Evaluating barriers to adopting telemedicine worldwide: a systematic review

Author links open overlay panelAndreaFernández CovesabcEnvelopeKarene Hoi TingYeungbEnvelopeIngeborg Mvan der PuttenaPersonEnvelopeE. Anthony SNelsonbdEnvelope

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https://doi.org/10.1016/j.healthpol.2022.07.012Get rights and content

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Highlights

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COVID-19 boosted teleconsultation adoption in Hong Kong and the Netherlands.

External context played a crucial role in teleconsultation uptake in both settings.

Hong Kong practitioners employed teleconsultation for chronic care management.

The dominant paradigm within Dutch practitioners was using teleconsultation for triaging purposes.

Comprehensive legislation and incentives are necessary for teleconsultation adoption in primary care.

Abstract

The COVID-19 pandemic has boosted the adoption of digital health technologies such as teleconsultation. This research aimed to assess and compare barriers and facilitators for teleconsultation uptake for primary care practitioners in Hong Kong and the Netherlands showed different penetration rates of teleconsultation. Most stakeholders in both settings shared similar barriers and facilitators in the organizational, professional, and intervention levels. However, external contextual factors (i.e., current teleconsultation legislation, available incentives, and level of public awareness) played an important and differing role in teleconsultation uptake and had a direct effect on the organization, the professionals involved, and the type of technology used. Political and organizational actions are required to develop a comprehensive legal framework for the sustainable development of teleconsultation in both settings.

Telehealth practice is increasing globally, partially in response to the sudden disruption brought upon by the COVID-19 pandemic. Telehealth usage is not without significant barriers which might be specific to each setting. These barriers need to be identified beforehand and may necessitate the development of individualized strategies to address them appropriately.

Most barriers can be categorized under the following:

Due to widespread social media usage, there is generally a great awareness of data privacy and confidentiality issues associated with being online. These issues are critical since it concerns health records and other private information related to treatment. These fears might discourage some from accepting telehealth as an alternative mode of availing healthcare services. Telehealth systems that incorporate data encryption and similar cyber-security measures must be employed. Clinicians must seek informed consent from their clients before each telehealth consultation and in a specific format.

Despite evidence to the contrary, the perceived cost is one of the important barriers preventing telehealth use. This is more prominent in low-resource settings. Investing in telehealth infrastructure such as broadband and other telehealth equipment in addition to personnel training is a concern for most. These costs can be minimized by selecting the most appropriate telehealth delivery methods for the intervention, setting, and population. For example, clinicians can use SMS or other asynchronous methods instead of real-time videoconferencing, if suitable. The modern smartphone is a comparatively inexpensive and self-sufficient device for most telehealth use cases.

Another area of concern is billing and financial reimbursement for telehealth services. The government or other regulatory bodies might provide guidance for billing for telehealth. Insurance coverage for telehealth services needs to be determined. In its absence, alternate means must be identified in consensus with the client before commencement.

Depending on the country and state (as in the case of the United States of America), telehealth practice may be under the purview of the law. Clinicians may need to obtain the mandated licence and meet other legal requirements as stipulated by law. In countries without clear legal requirements, the presiding professional body may have set certain guidelines in place that may assist clinicians in setting up their practice. The law may also impose strict data privacy requirements for patient safety.

On the other hand, the internet could also enable quacks and other bad actors to defraud people for telehealth services. Patients should be educated to look up their service providers' credentials before accepting or paying for any telehealth intervention.

Before the COVID-19 pandemic, clinicians and patients' general perception and attitudes towards telehealth were usually negative to mixed, probably motivated in part by the perceived lack of contact. Older clinicians and patients may be resistant to change and express more skepticism with telehealth. Although the acceptability might have increased after the pandemic, certain populations, especially in rural settings, might still express concerns about the use of telehealth for their healthcare needs. Increasing awareness through education can help mitigate these concerns.

These are usually associated with the technological requirements for conducting telehealth. They may include lack of broadband coverage or low bandwidth, lack of user-friendly telehealth hardware or software, and poor digital literacy. Broadband coverage and speeds are set to improve soon. The rollout of 5G worldwide will make telehealth easier due to the exponentially higher data transfer speeds. Globally, there has already been considerable improvement in internet accessibility in the past decade. Although, developing countries still have a long way to go in contrast to the rest of the world. Clinicians must collaborate with engineers, and designers must develop telehealth devices and software applications keeping in mind the needs of the target population. Besides training clinicians and patient education, poor digital literacy can be overcome with good design.

This might stem from a lack of training related to telehealth practice. Telehealth was not a standard inclusion in curricula before the COVID-19 pandemic. Clinicians need to be educated early, especially while training as healthcare students.The early exposure through dedicated training will help build confidence and comfort in using telehealth in their future practice.

On the other hand, the literacy of the client (both traditional and digital) and their education level may pose a barrier due to the nature of telehealth. This may necessitate designing telehealth applications based on simplicity and ease-of-use, keeping in mind such limitations.

Research related to telehealth is increasing due to the push for remote services provided by the COVID-19 pandemic. Telehealth is an effective alternative to in-person care in many medical conditions. Although, in specific applications, telehealth may still need further research before application in the community. Evidence-based telehealth practice will help prevent patients from receiving sub-optimal care that may deter their continued engagement in the long term. Similarly, high-quality research on telehealth applications globally will also help convince skeptics and make telehealth practice more accessible to a larger population in a variety of different settings. An ever-growing body of evidence will also help generate funds for future research that will help establish telehealth further in the mainstream.

Chapter 4 of 'The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary' discusses "seven deadly barriers" to telemedicine.

The video above enumerates the barriers to telehealth practice and suggests two methods to address them. First, it suggests educating the client about the benefits of telehealth. Secondly, it describes a process called 'shared informed decision-making' as a possible solution to decide on telehealth for a client. It mentions a paper by Elwyn et al., 2012 as reference material for the same. Shared informed decision-making refers to the process of treatment selection on the basis of current level of evidence and the client's preferences. The client is allowed to make an informed choice on their treatment.

The video above is an in-depth webinar that explains the critical barriers to telehealth patients face and provides guidance in overcoming them.

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