Asynchronous telehealth: a scoping review of analytic studies

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Amol Deshpande, Shariq Khoja, Julio Lorca, Ann McKibbon, Carlos Rizo, Donald Husereau, Alejandro R Jadad

Citation: Deshpande A, Khoja S, Lorca J, McKibbon A, Rizo C, Husereau D, Jadad AR. Asynchronous telehealth: a scoping review of analytic studies Open Med 2009;3(2):39‐61.


Note: Contributions (additions, edits, deletions) made to this scoping review will be used to create a publication based on the outcomes of this collaborative process. You must log in to contribute.


Contents


ABSTRACT

Background: Asynchronous telehealth captures clinically important digital samples (e.g., still images, video, audio, text files) and relevant data in one location and subsequently transmits these files for interpretation at a remote site by health professionals without requiring the simultaneous presence of the patient involved and his or her health care provider. Its utility in the health care system, however, still remains poorly defined. We conducted this scoping review to determine the impact of asynchronous telehealth on health outcomes, process of care, access to health services, and health resources.

Methods: A search was performed up to December 2006 of MEDLINE, CINAHL, HealthSTAR, the Database of Abstracts of Reviews of Effectiveness, and The Cochrane Library. Studies were included if they contained original data on the use of asynchronous telehealth and were published in English in a peer-reviewed journal. Two independent reviewers screened all articles and extracted data, reaching consensus on the articles and data identified. Data were extracted on general study characteristics, clinical domain, technology, setting, category of outcome, and results. Study quality (internal validity) was assessed using the Jadad scale for randomized controlled trials and the Downs and Black index for non-randomized studies. Summary data were categorized by medical specialty and presented qualitatively.

Results: The scoping review included 52 original studies from 238 citations identified; of these 52, almost half focused on the use of telehealth in dermatology. Included studies were characterized by diverse designs, interventions, and outcomes. Only 16 studies were judged to be of high quality. Most studies showed beneficial effects in terms of diagnostic accuracy, wait times, referral management, and satisfaction with services. Evidence on the impact of asynchronous telehealth on resource use in dermatology suggests a reduction in the number of, or avoidance of, in-person visits. Reports from other clinical domains also described the avoidance of unnecessary transfer of patients.

Conclusions: A significant portion of the asynchronous telehealth literature involves its use in dermatology. Although the quality of many original studies remains poor, at least within dermatology, there is consistent evidence suggesting that asynchronous telehealth could lead to shorter wait times, fewer unnecessary referrals, high levels of patient and provider satisfaction, and equivalent (or better) diagnostic accuracy when compared with face-to-face consultations. With the exception of a few studies in pediatric asthma, the impact of this intervention on individual health outcomes remains unknown.


Amol Deshpande, MD, MBA, is a consultant with Foresight Links Corporation, Toronto, Ontario, Canada. Shariq Khoja, MD, PhD, is an assistant professor in the Department of Community Health Sciences and Medical Director’s Office, Aga Khan University, Karachi, Pakistan. Julio Lorca, MD, is general director of the Institute for Innovation on Human Well-being in Malaga, Andalusia, Spain. Ann McKibbon, BSc, MLS, PhD, is associate professor (part-time) at the Health Information Research Unit, Faculty of Health Sciences, McMaster University, Hamilton, Ontario. Carlos Rizo, MD, is a PhD candidate in the Department of Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario. Donald Husereau, BScPharm, MSc, is director of project development at the Canadian Agency for Drugs and Technologies in Health, Ottawa, Ontario. Alejandro R Jadad, MD, DPhil, FRCPC, is professor, chief innovator and founder of the Centre for Global eHealth Innovation, University Health Network and University of Toronto, Toronto, Ontario.

Competing interests: ARJ owns Foresight Links Corporation [1], a consultancy company which works in the area of systematic reviews and evaluation. He is also a member of the Editorial Board of Open Medicine [2]. He may indirectly benefit from publication of this article.

Contributors: Amol Deshpande (AD) led the research and coordinated the project, including the design of data extraction tables, supervision of data extraction, confirmation of final selected trials, preparation of initial draft of the review and participation in subsequent report revisions. Alejandro R. Jadad (ARJ) conceived the project, developed the initial protocol, assisted in data extraction and participated in all phases of the writing of the report. Carlos Rizo (CR) extracted and tabulated data for the environmental scan and assisted in report writing. Ann McKibbon (AM) and Shariq Khoja (SK) selected trials and studies, extracted and tabulated data and reviewed the final report. Julio Lorca prepared the initial draft of the asynchronous telehealth environmental scan. Donald Husereau reviewed and provided comments on the research protocol and subsequent drafts. All of the authors contributed to the revisions of the report.

Funding source: This study was sponsored by the Canadian Agency for Drugs and Technologies in Health, Ottawa, Ont.

Correspondence: Dr. Alejandro R. Jadad, 225 Jarvis St., Suite 302, Toronto ON M5B 2C1; telephone +1 647 298 5639; fax +1 416 863 1100; ajadad@ehealthinnovation.org.



The need to deliver services to remote and underserved communities has been the main impetus behind the expansion of telehealth programs. Telehealth services that rely on real-time consultations, however, are realizing that their need to interact with dedicated, specialized facilities is limited by factors similar to those that affect traditional consultations, particularly the need to schedule face-to-face encounters between patients and health professionals. Telehealth programs may need to consider a shift toward a model that continues to rely on a physician’s real-time presence — a scarce commodity, given changing demographics and the lifestyle choices of physicians.[1],[2]

One form of telehealth, known as asynchronous (or store-and-forward) telehealth, helps provide administrative and support services to areas that lack health professionals who can meet the needs of the population locally. It has also been used to reduce the delay before referral to specialists. Because of the widespread penetration of technologies such as the Internet, personal digital assistants (PDAs), smart phones (voice-centric handheld devices that function as phones and as PDAs), and digital photography, and in view of reductions in the cost of data storage, patients and health professionals can capture clinically important digital samples and relevant data (e.g., pictures of moles or surgical wounds, electrocardiograms, spirometry results, radiological images) in various formats (e.g., audio, video, text) from any location and send them to health professionals at distant sites for assessment at a convenient time. The independence of this digitized information from real-time interactions between patients and health professionals, together with the low cost of the required infrastructure, could allow asynchronous telehealth to reduce wait times, provide opportunities to rethink the way in which high-demand services are organized, optimize the use of limited health resources, and promote equitable access to health professionals and services.

So far, clinical applications of asynchronous telehealth have not received the same degree of attention as real-time telehealth.[3] This qualitative scoping review addresses the impact of asynchronous telehealth on health outcomes, health delivery services, health care resource use, and user satisfaction.

Methods

A protocol, which is available from the corresponding author, was written a priori and followed throughout the review process. Article screening and data extraction were performed using TrialStat SRS 4.0 (Ottawa, Canada).

Literature search strategy

An information specialist (ME) prepared a detailed search strategy (online Appendix 1) combining 3 clusters of terms: the first focused on telehealth, the second on asynchronous forms of electronic communication, and the third on health services delivery. Electronic searches, performed up to mid-December 2006, included the following databases: MEDLINE (from 1966), CINAHL (from 1982), HealthSTAR (from 1975), the Database of Abstracts of Reviews of Effectiveness (DARE), and The Cochrane Library. The yield from the bibliographic databases was complemented with a scan of reference lists from eligible reports.


Selection method

An article was regarded as potentially eligible if it met all of the following criteria:

  • evaluated 1 or more clinical asynchronous services
  • involved the capture of digital clinical samples by physicians, community-based nurses, or trained members of the public
  • focused on the delivery of digital samples for assessment by specialists at separate locations, transferred electronically
  • included data on health outcomes, process of care, resource utilization, or user satisfaction
  • appeared in an English-language peer-reviewed journal since 1995.


Studies on clinical asynchronous telehealth were excluded if they focused only on diagnostic concordance among different methods (i.e., no other outcome data presented) or on technical issues (e.g., different modalities of telehealth or telehealth versus face-to-face consultations).

Two teams of 2 reviewers (AM and CL, and SK and HD) independently screened each title and abstract of a potentially eligible report. Two of the authors (ARJ and AD) resolved any discrepancies between the teams by independently reviewing each title and abstract or, if necessary, the full report. If disagreement persisted, a final decision was reached by consensus between ARJ and AD.


Data extraction and abstraction strategy

Both teams of reviewers extracted data independently, using unmasked copies of the reports. Where disagreements existed, the final set was reviewed independently by ARJ and AD. Any differences were resolved by consensus.

A standard data extraction form was used to collect the following information from each report:

  • general characteristics (e.g., name of lead author, publication title, year of publication, country of study)
  • study type (e.g., observational [i.e., non-experimental], experimental, or descriptive); if observational, the study was recorded as a case series, a cross-sectional effort, a cohort or a case-control study; where relevant, it was stated whether the study was identified as retrospective or prospective
  • technological characteristics of the telehealth platform (e.g., Integrated Services Digital Network [ISDN]- or Internet Protocol [IP]-based, resolution level)
  • patient population (e.g., sample size, demographic characteristics)
  • setting (e.g., rural or urban)
  • originator of the consultation (e.g., family physician, nurse, community member)
  • comparison group(s) (e.g., face to face)
  • purpose of the consultation (e.g., acute, non-acute, education, diagnosis, therapeutic support, follow-up)
  • outcomes measured and main findings (e.g., impact on health outcomes, process of care, resource use).

Health outcomes were defined as an effect on an individual’s health status or a clinical consequence (e.g., increased compliance with treatment or reduced burden of illness). Rates of diagnostic concordance, only if reported with other health or non-health outcomes, were considered for this category. Process of care outcomes described access to care, wait times, or time to completion for a clinical encounter. Outcomes on resource utilization included reports of cost-effectiveness data or impact on hospital admissions, visit frequency, or rate of referrals. User satisfaction was used to categorize feedback from a patient or provider on satisfaction, expectations, or acceptance of asynchronous telehealth.


Strategy for quality assessment

The methodological quality of each study was assessed using the Jadad scale for randomized controlled trials (RCTs),[4] and the Downs and Black checklist for observational studies and controlled clinical trials (CCTs).[5] The last question (question 27) on the Downs and Black checklist is designed to assess the study’s statistical power. Because the Downs and Black checklist was used only for qualitative studies and CCTs, we used a modified score with “0” or “1,” according to whether authors reported statistical power tests in the original article (score = 1) or not (score = 0). The modified scale allowed for a maximum possible total score of 28 for a given study.

The median study quality score was used to distinguish between low-quality and high-quality studies where no pre-specified score existed.[6] RCTs were considered to be of high quality if they received a Jadad score greater than 2 points or a score greater than 14 points using the Downs and Black checklist.


Data analysis

The reports were categorized by medical specialty. A general description was provided for the set of publications that met the inclusion criteria, based on general characteristics and quality scores for the individual publications. Evidence tables were produced to summarize the information extracted from the publications.

Results were presented qualitatively. A meta-analysis was considered to be inappropriate for the present review, given the clinical heterogeneity of the included studies. There were significant disparities among studies in clinical condition, acuity of health service delivery (acute, chronic), clinical setting, and technological intervention.


Results

The literature search yielded 238 publications, of which 139 reports were excluded because they did not address issues related to clinical asynchronous telehealth. A total of 99 potentially eligible publications required the full-text version for further investigation. After review of the full-text version, 37 reports were excluded for various reasons (see online Appendix 2).

From the remaining 62 publications, 10 were excluded because they did not involve medical areas traditionally associated with direct patient care. Six[7]-[8] of these involved pathology, while 4[9]-[10] addressed applications for use in radiology. Agreement between reviewers was high, although no formal statistical measure was completed.

A summary of the selection process is presented in Figure 1.


Study characteristics

Fifty-two studies were included in this review; of these, 7[11]-[12] were published before 2000. The study characteristics are presented in Tables 1 and 2.

The primary author was based in the United States for 22 studies[13],[14],[15]-[16] and in the United Kingdom for 15.[17],[18],[19]-[20],[21],[22]-[23] Primary authors for the remaining publications were based in a number of countries, with 3 from Italy[24]-[25] and 2 from the Netherlands.[26],[27] One study originated in Canada.[28]

Study designs included 3 RCTs[29],[30],[31] and 7 surveys.[32],[33],[34]-[35],[36],[37] Thirty-six publications were designed as case series studies, while 6 were characterized as cohort studies.

In 24 publications, no funding source for the study was documented.

Dermatology was the most frequently represented medical specialty (24 publications). Nine articles reported data based on results identified across various medical specialties;[38],[39],[40],[41],[42],[43],[44],[45],[46] 6 reported on musculoskeletal medicine,[47],[48],[49],[50],[51],[52] 4 on pediatrics,[53],[54],[55],[56] and 2 on ophthalmology.[57],[58] Other clinical settings included plastic surgery and the neurological sciences.


Quality assessment

One of 3 RCTs was judged to be of high quality[59] (see Table 1). Of the remaining 49 studies, 15 received high-quality ratings.[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71]-[72]

Data analyses and synthesis

Dermatology

Many publications in this group addressed more than 1 outcome. Health outcomes (mainly diagnostic accuracy), user satisfaction and resource use were the most commonly represented categories.

Health outcomes

Eleven publications evaluated the role of health outcomes. Ten of these reported on diagnostic concordance or diagnostic accuracy. Several publications reported high levels of diagnostic accuracy with the use of telehealth in dermatology. One study reported that diagnostic accuracy for teleconsultants as a group was obtained in 73% of all cases of skin lesions and in 90% of evaluations of skin cancer lesions.[73] Other reports documented rates of diagnostic accuracy varying from 75% to 88%.[74],[75],[76] Combining images from asynchronous telehealth with standard patient histories increased diagnostic accuracy to 90% and 82% (p < 0.001) for 2 teledermatologists.[77] The level of agreement with the gold standard (face-to-face consultation) was 0.91 (95% confidence interval [CI] 0.82-1.00) for clinical consultations using telehealth and 0.94 (95% CI 0.88-1.00) for dermatoscopy using telehealth (p > 0.05).[78] Discrepancies were reported in the ability of asynchronous telehealth to contribute to the development of a management plan. In 1 study,[79] an appropriate management plan was developed in 84% of the cases, but another study[80] suggested that the use of asynchronous telehealth was successful in 55% of cases, while 45% could not be properly assessed. Mallett reported that “advice only” was possible in 8% of cases.[81]

Process of care

Of the 9 publications that assessed process-of-care outcomes, most studies reported a reduction in time to consultation. The average time between referral and clinical advice was reported to be 46 hours (range 17-119, standard deviation [SD] 24) in 1 publication.[82] Massone reported that, of 133 requests analyzed, 80 (60%) were answered within a day.[83] The use of telehealth in dermatology resulted in a time to initial definitive intervention that was significantly shorter than that of usual care (median 41 days v. 127 days, p < 0.0001); 25 patients (18.5%) in the telehealth arm avoided the need to visit a dermatology clinic.[84] Klaz noted that the average wait times for asynchronous telehealth consultations (n = 435) were 50% less than those for face-to-face consultation.[85] The time to perform a consultation was also affected by the use of asynchronous telehealth: the time to complete a telehealth consultation was one-third shorter on average than an in-person assessment.[86] Three studies reported the ability to properly prioritize patients to address medical urgency.[87],[88],[89] White[90] reported that asynchronous telehealth, including the use of images, resulted in more accurate triage in 20 of the 40 (50%) cases. Telehealth use in dermatology also resulted in 14% of non-urgent referrals being upgraded to urgent, while another 24 of 136 (17%) were deemed to need assessment when none was planned.[91],[92]

The use of asynchronous telehealth in dermatology decreased the frequency of in-person visits or avoided them altogether. Eminovic[93] reported that 56 of 96 (58%) cases required less frequent in-person visits. The avoidance of an in-person visit ranged from 8% to 53%.[94],[95],[96],[97],[98],[99],[100],[101] One publication reported that the use of telehealth in dermatology resulted in the avoidance of 45% of in-person visits, producing a 15%-20% decline in workload.[102]


Resource utilization

Eleven publications on the use of telehealth in dermatology reported outcomes pertaining to resource use. Two studies[103],[104] quantified costs and reported their outcomes in 2[105],[106] separate publications. Asynchronous telehealth was found to be less expensive than real-time telehealth consultations, but its clinical usefulness was limited.[107] Whited[108] noted that the use of telehealth in dermatology was not associated with cost-savings but seemed to be cost-effective when the faster time to definitive treatment was taken into account.


User satisfaction

Patient or provider satisfaction in general was determined to be high in 11 publications assessing telehealth in dermatology. Ninety-three percent of patients reported that they were happy with telehealth consultations.[109] Klaz[110] noted an 89% patient satisfaction rate with higher results in rural areas than in urban areas. Two studies[111],[112] reported that 85% of patients said they would accept the use of telehealth in dermatology in the future, 18% feeling that the conventional asynchronous method was sufficient. In contrast, 38% to 40% agreed with the statement that they would prefer to discuss their skin problem with the dermatologist in person and preferred direct contact.[113],[114] In addition, 40% said that they would feel that something important was missing if they did not see the dermatologist in person. When placed in the context of longer wait times, 76% preferred to be assessed by telehealth rather than wait for an in-person consultation.[115]

Most dermatologists felt comfortable making a diagnosis and devising a treatment plan in those cases for which they had access to the image and the patient’s history.[116] One early study noted that 81% of general practitioners anticipated problems with implementation, while 15% said that expectations were high.[117] A more recent report documented that 84% of providers had high expectations at the start of the study and 21% had similar expectations at the end.[118] Furthermore, 21% were satisfied with the use of telehealth in dermatology, while 47% were dissatisfied and 32% were unsure. The most common reasons cited for negative responses were complex process and increased workload.

Studies involving multiple medical specialties

Health outcomes

Among the 9 articles in this group, none presented data on individual patient health outcomes for any of the medical specialties.


Process of care

Articles generally reported that less time was needed to process referrals. Most asynchronous telehealth cases (67%) had a total turn-around time of less than 72 hours, and the average turn-around time for store-and-forward cases was almost 40% faster than for real-time telehealth.[119] Replies within 1 day of referral were provided in 70%-87.5% of cases and within 3 days of referral in 100% of cases.[120],[121] Actual telehealth consultations were completed within 3 days in 14 cases (52%) and within 3 weeks in 24 cases (89%). Vladymyrszki[122] reported that the median interval between a request for consultation using telehealth services and it being conducted was less than 1 day, with an acceptance of treatment results in 88% of cases.

In mixed (i.e., multiple) medical specialities, 2 studies reported an approximate 15%-23% reduction in patient transfers.[123],[124] One Canadian study[125] reported that of the 101 patients evaluated, 8 emergency transfers were avoided, and 15 patients who would have required elective transfer were managed locally via telehealth. No study in this group provided actual cost data. One study stated, “Cost savings have been substantial, not only direct costs but long distance telephone charges have been markedly reduced.”[126]


Resource utilization

Among the 9 articles in this group, none were identified that presented data on the impact of asynchronous telehealth on the use of resources.

User satisfaction

Three studies[127],[128],[129] involving multiple medical specialties commented on patient and provider satisfaction. One study documented that patients were satisfied or very satisfied with the care received.[130] Two others commented on positive acceptance and a general perception of asynchronous telehealth as being beneficial.[131],[132]


Orthopedics

Five publications in the area of musculoskeletal medicine assessed trauma or injury.[133],[134],[135],[136],[137] One study focused on postoperative recovery after shoulder surgery.[138]


Health outcomes

One study assessed the validity of asynchronous telehealth, noting minimal diagnostic disagreement (5% intra-observer and 5.5% inter-observer differences) with face-to-face and similar treatment plans to deliver care.[139] None of the differences identified were regarded as serious (e.g., limb- or life-threatening). Archbold[140] reported that 17% of asynchronous consults changed the initial management plan. The authors reported that results of all imaging of the injury revealed that initial descriptions submitted by the referring physician were inaccurate with respect to the nature of the injury.


Process of care

The 1 study that assessed process of care documented that the average time spent by orthopedic specialists was longer in videoconferencing (21 minutes, SD 8) than in asynchronous telehealth consultations (19 minutes, SD 8). However, a clinician’s confidence in the diagnosis was generally lower with asynchronous consultations.[141]


Resource utilization

Studies in orthopedics reported that the transport of plain films by taxi was avoided in 10 referrals,[142] while in other settings patients avoided transfer or referral.[143],[144]


Pediatrics

All studies in this group reported health outcomes, while 3[145],[146],[147] evaluated resource use.


Health outcomes

The use of asynchronous telehealth for pediatric care was associated with positive health outcomes. Two studies, with a combined sample of 17 patients, assessed the effect of asynchronous telehealth in pediatric asthma.[148],[149] Inhaler technique scores and quality-of-life survey scores improved in the intervention group.[150] The use of asynchronous telehealth was also thought to be helpful in modifying the diagnosis in up to 15% of cases.[151] One study on acute illnesses noted a 63% reduction in absence from school due to sickness with the use of telehealth.[152]


Process of care

Three pediatric studies reported a decrease in health care use. Malone[153] noted a drop in emergency department visits (mean [SD] 3.85 [5.14], versus 0 visits, p < 0.05) and admissions (mean [SD] 1.57, [1.27], versus 0.286 [0.48], p < 0.05) compared with the year before. McConnochie[154] also reported fewer visits to the emergency department, while Callahan[155] reported avoidance of air evacuation in 12% of the population.


Other conditions

Health outcomes

Two studies focused on ocular conditions. Diagnostic agreement was reported in 12 of 15 cases that presented with strabismus.[156] Another study, in which a digital ophthalmoscope was used to screen for retinopathy, showed a detection rate twice as high with digital imaging (8.8%) compared with indirect ophthalmoscopy (4.4%).[157]


Process of care

One study, which assessed the provision of nonsurgical oncology consultations to underserved communities, reported that the use of synchronous and asynchronous telehealth resulted in enhanced communication with colleagues (86% and 80% respectively).[158] Kokesh[159] documented that the use of asynchronous telehealth for ear, nose, and throat disorders reduced wait times of 4 to 15 months “significantly,” although specific data were not provided.

Similar findings were noted in neurological conditions, where the treatment plan was changed in 50% of the cases as a result of the specialist’s advice and 1 transfer of a patient out of the country was avoided.[160] The use of asynchronous telehealth to transmit imaging in the context of neurosurgical evaluation reduced the need to transfer a patient by 50%.[161]


Resource utilization

One study was identified in this group as providing utilization data. In otolaryngology, 79 of 91 patients saved transport costs, producing a savings of US$307.57 per person.[162] This study concluded that for every $1 spent on reimbursement for telehealth, $8 in travel costs could be avoided.


Discussion

Similar to telehealth literature reviewed elsewhere,[163]-[164] the original literature in this review was of low methodological quality. Most publications did not appear to follow sound methodological principles, or described results based on small sample sizes that would be consistent with feasibility studies or pilot projects. However, despite the poor quality of evidence, certain trends were consistent across many studies.

Beyond diagnostic accuracy and concordance, most publications did not report meaningful data on health outcomes such as individual health status or other clinical parameters. The best evidence for improved health outcomes was found in the management of pediatric asthma. These studies reported positive effects on treatment compliance and a reduction in the need for acute intervention. This is consistent with previously reported evidence supporting the use of telehealth in the management of chronic conditions.[165]

Several publications, most on the use of telehealth in dermatology and some that assessed multiple medical specialties, reported a positive impact on process-of-care outcomes, including a reduction in time to consultation, shorter wait times, and less time to perform a consultation. In some cases, the reduction in wait times was significant relative to face-to-face care, decreasing by almost 50%.[166] Improved triage facilitated the prioritization of patients on the basis of urgency, thus enhancing workflow logistics. It remains unclear whether triage led to overall faster care or improved health outcomes. It is also unknown whether the expectation of faster and more effective care could be met if asynchronous technology were expanded beyond small pilot projects and feasibility studies.

The results of this scoping review are consistent with previous findings that the methods to assess the cost-effectiveness of telehealth are poor.[167] Most evidence for cost savings is implied through indirect reductions in resource utilization. Cost savings in these situations are achieved through the avoidance of patient-generated costs, such as those associated with travel, lost time from work, or caregiver reimbursement. These costs, although not insignificant, are variable and are correlated with travel distance; thus, it could be difficult to demonstrate cost-effectiveness in more urban areas. Other studies reported a decreased frequency or avoidance of patient transfers. This was most notable in the triage of surgical cases in orthopedics and neurosurgery. In these situations, it could be possible to avoid the mobilization of health professionals (e.g., ambulance attendant, nurse, physician).

The quality of literature on patient satisfaction, as in other aspects of telehealth, was considered to be poor.[168] Consistent with previous publications, however, satisfaction levels were found to be generally above 80% for the use of telehealth in dermatology, although some studies reported a preference for in-person consultation.[169],[170] The satisfaction ratings seemed to be influenced by wait times for obtaining traditional in-person care. Provider acceptance was mixed: compared with primary care providers, consultants were more amenable to the use of telehealth in dermatology. The latter group perceived the complexity of the referral process and the increased workload as negative factors. In most of the other clinical domains, however, clinicians reported a positive acceptance of the use of asynchronous telehealth.


Limitations

This scoping review has several limitations. The search of databases was performed in December 2006. Asynchronous telehealth, with its low-cost technology and potential to decrease reliance on scarce resources for real-time consultation, is still rapidly evolving. Systematic reviews must be updated regularly to ensure that our knowledge of asynchronous telehealth is up to date with new evidence.[171]

The literature search was restricted to English publications. Although there could be reports published in other languages, previous studies have suggested that restricting literature searches to English does not bias systematic reviews of conventional medical interventions.[172]

The scope of asynchronous telehealth was limited in this review. Specifically, the search strategy focused on the clinical applications of asynchronous telehealth but may not have identified all evaluations of remote home-based monitoring. Better evidence for improved health outcomes appears to originate from this latter body of literature. A review focusing on this area may generate more robust results to support the use of asynchronous telehealth. Additionally, the 10 publications that assessed the use of asynchronous telehealth in pathology and diagnostic radiology were not included in this report. These clinical domains may add information with respect to the benefits of asynchronous telehealth. These publications were eliminated to maintain consistency with other literature on asynchronous telehealth, which generally exclude those medical specialties that traditionally do not involve direct patient care.

Despite repeated calls for improved study designs, methodological quality and standardized outcome assessments, the overall quality of the telehealth literature remains poor. However, although the evidence is weak, there are trends, especially within dermatology, that support the use of asynchronous telehealth as a supplement, rather than as a replacement, for other health services. Specifically, there is consistent evidence suggesting that asynchronous telehealth could lead to shorter wait times, fewer unnecessary referrals, high levels of patient and provider satisfaction, and equivalent (or even better) diagnostic accuracy in comparison with face-to-face consultations.


Acknowledgments

We applied the “first-last” author emphasis approach for the sequence of authors. We are grateful to Marina Englesakis, information specialist, for providing valuable feedback in developing the search strategy and completing searches of the databases; Hammad Durrani (HD) and Cynthia Lokker (CL) for their help in data extraction; Dijana Vasic and Vladan Jovic for their aid in retrieving the articles for this review; and Melissa Ohotski and Jessie Venegas-Garcia for their assistance in preparing citation lists. Martha Garcia, from Foresight Links Corporation, provided management and administrative oversight throughout all phases of the project.


Table 1: General characteristics for studies included in review

Author
Year of publication
Country
Funding source
Type of study
Quality score
(DB)

Abboud [24]
2005
USA
Not reported
Case series
19
Archbold [42]
2005
UK-Ireland
Vodaphone
Case series
16
Baba [63]
2005
Turkey
Not reported
Case series
18
Barnard [25]
2000
USA
Not reported
Case series
15
Baruffaldi [55]
2002
Italy
Not reported
Case series
10
Beach [43]
2000
UK
NHS Executive, (telemedicine equipment loaned by ADV Communications and software by Telemarque Ltd
Case series
6
Brandling-Bennett [26]
2005
USA
Not reported
Case series (retrospective)
13
Callahan [27]
2005
USA
US Army Medical Research Acquistion
Case series
12
Chan [28]
2003
USA
US Army Medical Research Acquistion
Case series
17
Chen [62]
2004
Taiwan
Not reported
Case series
14
Collins [46]
2004
UK
NHS R&D Health Technology Assessment Programme
Survey
15
Collins [45]
2004
UK
NHS R&D Health Technology Assessment Programme
Survey
17
Collins [44]
2000
UK
NHS R&D Health Technology Assessment Programme
Survey
12
Eminovic [58]
2003
The Netherlands
KYOS Research foundation(non-profit organization based at the dermatology department of the AMC)
Cohort (prospective)
19
Fortin [60]
2003
Canada
Health Canada Transition Fund
Case series and semi-structured interview
13
Gomez [23]
1996
USA
Not reported
Cohort (retrospective)
10
Heautot [18]
1999
France
Ministry of Industry, the Region of Brittany
Case series
8
Helveston [29]
2001
USA
Equipment sponsored by Education and Research Foundation for Children’s Eyes, Indianapolis, Indiana, and Clody and Riley’s “One-Eyed Golf.”
Case series (before and after)
8
Hersh [30]
2002
USA
Eugene Garfield Foundation, OHSU Hospital, OHSU Medical Group, and Asante Health System
Survey
12
Hockey [66]
2004
Australia
Commonwealth Department of Health and Ageing (Medical Specialist Outreach Assistance Programme)
Case series
11
Klaz [64]
2005
Israel
Israel Defense Forces Medical Corps.
Multicenter uncontrolled cohort (prospective)
18
Knol [59]
2006
The Netherlands
Not reported
Cohort (prospective)
13
Kokesh [31]
2004
USA
Not reported
Case series (descriptive)
2
Krupinski [19]
1999
USA
US Department of Agriculture Rural Utilities Service Distance Learning, U.S Department of Commerce, National telecommunications and Information Administration, Office of Rural Health Policy, Department of Health and Human Services Rural
Case series
12
Krupinski [32]
2004
USA
Not reported
Cohort (retrospective)
12
Larcher [56]
2003
Italy
Public Health Institute of the Government of Italy
Survey
13
Lau [33]
2002
USA
Not reported
Case series (descriptive)
9
Loane [47]
2000
UK
NHS R&D
RCT
2(JS)
Mahendran [48]
2005
UK
Not reported
Case series
13
Malacarne [57]
2004
Italy
Not reported
Case series
11
Mallett [49]
2003
UK
Not reported
Case series
6
Malone [34]
2004
USA
Pacific Telehealth and Technology Hui and Medical Health care facilities
Case series
12
Mandall [50]
2005
UK
Not clearly stated
RCT
3(JS)
Massone [67]
2006
Austria
Not reported
Case series (descriptive)
7
McConnochie [35]
2005
USA
US Department of Commerce Technology Opportunities Program, Robert Wood Johnson Foundation Local Initiative Funding
Case series (before and after)
15
Moreno-Ramirez [65]
2006
Spain
‘Instituto Carlos III’ of the Spanish Health Ministry
Case series
14
Mukundun [36]
2003
USA
Swifen Charitable Trust, Cantebury, England (equipment)
Case series
11
Pak [22]
1999
USA
Walter Reed Army Medical Center
Cohort (retrospective)
10
Pap [37]
2002
USA
Not reported
Case series
11
Patterson [51]
2001
UK
Not reported
Case series
12
Person [38]
2003
USA
THE PACIFIC ISLAND HEALTH CARE PROJECT (PIHCP)
Case reports
6
Person [39]
2000
USA
Not reported
Case series
6
Rodas [109]
2005
Ecuador
NASA and Instituto de Investigacionesde la Universidad de Cuenca (IDIUC).
Case series
11
Sibson [20]
1999
UK
NHS Research and Development Waiting List Taskforce fund.
Case series and survey
15
Taylor [52]
2001
UK
Not reported
Case series
17
Vassallo [53]
2001
UK
The Swinfen Charitable Trust (SCT)
Case series
12
Vladzymyrskyy [61]
2005
Ukraine
Not reported
Case series
8
Weinstock [40]
2002
USA
Cooperative Studies Program, Office of Research and Development, Department of Veterans Affairs
Survey
14
White [21]
1999
UK
Not reported
Case series
7
Whited [41]
2002
USA
VA Health Services Research and Development Service.
RCT
2(JS)
Williams [54]
2001
UK
Not reported
Survey
10
Zelickson [17]
1997
USA
Not reported
Case series
13

Table 2: Components and outcomes of studies included in review

Study
Sample
Intervention
Clinical domain
Level of care
Outcome category (H,P,R,S)
Results

Abboud
2005 [24]

100 patients aged 8–79 yr with disorders of upper extremity
Use of electronic history and digital image capture of radiological films and affected extremity with consumer quality camera and storage on PC
Orthopaedic
Diagnostic
H
5% intra-observer differences and 5.5% inter-observer in diagnoses or treatment when comparing the face-to-face and electronic evaluations (none life/limb threatening). Established intra-observer agreement of diagnosis and treatment plan (kappa=0.92 and 0.90, respectively) and inter-observer agreement of diagnosis and treatment plan (kappa=0.86 and 0.90, respectively)
Archbold
2005 [42]
46 consecutive trauma consultations age range 4-90 yr
Multi-media cellphone to capture images (mobile platform) including plain films and wound
Orthopaedic
Diagnostic
H, R, S
8 of 46 consults felt to have changed the initial management and 10 referrals avoided forwarding plain films by taxi (cost savings), patient care improved in 34 out of the 46 cases (trauma surgeon) and 36 out of 46 cases (emergency physician). Ease of use acceptable 70% of the time.
Baba
2005 [63]
242 skin lesions on 228 patients aged 2-82 yr
PC-based Web camera videoconferencing compared with electronic transfer of history and images obtained with digital camera
Dermatology
Diagnostic
H, S
Conventional store-and-forward method diagnostic accuracy of 2 teledermatologist was 81% and 75%, but with combined method the corresponding values were 90% and 82% (P<0.001 for both).
No significant difference in inter-observer agreement.
Use of Web camera videoconferencing improved patient satisfaction with teledermatology.
85% of subjects would accept telehealth for dermatology in the future, of which, 82% thought that telehealth consultation should include videoconferencing with Web cameras.

Barnard 2000 [25]
8 dermatologists using telehealth evaluated 50 cases involving various skin conditions, submitted by other dermatologists


Digital images taken with camera of lesions followed by brief electronic history
Dermatology
Diagnsotic
H
Diagnostic accuracy for skin cancers was 88% versus 90% (range, 75–100%) for the in person and telehealth consultants, respectively. For all confirmed cases the accuracy was 84% (in-person) compared to 73% (range, 65–88%). Telehealth consultants changed their primary diagnosis in 11% of cases (range, 2–22%). Biopsy rates were not significantly different between telehealth consultants (45%) and in-person dermatologists (40%).
Baruffaldi 2002 [55]
65 telehealth consultations for second opinion on work-related injuries
Real-time VC (PC with document camera) or asynchronous with transfer of files across ISDN
Orthopaedic
Diagnostic
P
Average time spent was slightly longer in videoconferences (21 min, SD 8) than in asynchronous telehealth consultations (19 min, SD 8). The clinicians’ confidence in diagnosis was lower in asynchronous telehealth consultations. Clinical complexity of the case and the organizational requirements were declared to be the main factors affecting the choice of consulting procedure. Asynchronous method was preferred in the majority of cases although there were some concerns about the diagnostic quality of the information transmitted.
Beach 2000 [43]
71 patients entering minor injury units
Low-cost VC and asynchronous telehealth transmitted over ISDN (no detail data provided)
Orthopaedic
Diagnostic
R
Data obtained in some cases avoided transfer or referral. Some changes in diagnosis and treatment for remote physician (no detailed data provided).
Brandling-Bennett 2005 [26]
264 general clinic visits on 214 patients (age range 3 moto 80 yr) in rural Cambodia


Electronic history and digital images sent by email via satellite connection
Multiple
Diagnostic
S
All patients surveyed either “very satisfied” (46%) or “satisfied” (54%) with their care, and most patients were willing to pay for a visit, with a median amount of USD 0.63.
Callahan 2005 [27]
267 paediatric consultations from 16 different sites mean age 5 (SD 5) yr
Web-based, store-and- forward, asynchronous, provider-provider telehealth consultation with image capture device (digital camera, scanner, and video camera)
Paediatrics
Diagnostic
H, P, R
Mean response time by a consultant was 32  (SD 14) hr. Initial diagnosis was changed or modified in 15% (39/267) of cases, the diagnostic plan was changed or modified in 21% (57/267), and the treatment plan was changed or modified in 24% (64/267) (P .01 for all). Routine air evacuations were avoided in 32 cases (12%).
Chan 2003 [28]
10 children (age range 6-17 yr) with asthma submitting 321 videos of inhaler use and 309 peak flow meter videos undergoing virtual versus office based education
Home-based computer and video camera with Internet access
Paediatrics (asthma)
Therapeutic
H, S
Inhaler technique scores improved significantly (87% in period 1) compared with period 2 (94%). Less controller medication period 1, mean 0.8 (SD 0.6), compared with 0.5 (SD 0.3). Peak flow values increased significantly. Overall, no change in quality of life but caregivers in virtual-education group reported increase in patients’ quality-of-life survey scores. Emergency department visits and hospital admissions were avoided. High rate of satisfaction with home telehealth monitoring
Chen 2004 [62]
113 patients (mean age 53 yr) screening for ocular disorders in Tungyin, China
Digital ophthalmoscopy with image capture and transmission over ADSL
Ophthalmology
Diagnostic (screening)
H
In screening for retinopathy, the detection rate for digital imaging (8.8%) was two times higher than indirect ophthalmoscopy (4.4%). Community-based screening for four categories of eye disease successfully demonstrated.
Collins 2004  [45]
148 responses from 208 dermatology patients enrolled in RCT comparing traditional in-person care to telehealth consultation
Asynchronous telehealth (not specified)
Dermatology
Diagnostic
S
No statistical difference in satisfaction of care between 2 groups. 85% of telehealth consultation group happy to use this system, 38% prefer to discuss their skin problem with dermatologist in person. 40% feel that something important was missing if they did not see the dermatologist in person. 76% would rather have their skin problem managed via telehealth than have to wait.
Collins 2004 [46]
36/42 GPs enrolled in an RCT responded to a before-and-after questionnaire
Asynchronous telehealth (not specified)
Dermatology
Diagnostic
S
86% enthusiastic about telehealth for dermatology in contrast to 21% at end of study who felt all expectations had been met; 21% satisfied, 47% dissatisfied and 32% unsure; 31% confident in diagnosis and management, 28% unconfident and 41% unsure; high expectations pre-trial were more likely to be satisfied (Kendall’s tau-b=0.51, p=0.023); 12/26 felt positive about improved access; 11/33 felt referral process complex, while 18/33 reported increased workload.
Collins 2000 [44]
26 responses from a total of 35 GPs who agreed to participate in RCT
Asynchronous telehealth (not specified)
Dermatology
Diagnostic
S
81%, (n=21; 95% CI 55–91%) anticipated problems with implementing the system. 15% (n=4; 95% CI 5–36%) respondents said their expectations for telehealth in dermatology were high. One in four respondents (27%, n=7; 95% CI 9–45%) felt confident or very confident about the diagnosis and management generated through telehealth for dermatology
Eminovic 2003 [58]
96/105 patients recruited (aged 4 mo to 72 yr) with various skin lesions


Submission of electronic form and 4 digital images taken by patient
Dermatology
Diagnostic
H, R
71% of cases further investigation proposed. 58% of cases needed (less frequent) in person consultation. For 23% of patients no kind of hospital visit required.
Fortin 2003 [60]
118 transmissions involving 101 patients in Quebec; various clinical domains
Store-and-forward imaging along with videoconferencing for other areas
Multiple
Diagnostic (19 patients received follow-up)
H, R, S
8 emergency transfers avoided and 15 patients requiring elective transfer were managed locally. 3 unanticipated transfers carried out. 13/15 patients satisfied. 25 health professionals interviewed and ‘majority’ perceived as beneficial.
Gomez 1996 [23]
240 consults from 12 remote telehealth sites across multiple clinical domains
Various digital image capture devices and transmission via satellite or commercial telephone lines
Multiple
Diagnostic
P
Most consults were routine (88%); 94% of consults were completed within the predefined telehealth response criteria (24 hr for routine consults and 3 hr for emergencies).
Heautot 1999 [18]
Patients presenting for emergency neurosurgical consults at distant hospital. 3 phases: (I) 11 patients (no asynchronous); (II) 51cases (image transfer ISDN); and (III) unknown.
Proprietary software and DICOM to submit radiological images over ISDN/ATM
Neurosurgery
Diagnostic
H, R, S
Phase I: 10/11 patients transferred. of which 4 could have been avoided with images, Phase II: 34/48 (71%) actual patient transfers with 8/48 transfers avoided. Phase III: 62% transferred with image helpful in 50% of cases. Up to 50 % unnecessary patient transfers avoided. Non-urgent advice requests increased from 0 to 21%. ATM network, the service gave satisfaction to all the physicians.
Helveston 2001 [29]
Total of 50 patients with strabismus in various countries, with 30 in Cuba
Digital image with PC storage on disk and transmission as attachment to email
Ophthalmology
Diagnostic
R
The transmission of text and images by email was trouble-free, and communication in English was effective. The store-and-forward technique is a relatively simple, inexpensive, and versatile method of telehealth.
Hersh2002 [30]
31 clinicians in Oregon given access to a system to pose clinical questions
Web-based asynchronous application
Non-specific
Support (physician)
S
Clinicians displayed modest but enthusiastic use.
Hockey 2004 [66]
15 GPs in Australia submitting 63 email consultation requests where no dermatologist access was available locally
Submission via email of electronic copy of history and digital image using consumer based camera
Dermatology
Diagnostic
H, P
in majority (53/63) of cases management plan was developed based on email; 10 cases (16%) additional images or biopsy results requested (image quality inadequate). Average time between receiving referral and clinical advice being provided was 46 hours. GPs made more referrals the longer they stayed in study.
Klaz 2005 [64]
18 physicians in military units recruiting 435 patients (aged 18-39 yr) with non-pgimented skin from rural and urban centres. No comparison group.
Digital images uploaded from camera and sent along with electronic questionnaire via email
Dermatology
Diagnostic
P, R, S
Diagnosis using telehealth possible for 95% of 435. 22% of referrals required face-to-face consultation. Satisfaction high/very high among 89% patients in rural and urban clinics-significantly higher in rural units. Average wait time 50% less than face-to-face appointment. 87% PCPs were satisfied with the quality of the service and its contribution to their knowledge. Rural physicians rated level of service and overall satisfaction higher.
Knol 2006 [59]
505 consultations in 503 patients (aged 0-96 yr) with skin lesions. Face-to-face comparison only for those requiring follow-up.
Electronic form and digital image transmission by email
Dermatology
Diagnostic
H, P, R
No difference between initial diagnosis and face-to-face in those requiring further follow-up. 163 patients were not referred because of telehealth--a reduction of 53% (163/306); 17% of cases required traditional consultation when none was intended by GP.
Kokesh 2004 [31]
91 patients provided store-and-forward services from rural communities with ear, nose and throat conditions
Video-otoscopy, digital surgical microscopy and other digital image capture devices for otolaryngology (details unspecified)
Otolaryngology
Diagnostic and Therapeutic
P, R
Analysis of the first 91 store-and-forward cases reimbursed by Medicaid revealed significant savings to Medicaid. Of 91 cases, 79 saved transport for the patient and escort at an average round-trip cost of
$307.57/person. For every $1 spent on reimbursement for telehealth, almost $8 of travel cost was avoided. Wait times from 4-15 mo were reduced “significantly”.
Krupinski 1999 [19]
Unknown sample size. Based on review of program workload of 35 cases/month across 39 subspecialties.
Multiple types of data/image capture and transfer to proprietary software via ATM
Multiple
Diagnostic
P
Majority of store-and-forward cases (67%) have a total turn-around time of <72 hours (mean 93.01h, SD 142.43) compared with real-time cases (28%) with a total turn around
time of <72 hours. (mean=242.71h, SD 271.63). (t=8.051, df=498, p=0.0001). Main difference occurred in time from notification of consultant until consultation (RT-mean=175.05h vs. SF-36.62h) SS: (t=8.52, df=498, p=0.0001)

Krupinski 2004 [32]
Comparison of 50 dermatology patients assessed by telehealth to convenience sample of 50 assessed by face-to-face consultation
Digital image captured with camera and uploaded to proprietary software
Dermatology
Diagnostic
R
In-person group had fewer records about actions taken as a result of the consultation (e.g. performed a biopsy, prescribed a medication): 12% of the in-person records compared with 43% in telehealth (P<0.01). Both groups had similar follow-up rate with 8% vs. 10% (p>0.05).
Larcher 2003 [56]
Two questionnaires with responses of 33/35 and 22/38 physicians before and after performing 98 asynchronous telehealth consultations with cancer patients
Web-based telehealth (no details provided)
Oncology
Diagnostic
/Therapeutic
/Support

S
Both modalities of telehealth consultation useful in enhancing communication with colleagues (86% synchronous, 80% asynchronous). Major difficulties encountered were in the introduction of the system into the daily routine. User satisfaction: 78% of sessions set goal was reached
Lau 2002 [33]
6 patients (average age 59 yr) followed post-operatively after shoulder surgery.
Web-based messaging system to send multimedia information and implement web-forms
Orthopaedic
Rehabilitative/
Follow-up (post-operative)

S
User satisfaction between neutral and satisfied with overall mean rating 3.4 out of 5 (SD=0.85)
Loane 2000 [47]
204 patients (aged 4 moto 89 yr) randomized into 2 groups of 102 patients each with various skin lesions
Real-time telehealth for dermatology (VC across ISDN) compared with still images from instant camera sent by post and face-to-face intervention
Dermatology
Diagnostic
H, R
46% real-time telehealth dermatology consultations required at least one other hospital appointment compared with 45% of conventional outpatients and 69% of store-and-forward consultations. The latter was less expensive (€22.11 vs. €61.03) but clinical usefulness was limited. With sensitivity analysis real-time telehealth was as economical as conventional care when less artificial assumptions applied.
Mahendran 2005 [48]
163 patients presenting with 1 dermatological lesion compared with FTF
Electronic history and image capture with digital camera transmitted via email
Dermatology
Diagnostic
H, R
Management plan appropriate in 55% of consultations using telehealth (22% could have avoided face-to-face and 33% sent directly to minor surgery). 45% could not be managed by SF.
Malacarne 2004 [57]
25 consecutive patients across 9 different specialty areas transmitted between Africa and Italy
Multiple types of data capture (patient history, ECG, radiology etc.) with transmission over ISDN
Dermatology
Diagnostic
R
In 60% of cases, just 1 consultation was sufficient. Choosing the right specialist was the most critical phase of the operation.
Mallett 2003 [49]
727 images on 325 referrals (agee 4 mo -94 yr) with variety of skin lesions. Face-to-face comparison.
Digital image capture with camera and transmission via email over ISDN
Dermatology
Diagnostic
H, R
95% concordance with telehealth. An "advice only" service was requested and given for only 26 patients (8%) while 256 patients required outpatient visit. (i.e. majority of patients still need to be seen in the outpatient clinic). Telehealth unlikely to have significant impact on patient workload or solve waiting list problems.
Malone2004 [34]
7 patients (mean age 11.9 [SD 3.7] yr) with asthma
Web-based asthma pathway with MPEG video and spirometry
Paediatrics (asthma)
Therapeutic Support
H, R
Fewer ED visits for asthma (mean [SD]: 3.85 [5.14], range 0–15 vs. 0 visits, p<0.05); Fewer unscheduled acute clinic visits (mean [SD]: 1.57 [1.27], range 0–4 vs. 0.286 [0.48], p<0.05) in study year versus preceding year. 2 hospitalizations in year prior to and no patients hospitalized during the study; provider use of asthma action plan increased from 24% to 73% (p<0.01) and provision of asthma education increased from 18% to 73%, (p<0.01). Providers not more likely to order spirometry (12% vs. 18%).
Mandall 2005  [50]
2 groups of 80 patients (mean age 13.1 yr) for intervention and 247 controls (mean age 13.8 yr) for orthodontic screening
Electronic history and digital images taken with camera and sent via email
Dentistry
Screening
H, S
Sensitivity=0.80, and specificity=0.73 suggesting good screening test. However, low negative predictive value at 0.50. No difference between attendance for first appointment. 131/200 providers responded to survey and 70% felt teledentistry good idea.
Massone 2006 [67]
Physician request for 783 requests for consultations: 285 for pigmented lesions and 440 non-specific and 58 non-melanoma skin cancer
Website allowing uploading of 3 digital images and form for patient clinical data
Dermatology
Diagnostic
P
Of a total 133 requests analysed, 80 (60%) were answered within 1 day, 47 (35%) within 1 week, 5 (4%) within 2 weeks and 1 (1%) consultation was answered in more than 2 weeks.
McConnochie 2005 [35]
5 inner city child care centers with avgerage of 138 children per centre
presenting with acute illness

Computer with teleconferencing camera, digital camera and electronic stethoscope submitted by broadband
Paediatrics (acute illness)
Diagnostic and treatment
H, R
Absence due to illness (ADI) was 4.07/100 child days with telemedicine compared with 8.78/100 child-days without. A 63% reduction in ADI was attributable to telemedicine. Telemedicine intervention resulted in 7.0% exclusion from child care and in-person visits for 2.8%. Surveys of parents indicated 91.2% of telemedicine contacts allowed them to stay at work. 93.8% of problems managed by telemedicine would otherwise have led to an office or emergency department visit.
Moreno-Ramirez 2006 [65]
63 patients with skin lesions enrolled with 61 cases evaluated. No comparison group.
Digital clinical images and dermatoscopic images taken and submitted via intranet
Dermatology
Diagnostic
H, P, R
Agreement with gold standard 0.91 (95% CI 0.82–1.00) for clinical teleconsultation and 0.94 (95% CI 0.88–1.00) for teledermatoscopy (p > 0.05). Teledermatoscopy increased economic investment of teledermatology facility by 2.4 times. GP spent 1.5 times longer on dermatoscopic teleconsultations.
Teledermatoscopy improved the teledermatology-based screening system for pigmented lesions.

Mukundun 2003 [36]
8 patients from Solomon Islands referred by medical student for variety of conditions
Digital image capture of clinical lesions and patient data and submission via email
Multiple
Diagnostic
P
7/8 replies received <1d and 8/8 <3d; 50 additional referrals with >2/3 responded to <24h and 80% <3d.
Pak 1999 [22]
100 cases with skin lesions from referral sites including 8 primary care clinics and hospitals without dermatologists. No comparison group.
Digital image capture with camera and transmission over the Internet
Dermatology
Diagnostic
P, R, S
45% of patients avoided dermatologist visit resulting in 15-20% decline in workload; 17% required follow-up with dermatologist. Most patients felt teledermatology met their healthcare needs; 27% of follow-up cases required in person visit and 73% could be followed telephonically. Consultants took 7.7 minutes (teleconsult) vs. 20 minutes (in-person) with 70% comfortable with the diagnostic impression. Patient satisfaction during follow-up much lower due to wait for real-time appointment or lack of follow-up from primary care physician.
Pap 2002 [37]
20 patients evaluated at random referred to plastic surgery service
Digital image capture of clinical lesion and radiographs with camera and transmission via email
Plastic surgery
Diagnostic
P, S
Email generated <10 minutes and received by attending physician <5 minutes. A ttending physicians reported thorough satisfaction with picture quality, the speed of transmission, and screen resolution.
Patterson 2001[51]
12 patients (age range 15–57 yr) with various neurological conditions
Digital image capture with camera and transmission via email
Neurology
Diagnostic
H, R
8 cases considered complicated by the neurologist (preferred video-link consultation); advice beneficial in 75% of complex and in all straightforward cases; 50% patients had care changed from specialist advice and one patient transfer out of country was avoided.
Person 2003 [38]
2 girls with traumatic injuries
Not specified
Orthopaedic
Therapeutic
R
2 cases illustrate cost savings and avoidance of transfer (no details provided).
Person 2000 [39]
Over 200 patients with multiple conditions in first 6 months of program in Micronesia
Digital image capture with upload to Web-based system
Multiple
Diagnostic
R, S
Cost savings direct and long distance telephone charges. Every patient treated at home represents savings $10-20k; “…acceptance by the referring and consulting physicians alike has been overwhelming”.
Rodas 2005 [109]
144 pre-operative and 50 post-operative patients in Cuenca, Ecudaor
Real-time and store-and-forward using digital image capture and transmission via email over POTS
Pre and post operative assessment
Therapeutic
H, P
In 101 preoperative evaluations, agreement in 78 cases (77%); in 37 postoperative evaluations agreement in 36 cases (97%). “Telemedicine may reduce the time required on site for preoperative planning, and may provide reliable postoperative surveillance, improving the efficiency of mobile surgery services. “
Sibson 1999 [20]
23 patients (age range 9-74 yr presenting with suspicious skin lesions
Digital image of clinical lesion and relevant history and submission via email (over ISDN) compared with face to face intervention
Dermatology
Diagnostic
H, S
75% of patient "agreed" or "strongly agreed" with remote expert opinion; 77% (n=14) of respondents either "very comfort able" or "comfortable" with having their lesion photographed. No respondent reported any concerns regarding the electronic transfer of their clinical information using telemedicine; 100 % clinician agreement between the diagnostic opinions from both plastic surgeons from the virtual and real mole clinics.
Taylor 2001 [52]
194 patients presenting with skin lesions
Video camera to record still images and electronic recording of patient data
Dermatology
Diagnostic
H, P, R
77% agreement between diagnoses of the dermatologists using the system to inspect images and face-to-face dermatologist. Fewer urgent appointments (32% compared with 64%). 31% of cases patient did not need to be seen-15% of these cases (5% of the total). However, their diagnosis differed significantly from that of the consultant who saw the patient; 14% of patients conventionally assigned a non-urgent appointment would have been seen urgently.
Vassallo 2001 [53]
27 patients across five different specialties
Digital camera to capture images and transfer via email
Multiple
Diagnostic
P, R
Initial email replies were received < 1d of referral in 70% of cases and < 3d in 100%; consultation complete < 3d in 14 cases (52%) and < 3 weeks in 24 cases (89%); referral judged beneficial in 24 cases (89%); 4 patients (15% of the total) and their families were spared the considerable expense and unnecessary stress of travelling abroad for a second opinion.
Vladzymyrskyy 2005  [61]
210 patients across multiple clinical domains but most related to trauma (age range from one moto 85 yr)
Telemedical workstation with computer, digital camera, Web camera, email and videoconferencing
Multiple
Diagnostic
P
Median interval between request for a teleconsultation and it being carried out was <1d; majority of cases required single adviser; 11% of cases, more >3 advisers were required; treatment suggested by consultant accepted in 88% of cases.
Weinstock 2002 [40]
100 of 112 eligible patients with skin lesions and 19/22 primary care providers. No comparison group.
Store-and-forward (unspecified)
Dermatology
N/A
S
42% of patients thought program excellent/good and 37% fair. 75% patients would recommend program. 87% reported teledermatologist was excellent/good--greatest concern was their lack of direct contact with their dermatologis.t 63% of providers rated clinic excellent/good and 21% as average. 74% rated usefulness of the program as excellent/good and would recommend the program to another provider. Other concerns were wait time and follow-up. Privacy concerns were not commonly mentioned.
White 1999 [21]
40 patients with skin lesions referral info vs. referral info and images. No comparison group.
Digital image captured with camera and sent with electronic patient data using wide area network over ISDN
Dermatology
Diagnostic
P, R, S
Patients more accurately triaged in at least 50% of cases (with image) and 25% of patients did not require outpatient dermatological appointment. Dermatologists rated image quality at 7.5 on a 10-point scale.
Whited 2002 [41]
275 patients with skin lesions with 135 randomized to intervention
Digital image capture with standardized history and electronic consult request compared with face to face
Dermatology
Diagnostic
P
Teledermatology arm reached a time to initial definitive intervention significantly sooner than did usual care (median 41 days versus 127 days, p<0.0001, log-rank test); 18.5% of patients in the teledermatology arm avoided need for clinic-based visit compared to zero patients in the usual care arm of the study (p=0.001, z-test). Teledermatology not cost-savings per patient ($34.60 vs. $21.40) but found to be cost-effective based on faster time to definitive treatment with teledermatology.
Williams 2001 [54]
141/195 patients with teledermatology appointments (aged 18–90 yr)
Not specified
Dermatology
Diagnostic
S
93% reported they were happy with the teleconsultation. 86% reported that it was more convenient than going to the outpatient clinic. 40% agreed that they would feel more comfortable seeing the dermatologist in person while only 58% were comfortable with not speaking to the dermatologist about their skin condition. Absence of interaction with dermatologist and delay in receiving management advice may contribute to somewhat low satisfaction rates.
Zelickson 1997 [17]
29 nursing home residents with skin lesions compared with FTF
Video camera for image capture of lesion and still-image telephone
Dermatology
Diagnostic
H, S
88% of cases with the history and image given correct diagnoses. No incorrect diagnoses or treatment plans would have given rise to substantial morbidity. Dermatologists comfortable in making diagnosis and treatment plan in all cases with both image and patient history.

Appendices


References

How to cite a new reference:

Indicate the new reference in the text of this wiki by using a capital letter enclosed in round brackets (e.g. (A)), and add the reference with a link to the full article here. For example:


New references

A. Deshpande A, Khoja S, Lorca J, McKibbon A, Rizo C, Husereau D, Jadad AR. Asynchronous telehealth: a scoping review of analytic studies Open Med 2009;3(2):39‐61. [wikiSR]



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