimension to a multidimensional space. For example, a clinical outcome in socioeconomic analysis can be defined using multidimensional parameters. Comprehensive: The proposed framework is a comprehensive framework; it includes all the dimensions mentioned in existing frameworks without being prescriptive. This allows any existing framework to be defined as an instance of the proposed framework.

Describing existing telehealth trials and programs using this framework is easy and has proven to be a valuable exercise. Comparing existing telehealth trials is made easier. Describing telehealth trials from a sociotechnical perspective is also made easier. Because of the generic nature of the framework, it inherently brings the flexibility as a double-edged sword. It has a potential

402 TELEMEDICINE and e-HEALTH A P R I L 2 0 1 4

weakness to be misused unless the proper guidelines are provided. The mapping presented in this article provides a set of guidelines on how the framework can be used. However, providing a set of comprehensive guidelines is difficult and challenging. In order to conduct a proper validation of the framework, we need to evaluate all dimensions of the framework within a program. This will require a large-scale deployment of the telehealth program, covering different aspects of health domains using different communication infrastructure and technologies in different environment settings. With the current advancement of technologies and rising healthcare costs, such deployments are not far from reality. It is worth mentioning four emerging trends we have encountered in telehealth applications while mapping existing programs to our framework. These trends will have a huge impact on the future health services; thus, the future research should be directed toward utilizing technologies resulting from these new trends. The first trend is driven by the advanced telecommunication infrastructures. The availability of high-speed, low-latency, and highly available communication infrastructure, such as the one provided by fiber optics, enables us to develop and deploy highly interactive and real-time telehealth applications. Examples of such application include tele–critical care, telesurgery, and haptic-based tele-education. Furthermore, the future trend in this direction is to have multiple channel-interactive telepresence applications, where each channel may be used for one specific task or content. Such applications would enable medical professionals to perform clinical tasks by sharing audiovisual materials along with a patient’s personal health records in a real-time scenario. This trend was identified while studying the communication technologies in our framework. The second trend is driven by the advancement in the telehealth technology space, which enables us to do things in a smarter and intelligent way. Advanced telecare44 is an example of this trend. These applications do not rely on the availability of high bandwidth. The growing numbers of smarter homecare devices such as fall detectors, bed occupancy sensors, door exit sensors, and pill dispensers

A FRAMEWORK FOR TELEHEALTH

fall into this category. High latency is not an impediment for such applications. Therefore, these applications can be implemented using the current satellite technology offered by broadband technology. We have identified this trend while mapping the existing trials and programs onto health services in our framework. The third trend is related with the socioeconomic aspect of telehealth. Broadband technology has made the communication infrastructures highly available. It is within the reach of most citizens. The costs of communication and devices are getting cheaper every year. The acceptance of technology-based solution for healthcare will likely to increase among both citizens and medical professionals. The aging population and shortage of healthcare workforce also drive stakeholders toward telehealth technologies. These socioeconomic changes will play a key role in defining the future of telehealth applications. This trend was evident in the literature reviewed to capture the socioeconomic aspect of the framework. The fourth trend is the advancement of information and communication technologies. Two emerging trends in this space are the cloud and social media (or Web 2.0). The cloud deals with the information technology infrastructures, whereas the social media aspect deals with the interactions among people. We believe that the future telehealth applications will most likely use these technologies to make them more pervasive and collaborative and thus integrate patients with other stakeholders in their healthcare such as family, friends, and caregivers within a reasonable cost.

Acknowledgments The authors would like to acknowledge Sarah Dods, theme leader of CSIRO digital productivity and services flagship, for supporting this activity and providing valuable comments and ideas.

7. Tulu B, Chatterjee S, Laxminarayan S. A taxonomy of telemedicine efforts with respect to applications, infrastructure, delivery tools, type of setting and purpose. HICSS: Proceedings of the 38th Annual Hawaii International Conference on System Sciences (HICSS¢05). Piscataway, NJ: IEEE, 2005;6:147b. 8. Doughty K, Monk A, Bayliss C, Brown S, Dewsbury L, Dunk B, Gallagher V, Grafham K, Jones M, Lowe C, McAlister C, McSorley K, Mills P, Skidmore C, Stewart A, Taylor B, Ward D. Telecare, telehealth and assistive technologies: Do we know what we’re talking about? Journal of Assistive Technologies 2007;1:6–10. 9. Vincent A, Cusack CM, Pan E, Hook JM, Kaelber DC, Middleton B. A new taxonomy for telehealth technologies. AMIA Annu Symp Proc 2007:1145. 10. Sufi F, Fang Q, Khalil I, Mahmoud SS. Novel methods of faster cardiovascular diagnosis in wireless telecardiology. IEEE J Selected Areas Communications 2009;27:537–552. 11. Barrett M, Larson A, Carville K, Ellis I. Challenges faced in implementation of a telehealth enabled chronic wound care system. Rural Remote Health 2009;9:1154. 12. Barry CJ, Constable IJ, McAllister IL, Kanagasingam Y. Diabetic screening in Western Australia: A photographer’s perspective. J Vis Commun Med 2006;29:66–75. 13. Buist A, Coman G, Silvas A, Burrows G. An evaluation of the telepsychiatry programme in Victoria, Australia. J Telemed Telecare 2000;6:216–221. 14. Chan FY. Fetal tele-ultrasound and tele-therapy. J Telemed Telecare 2007;13:167–171. 15. Cregan P, Stapleton S, Wilson L, Qiao RY, Li J, Percival T. The ViCCU Project— Achieving virtual presence using ultra broadband internet in a critical clinical application—Initial results. Stud Health Technol Inform 2005;111:94–98. 16. Griffiths L, Blignault I, Yellowlees P. Telemedicine as a means of delivering cognitive-behavioural therapy to rural and remote mental health clients. J Telemed Telecare 2006;12:136–140. 17. Harris V, Smith AC, Armfield NR. Education for regional health professionals using mobile videoconferencing. J Telemed Telecare 2007;13(Suppl 3):44–47. 18. Hutchins M, Stevenson D, Gunn C, Krumpholz A, Adriaansen T, Pyman B, O’Leary L. Communication in a networked haptic virtual environment for temporal bone surgery training. Virtual Reality 2006;9:97–107. 19. Miguel KDS, Smith J, Lewin G, Smith R. Telehealth research across the community—Remote monitoring of chronic obstructive pulmonary disease. Silver chain white paper. 2010. Available at www.dreaming-project.org/ documents/SIL17572_TELEHEALTH_RATC_v3.pdf (last accessed March 27, 2013).

Disclosure Statement No competing financial interests exist.

REFERENCES 1. NICTA; prepared by Hanlen L, Robertson P. Telemedicine in the context of the National Broadband Network. Report by NICTA submitted to the Department of Broadband, Communications and the Digital Economy. 2010. Available at www.archive.dbcde.gov.au/__data/assets/pdf_file/0020/130277/NICTA-Telemedicine_ Report_cr_-pdf.pdf (last accessed March 27, 2013). 2. Bashshur R, Shannon G, Krupinski E, Grigsby J. The taxonomy of telemedicine. Telemed J E Health 2011;17:484–494. 3. Edwards J, Handler TJ, Lovelock JS, Shaffer V, Fenn J, Ekholm J. Hype cycle for telemedicine. Publication number G00169011. Stamford, CA: Gartner Industry Research, 2009. 4. Pan E, Cusack C, Hook J, Vincent A, Kaelber DC, Bates DW, Middleton B. The value of provider-to-provider telehealth technologies. Telemed J E Health 2008;14:446–453. 5. Maeder AJ. Telehealth standards directions supporting better patient care. Presented at Australia’s 2008 Health Informatics Conference. 2008. Available at www.hisa.org.au/system/files/u2233/36-Chapter31.pdf (last accessed March 27, 2013). 6. Tulu B, Chatterjee S, Maheshwari M. Telemedicine taxonomy: A classification tool. Telemed J E Health 2007;13:349–358.

20. Mathews KA, Elcock MS, Furyk JS. The use of telemedicine to aid in assessing patients prior to aeromedical retrieval to a tertiary referral centre. J Telemed Telecare 2008;14:309–314. 21. Smith AC, Gray LC. Telemedicine across the ages. Med J Aust 2009;190:15–19. 22. Masek M, Lee C, Lam CP, Tan K, Fyneman A. Remote home-based ante and post natal care. Proceedings of the 11th IEEE International Conference on e-Health Networking, Applications & Services. Piscataway, NJ: IEEE, 2009:60–65. 23. Wilson LS, Stevenson DR, Cregan P. Telehealth on advanced networks. Telemed J E Health 2010;16:69–79. 24. St George I, Cullen M, Gardiner L, Karabatsos G. Universal telenursing triage in Australia and New Zealand—A new primary health service. Aust Fam Physician 2008;37:476–479. 25. Anvari MS. Establishment of the world’s first telerobotic remote surgical service for provision of advanced laparoscopic surgery in a rural community. Ann Surg 2005;241:460–464. 26. Darkins A, Ryan P, Kobb R, Foster L, Edmonson E, Wakefield B, Lancaster AE. Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic condition. Telemed J E Health 2008;14:1118– 1126.

ª M A R Y A N N L I E B E R T , I N C .  VOL. 20

NO. 4  APRIL 2014

TELEMEDICINE and e-HEALTH 403

NEPAL ET AL.

27. Department of Health. Whole systems demonstrator programme: Headline findings: December 2011. Available at www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_131684 (last accessed September 19, 2012). 28. Godleski L, Darkins A, Peters J. Outcomes of 96,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006–2010. Psychiatr Serv 2012;63:383–385. 29. Healthware. Healthware final publishable report. 2012. Available at http:// cordis.europa.eu/documents/documentlibrary/114724441EN6.pdf (last accessed March 13, 2013). 30. Kobb R, Chumbler NR, Brennan DM, Rabinowitz T. Home telehealth: Mainstreaming what we do well. Telemed J E Health 2008;14:977–981. 31. Sanders C, Rogers A, Bowen R, Bower P, Hirani S, Cartwright M, Fitzpatrick R, Knapp M, Barlow J, Hendy J. Exploring barriers to participation and adoption of telehealth and telecare within the Whole System Demonstrator trial: A qualitative study. BMC Health Serv Res 2012;12:220. 32. Shimizu S, Nakashima N, Okamura K, Tanaka M. One hundred case studies of Asia-Pacific telemedicine using a digital video transport system over a research and education network. Telemed J E Health 2009;15:112–117. 33. Van der Heijden JP, de Keizer NF, Bos JD, Spuls PI, Witkamp L. Teledermatology applied following patient selection by general practitioners in daily practice improves efficiency and quality of care at lower cost. Br J Dermatol 2011;165:1058–1065. 34. Ontario Telemedicine Network. Ontario Telemedicine Network 2010/11 annual report. Available at http://otn.ca/sites/default/files/2011–12_annual_report_0.pdf (last accessed April 14, 2012). 35. European Space Agency. Cost benefit analysis of satellite-enhanced telemedicine and ehealth service in Sub-Saharan Africa. 2008. Available at http://iap.esa.int/sites/default/files/ESA%20Telemedicine%20and%20eHealth% 20Report_FullVersion_04122008.pdf (last accessed March 19, 2013). 36. Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez A. The burden of disease and injury in Australia 2003. Catalog number PHE 82. Canberra: Australian Institute of Health and Welfare, 2007. 37. Naditz A. Coming to your senses: Future methods of patient monitoring and home healthcare. Telemed J E Health 2009;15:511–516.

404 TELEMEDICINE and e-HEALTH A P R I L 2 0 1 4

38. Waegemann CP. mHealth: The next generation of telemedicine? Telemed J E Health 2010;16:23–25. 39. Demiris G, Afrin LB, Speedie S, et al. Patient-centered applications: Use of information technology to promote disease management and wellness. A white paper by the AMIA Knowledge in Motion Working Group. J Am Med Inform Assoc 2008;15:8–13. 40. Ackerman M, Locatis C. Advanced networks and computing in healthcare. J Am Med Inform Assoc 2011;18:523–528. 41. Nicolini D. The work to make telemedicine work: A social and articulative view. Soc Sci Med 2006;62:2754–2767. 42. Jennett PA, Affleck Hall L, Hailey D, Ohinmaa A, Anderson C, Thomas R, Young B, Lorenzetti D, Scott RE. The socio-economic impact of telehealth: A systematic review. J Telemed Telecare 2003;9:311–320. 43. Peters L, Sellick K. Quality of life of cancer patients receiving inpatient and home-based palliative care. J Adv Nurs 2006;53:524–533. 44. Department of Health. System demonstrator programme in UK. 2012. Available at www.dh.gov.uk/health/2012/01/roll-out-of-telehealth-and-telecare-tobenefit-three-million-lives/www.kingsfund.org.uk/document.rm?id = 9341 (last accessed March 19, 2013).

Address correspondence to: Surya Nepal, PhD Computational Informatics Commonwealth Scientific and Industrial Research Organization Corner of Vimiera and Pembroke Roads Marsfield, NSW–2122 Australia E-mail: [email protected] Received: March 27, 2013 Revised: August 2, 2013 Accepted: August 2, 2013

A framework for telehealth program evaluation.

Evaluating telehealth programs is a challenging task, yet it is the most sensible first step when embarking on a telehealth study. How can we frame an...
518KB Sizes 3 Downloads 4 Views