1Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242
Open Access
AbstrActbackground The use of telehealth steadily increases as it has become a viable modality to patient care. Early adopters attempt to use telehealth to deliver high-quality care. Patient satisfaction is a key indicator of how well the telemedicine modality met patient expectations.Objective The objective of this systematic review and narrative analysis is to explore the association of telehealth and patient satisfaction in regards to effectiveness and efficiency.Methods Boolean expressions between keywords created a complex search string. Variations of this string were used in Cumulative Index of Nursing and Allied Health Literature and MEDLINE.results 2193 articles were filtered and assessed for suitability (n=44). Factors relating to effectiveness and efficiency were identified using consensus. The factors listed most often were improved outcomes (20%), preferred modality (10%), ease of use (9%), low cost 8%), improved communication (8%) and decreased travel time (7%), which in total accounted for 61% of occurrences.conclusion This review identified a variety of factors of association between telehealth and patient satisfaction. Knowledge of these factors could help implementers to match interventions as solutions to specific problems.
IntrOductIOnRationaleThe mental image of medical house calls is one of archaic practices in small towns and otherwise rural communities, or something associated with concierge medicine. However, telehealth brings the doctor back into the patient’s home. Healthcare has begun tran-sitioning to more technological-delivered services, making it possible to receive health-care services from the comfort of one’s home, without driving to the clinic, or frustratingly trying to find a parking spot before one’s appointment. This review examines tele-health and any association it might have with patient satisfaction.
This review uses the definition of telehealth from WHO:
The delivery of health care services, where distance is a critical factor, by all health care professionals using
information and communication technologies, for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, in all the interests of advancing the health of individuals and their communities.1
Following WHO’s example, we did not distin-guish between telehealth and telemedicine; instead we used the term telehealth to address both telehealth and telemedicine.1 This broad definition of telehealth encompasses several modes of delivery, such as videoconferencing, mobile applications and secure messaging. WHO recognises several branches of tele-medicine: teleradiology, teledermatology, telepathology and telepsychology.1 With the increased use of technology in healthcare, there has been a great emphasis on telehealth
Telehealth and patient satisfaction: a systematic review and narrative analysis
Clemens Scott Kruse, Nicole Krowski, Blanca Rodriguez, Lan Tran, Jackeline Vela, Matthew Brooks
To cite: Kruse CS, Krowski N, Rodriguez B, et al. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242
► Prepublication history and additional material for this paper are available online. To view these files please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2017- 016242).
Received 2 February 2017Revised 23 June 2017Accepted 23 June 2017
Texas State University, San Marcos, Texas, USA
correspondence toDr Clemens Scott Kruse; scottkruse@ txstate. edu, scottkruse@ sbcglobal. net
Research
strengths and limitations of this study
► Inserting technology into a medical intervention should not be without deliberate design. This review serves as a voice of the patient to help guard against the implementation of technology merely for its convenience or shiny appeal.
► This study uses the Preferred Reporting Items for Systematic Reviews and Meta Analysis standard, which is an internationally recognised protocol for the conduct and reporting of systematic reviews that increases the validity of the results.
► A group >30 selected from Medical Subject Headings key terms indexed through established research databases increases the reliability of the review.
► Published studies do not often clearly set out reasons for inserting technology into an intervention, and therefore, it is not clear whether the patient satisfaction observed was congruent with the change of intervention.
► Telehealth, in general, is a relatively new topic in medicine (since the 1990s) so inferences that result from studies are difficult to compare to older, more traditional interventions.
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Open Access
because it can extend the services of providers to remote locations and capitalise on the availability of subject matter experts and overcome the barrier of proximity. Telehealth extends access, and it has the potential of making healthcare services more convenient for patients, especially those in rural areas, those with small children (child care) and those with mobility restrictions.2 3
Patient satisfaction is a growing concern in all aspects of healthcare, and as the voice of the customer, it is a measure of quality that is published in the USA through its Healthcare Effectiveness Data and Information Set, and it can be tied to reimbursements from the Center for Medi-care and Medicaid through results of Hospital Consumer Assessment of Healthcare Providers and Systems. As with traditional modalities of healthcare delivery, telehealth relies heavily on reports of patient satisfaction because the patients are the only source of information that can report how they were treated and if the treatment received met the patients’ expectations of care.4 5 If the patients are not happy with their healthcare services being provided remotely, the service becomes redundant and expen-sive. With the increase in prevalence of telehealth, it is important to maintain the key quality indicator of patient satisfaction regardless of modality of delivery. The voice of the customer needs to be continuously heard so that telehealth developers can exercise agility in the develop-ment process while the healthcare organisation continues to develop more technology-based care that meets the needs of patients and providers. The technology base inherent to telehealth dramatically changes the mode of delivery, but a strong patient-to-provider relationship must be maintained independent of the modality. A defi-nition of patient satisfaction, effectiveness and efficiency is provided at the end of the article.
ObjectiveWe had multiple research questions. R1: Is there an asso-ciation of telehealth with patient satisfaction? R2: Are there common facilitators of either efficiency or effec-tiveness mentioned in the literature that would provide a positive or negative association between telehealth and patient satisfaction?
MethOdsInformation sources, search and study selectionThe two sources of data were the Cumulative Index of Nursing and Allied Health Literature (CINAHL) via EBSCOhost and PubMed (MEDLINE). We used the Preferred Reporting Items for Systematic Reviews and Meta Analysis as our basis of organisation.6 We used a variety of key search terms, as listed in the Medical Subject Headings combined with Boolean operators. Search terms were adapted for use in the different databases. Details for each database are provided as onlinesupple-mentary file 1.
Inclusion criteria were 2010–2017, English only, full text available and human research. We also filtered for all
but academic publications (peer-reviewed in CINAHL) and in CINAHL we excluded MEDLINE to eliminate the duplicates already captured in PubMed. Instead of including reviews in the analysis, two reviews on a similar topic were earmarked for later comparison with our own results. Abstracts were reviewed for suitability based on our research concept that included both telehealth and some assessment of patient satisfaction.
data collection processA flow chart of our data collection process is located as online.supplementary material. Before reviewing abstracts for suitability to our objective, we agreed to look for articles that included telehealth and some measure of patient satisfaction. Articles were assessed according to the inclusion and exclusion criteria described above. Discussion sessions and consensus meetings were held to increase the inter-rater reliability of the group as they conducted the screening and analysis. During the consensus meetings, factors and themes were identified through observation and discussion; for example, as we discussed the articles, it became evident that patient satisfaction was often stated in terms of effectiveness and efficiency, so these became the themes.
Standard systematic review procedures were followed to control for selection bias and ensure our search was exhaustive.
Reviewers compiled their notes on patient satisfaction, effectiveness and efficiency in a literature matrix. Another consensus meeting was conducted to discuss findings and make inferences. During the consensus meeting, indi-vidual observations were discussed and combined into similar groupings throughout the sample to simplify our assessment of associations. This is a form of narrative analysis and sensemaking.7 Observations of effectiveness and efficiency were combined and sorted into an affinity matrix for final analysis.
data items and summary measuresOur litmus test was to include articles that included a combination of telehealth and patient satisfaction, and a measure or assessment of effectiveness or efficiency. We eliminated those that fell short of those goals.
risk of bias in individual studies and risk of bias across studiesBias was discussed during consensus meetings. The consensus meetings served as a control on our own selec-tion bias and selective reporting within studies.
summary measures and synthesis of resultsOur review examines articles that combine telehealth intervention with patient satisfaction and include some mention of effectiveness or efficiency. A physical count of these observations was made. After all observations were combined into an Excel file, and after all observations were condensed into themes of effectiveness or efficiency, all themes were displayed in an affinity matrix to identify the number of occurrences of each theme. These were sorted by frequency.
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3Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242
Open Access
Figure 1 Literature search process with inclusion and exclusion criteria. CINAHL, Cumulative Index of Nursing and Allied Health Literature.
resultsStudy selection, study characteristics and results of individual studiesOur search process is illustrated in figure 1.
After the initial search yielded 2193 results, 193 under-went abstract and then full-text review resulting in 44 papers being included in the study.
Table 1 lists a summary of our analysis and observa-tions from our team (n=44). For every article/study in the sample, we made observations for satisfied, which was a screening criteria, and effective and efficient. Studies are listed in order of publication with the most recent at the top. The reference numbers correspond to those in the references section.
synthesis of resultsWe analysed the way 44 articles reported patient satis-faction.8–51 In tota, 248 9 11 13 15–18 21–25 27–29 32 33 35 38 40 44
45 47 studies reported patient views on effectiveness, 610 12 14 30 41 51 studies reported patient satisfaction and
1419 20 26 31 34 36 37 39 42 43 46 48–50 studies reported both. The third column lists comments and details that could point to selection bias. Potential risk of bias among papers included no randomisation,12 small sample size,11 13 18 21 23
25 28 33 35 36 41 48 50 limited population,15 20 27 29 31 45–47 gender bias,19 20 23 38 47 technology bias,18 23 44 50 selection bias,24 32 38 geographically limited,8 9 12 14 16 17 34 37 43 age bias,20 29 30 38 44
51 education bias30 38 and racial bias.44 51
Additional analysisTable 2 outlines the frequency with which different factors were raised among the included paper. Through a narrative analysis we identified commonalities among the various studies (19 factors) and compiled them into an affinity matrix to show frequency of occurrence. The matrix is sorted by frequency of occurrence.
We acknowledge that frequency of occurrence does not equate to importance, but it has been used in other literature reviews as simply an issue of probability.52–54 Five factors were mentioned in the literature 65/119
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Open Access
Tab
le 1
C
omp
ilatio
n of
ob
serv
atio
ns fo
r ou
r sa
mp
le
Dat
eA
utho
rT
itle
Jour
nal
Sum
mar
y/re
leva
nce
Tech
nolo
gy
used
Po
tent
ial b
ias,
sam
ple
siz
e,
mis
cella
neo
us c
om
men
ts
Ap
ril 2
017
Sch
ulz-
Hei
k et
al8
Res
ults
from
a c
linic
al y
oga
pro
gram
for
vete
rans
via
tel
ehea
lth
pro
vid
es c
omp
arab
le s
atis
fact
ion
and
hea
lth im
pro
vem
ents
to
in-
per
son
yoga
.
BM
C C
omp
lem
ent
Alte
rn M
edC
linic
al y
oga
with
US
Vet
eran
s A
ffairs
p
opul
atio
nV
ideo
conf
eren
cing
VA p
opul
atio
n in
Pal
o A
lto
only
(geo
grap
hica
lly li
mite
d),
acce
pta
ble
sam
ple
siz
e (n
=29
con
trol
, n=
30 in
terv
entio
n)
Janu
ary
2016
Iqb
al e
t al
9C
ost
effe
ctiv
enes
s of
a n
ovel
at
tem
pt
to r
educ
e re
adm
issi
on
afte
r ile
osto
my
crea
tion
JSLS
Pat
ient
sat
isfa
ctio
n: s
atis
fact
ion
scor
ed 4
.69
out
of 5
Effe
ctiv
e: h
osp
ital r
ead
mis
sion
rat
es
dec
reas
ed $
63 8
21 (7
1%) (
p=
0.00
2)
Tele
pho
ne c
all (
dai
ly)
for
3 w
eeks
aft
er
dis
char
ge
Lim
ited
to
one
area
of t
he c
ount
ry
and
ben
efici
arie
s to
Uni
vers
ity
of F
lorid
a he
alth
sys
tem
(g
eogr
aphi
cally
lim
ited
), go
od
sam
ple
siz
e (n
=23
pre
inte
rven
tion,
n=
32 p
ostin
terv
entio
n)
May
201
6M
ulle
r et
al10
Acc
epta
bili
ty, f
easi
bili
ty, a
nd c
ost
of t
elem
edic
ine
for
nona
cute
he
adac
hes:
a r
and
omiz
ed s
tud
y co
mp
arin
g vi
deo
and
tra
diti
onal
co
nsul
tatio
ns
J M
ed In
tern
et R
esU
sed
tel
ehea
lth t
o d
iagn
ose
and
tre
at n
on-
acut
e he
adac
hes
Sat
isfa
ctio
n: p
atie
nts
satis
fied
with
vid
eo a
nd
soun
d q
ualit
yE
ffici
ent:
med
ian
trav
el d
ista
nce
for
rura
l p
atie
nts
was
7.8
hou
rs, c
ost
€249
, los
t in
com
e €2
34 p
er v
isit
(sav
ed)
Effe
ctiv
e: in
terv
entio
n gr
oup
's c
onsu
ltatio
ns
wer
e sh
orte
r th
an c
ontr
ol g
roup
Vid
eoco
nfer
enci
ngN
on-a
cute
hea
dac
he
pat
ient
s fr
om N
orth
ern
Nor
way
, st
rong
sam
ple
siz
e (n
=20
0),
par
ticip
ants
ran
dom
ised
Ap
ril 2
016
Dia
s et
al11
Voic
e te
lere
hab
ilita
tion
in
Par
kins
on's
dis
ease
Cod
asS
atis
fact
ion:
rep
orte
d a
s hi
gh E
ffect
ive:
pre
fere
nce
for
tele
heal
th in
terv
entio
nV
ideo
conf
eren
ce a
nd
tele
pho
ne85
% m
ale
(gen
der
bia
s),
vid
eoco
nfer
enci
ng m
imic
ked
th
e fa
ce-t
o-fa
ce r
ehab
ilita
tion
for
Par
kins
on’s
pat
ient
s, s
mal
l sa
mp
le s
ize
(n=
20)
Nov
emb
er 2
016
Lang
abee
r et
al12
Tele
heal
th-e
nab
led
em
erge
ncy
med
ical
ser
vice
s p
rogr
am r
educ
es
amb
ulan
ce t
rans
por
t to
urb
an
emer
genc
y d
epar
tmen
ts
Wes
t J
Em
erg
Med
Sat
isfa
ctio
n: n
o d
ecre
ase
Effi
cien
t: 5
6% r
educ
tion
in a
mb
ulan
ce
tran
spor
ts a
nd 5
3% d
ecre
ase
in r
esp
onse
tim
e fo
r th
e in
terv
entio
n gr
oup
tha
n th
e co
ntro
l
Tele
pho
neLi
mite
d t
o p
atie
nts
regi
onal
to
Hou
ston
, Tex
as (g
eogr
aphi
cally
lim
ited
), no
ran
dom
isat
ion,
str
ong
sam
ple
siz
e (n
=55
70)
2016
Hoa
as e
t al
13A
dhe
renc
e an
d fa
ctor
s af
fect
ing
satis
fact
ion
in lo
ng-t
erm
te
lere
hab
ilita
tion
for
pat
ient
s w
ith
chro
nic
obst
ruct
ive
pul
mon
ary
dis
ease
: a m
ixed
met
hod
s st
udy
BM
C M
edic
al
Info
rmat
ics
and
D
ecis
ion
Mak
ing
Sat
isfa
ctio
n: g
ener
ally
hig
hly
satis
fied
Effe
ctiv
e: in
crea
sed
hea
lth b
enefi
ts, s
elf-
effic
acy,
ind
epen
den
ce, e
mot
iona
l saf
ety
and
m
aint
enan
ce o
f mot
ivat
ion
Web
pag
e fo
r d
aily
te
lem
onito
ring
and
sel
f-ca
re a
nd
wee
kly
follo
w-u
p
vid
eoco
nfer
ence
co
nsul
ts w
ith a
p
hysi
othe
rap
ist
Rem
ote
pop
ulat
ion
of n
orth
ern
Nor
way
, sm
all s
amp
le s
ize
(n=
10)
2016
Jaco
bs
et a
l14P
atie
ntsa
tisfa
ctio
n w
ith a
te
lera
dio
logy
ser
vice
in g
ener
al
pra
ctic
e
BM
C F
amily
Pra
ctic
eS
atis
fact
ion:
isla
nd r
esid
ents
, the
eld
erly
and
th
ose
with
no
hist
ory
of t
raum
a w
ere
mor
e sa
tisfie
d w
ith t
he t
echn
ical
and
inte
rper
sona
l as
pec
ts o
f the
tel
econ
sulta
tion
than
non
-re
sid
ents
, you
nger
pat
ient
s an
d t
hose
with
hi
stor
y of
tra
uma
Tele
rad
iolo
gyR
estr
icte
d t
o ru
ral h
ealth
and
N
ethe
rland
s (g
eogr
aphi
cally
lim
ited
), st
rong
sam
ple
(n=
381)
Feb
ruar
y 20
17B
rad
bur
y et
al15
Util
izin
g re
mot
e re
al-t
ime
vid
eoco
nfer
enci
ng t
o ex
pan
d
acce
ss t
o ca
ncer
gen
etic
ser
vice
s in
com
mun
ity p
ract
ices
: A
mul
ticen
ter
feas
ibili
ty s
tud
y
Jour
nal o
f Med
ical
In
tern
et R
esea
rch
Sat
isfa
ctio
n: a
ll p
atie
nts
rep
orte
d s
atis
fact
ion
and
kno
wle
dge
incr
ease
d s
igni
fican
tlyE
ffect
ive:
gen
eral
anx
iety
and
dep
ress
ion
dec
reas
ed
Vid
eoco
nfer
enci
ngR
estr
icte
d t
o P
hila
del
phi
a,
Pen
nsyl
vani
a (g
eogr
aphi
cally
lim
ited
), go
od s
amp
le s
ize
(n=
41)
Con
tinue
d
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Open Access
Dat
eA
utho
rT
itle
Jour
nal
Sum
mar
y/re
leva
nce
Tech
nolo
gy
used
Po
tent
ial b
ias,
sam
ple
siz
e,
mis
cella
neo
us c
om
men
ts
Janu
ary
2016
AlA
zab
and
K
had
er16
Tele
nep
hrol
ogy
app
licat
ion
in
rura
l and
rem
ote
area
s of
Jor
dan
: b
enefi
ts a
nd im
pac
t on
qua
lity
of li
fe
Rur
al a
nd R
emot
e H
ealth
Sat
isfa
ctio
n: p
atie
nt s
atis
fact
ion
mea
n=96
.8E
ffect
ive:
mea
n S
F8 s
core
incr
ease
d
sign
ifica
ntly
(phy
sica
l com
pon
ents
of q
ualit
y of
life
)
Ele
ctro
nic
mon
itorin
g an
d t
elep
hone
cal
lsR
ural
hea
lth (g
eogr
aphi
cally
lim
ited
), st
rong
sam
ple
siz
e (n
=64
)
Mar
ch 2
016
Fiel
ds
et a
l17R
emot
e am
bul
ator
y m
anag
emen
t of
vet
eran
s w
ith o
bst
ruct
ive
slee
p
apne
a
Sle
epS
atis
fact
ion:
no
diff
eren
ce in
func
tiona
l ou
tcom
es, p
atie
nt s
atis
fact
ion,
dro
pou
t ra
tes
or
obje
ctiv
ely
mea
sure
d P
AP
ad
here
nce
Effe
ctiv
e: t
elem
edic
ine
par
ticip
ants
sho
wed
gr
eate
r im
pro
vem
ent
in m
enta
l hea
lth s
core
s an
d t
heir
feed
bac
k w
as p
ositi
ve
Tele
mon
itorin
g an
d
tele
pho
ne fo
llow
-up
ca
lls
Res
tric
ted
to
vete
rans
in t
he
Phi
lad
elp
hia
area
(geo
grap
hica
lly
limite
d),
good
sam
ple
siz
e (n
=60
)
Janu
ary
2016
Geo
rgss
on a
nd
Sta
gger
s18Q
uant
ifyin
g us
abili
ty: a
n ev
alua
tion
of a
dia
bet
es m
Hea
lth s
yste
m
on e
ffect
iven
ess,
effi
cien
cy,
and
sat
isfa
ctio
n m
etric
s w
ith
asso
ciat
ion
user
cha
ract
eris
tics
in
the
US
and
Sw
eden
Jour
nal o
f the
A
mer
ican
Med
ical
In
form
atic
s A
ssoc
iatio
n
Sat
isfa
ctio
n: g
ood
Effe
ctiv
e: g
ood
but
not
exc
elle
nt u
sab
ility
mH
ealth
ap
plic
atio
nYo
unge
r p
atie
nts
with
mor
e ex
per
ienc
e w
ith in
form
atio
n te
chno
logy
sco
red
hig
her
than
ot
hers
(age
and
tec
hnol
ogy
bia
s),
smal
l sam
ple
siz
e (n
=10
)
Mar
ch 2
016
Pol
insk
i et
al19
Pat
ient
s' s
atis
fact
ion
with
and
p
refe
renc
e fo
r te
lehe
alth
vis
itsJo
urna
l of G
ener
al
Inte
rnal
Med
icin
eS
atis
fact
ion:
33%
pre
ferr
ed t
eleh
ealth
vis
its t
o tr
aditi
onal
in-p
erso
n vi
sits
; wom
en p
refe
rred
te
lehe
alth
vis
itsE
ffici
ent:
tel
ehea
lth in
crea
sed
acc
ess
to c
are.
La
ck o
f ins
uran
ce in
crea
sed
od
ds
of p
refe
rrin
g te
lehe
alth
Effi
cien
t: o
ther
pos
itive
pre
dic
tors
wer
e q
ualit
y of
car
e re
ceiv
ed, t
eleh
ealth
con
veni
ence
an
d u
nder
stan
din
g of
tel
ehea
lth
Vid
eoco
nfer
enci
ng
at M
inut
e C
linic
s w
ith d
iagn
ostic
too
ls
oper
ated
by
a nu
rse
70%
wom
en (g
end
er b
ias)
, tes
t w
as c
ond
ucte
d in
Cal
iforn
ia a
nd
Texa
s (c
onve
nien
ce s
amp
le),
stro
ng s
amp
le (n
=17
34)
2015
Levy
et
al20
Effe
cts
of p
hysi
cal t
hera
py
del
iver
y vi
a ho
me
vid
eo
tele
reha
bili
tatio
n on
func
tiona
l an
d h
ealth
-rel
ated
qua
lity
of li
fe
outc
omes
Jour
nal o
f R
ehab
ilita
tion
Res
earc
h an
d
Dev
elop
men
t
Sat
isfie
d: a
ll b
ut o
ne p
artic
ipan
t re
por
ted
sa
tisfie
d o
r hi
ghly
sat
isfie
dE
ffect
ive:
par
ticip
ants
dem
onst
rate
d s
igni
fican
t im
pro
vem
ent
in m
ost
outc
omes
mea
sure
sE
ffici
ent:
par
ticip
ants
avo
ided
2,7
74.7
=/–
31
97.4
tra
vel m
iles,
46.
3±53
.3 h
ours
or
driv
ing
time,
and
$11
51.5
0 ±
$13
26.9
0 in
tra
vel
reim
bur
sem
ent
Vid
eoco
nfer
enci
ngC
onve
nien
ce s
amp
le, 9
2% m
ale
(gen
der
bia
s), 6
9% >
64 y
ears
(age
b
ias)
, US
Vet
eran
s on
ly, s
mal
l sa
mp
le (n
=26
)
2014
Hol
mes
and
C
lark
21Te
chno
logy
-ena
ble
d c
are
serv
ices
: no
vel m
etho
d o
f man
agin
g liv
er
dis
ease
Gas
troi
ntes
tinal
N
ursi
ngS
atis
fied
: hig
h, p
atie
nts
liked
the
sel
f-m
anag
e as
pec
tE
ffect
ive:
par
ticip
ants
lost
wei
ght,
out
com
es
imp
rove
d, r
ead
mis
sion
s d
ecre
ased
from
12
to 4
E
ffici
ent:
ave
rage
cos
t p
er p
atie
nt 6
8.86
Brit
ish
pou
nds
Rem
ote
mon
itorin
g an
d t
ext
mes
sagi
ngS
mal
l sam
ple
siz
e (n
=12
)
2015
Levy
et
al22
The
Mob
ile In
sulin
Titr
atio
n In
terv
entio
n (M
ITI)
for
insu
lin
glar
gine
titr
atio
n in
an
urb
an,
low
-inc
ome
pop
ulat
ion:
ra
ndom
ized
con
trol
led
tria
l p
roto
col
JMIR
Res
earc
h P
roto
cols
Hig
hly
satis
fied
: pat
ient
sin
the
inte
rven
tion
grou
p r
epor
ted
hig
her
leve
ls o
f sat
isfa
ctio
nE
ffect
ive:
sig
nific
antly
mor
e in
the
inte
rven
tion
grou
p h
ad r
each
ed t
heir
optim
al in
sulin
leve
ls
Mob
ile In
sulin
Titr
atio
n In
terv
entio
nTr
ue e
xper
imen
t (r
and
omis
ed,
good
sam
plin
g te
chni
que
)
Tab
le 1
C
ontin
ued
Con
tinue
d
on March 14, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016242 on 3 A
ugust 2017. Dow
nloaded from
6 Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242
Open Access
Dat
eA
utho
rT
itle
Jour
nal
Sum
mar
y/re
leva
nce
Tech
nolo
gy
used
Po
tent
ial b
ias,
sam
ple
siz
e,
mis
cella
neo
us c
om
men
ts
2015
Moi
n et
al23
Wom
en v
eter
ans’
exp
erie
nce
with
a
web
-bas
ed d
iab
etes
pre
vent
ion
pro
gram
: a q
ualit
ativ
e st
udy
to
info
rm fu
ture
pra
ctic
e
Jour
nal o
f Med
ical
In
tern
et R
esea
rch
Effe
ctiv
e: im
pro
ved
beh
avio
ural
out
com
es,
mor
e ap
pro
pria
te fo
r w
omen
Sat
isfie
d: p
artic
ipan
ts fe
lt em
pow
ered
and
ac
coun
tab
le, t
hey
felt
it w
as c
onve
nien
t an
d a
go
od fi
t w
ith t
heir
heal
th n
eed
s an
d li
fest
yle
Web
-bas
edW
omen
vet
eran
s, c
omp
uter
lit
erac
y w
as a
n is
sue
for
som
e (g
end
er b
ias)
, sm
all s
amp
le s
ize
(n=
17)
2015
Cot
rell
et a
l24P
atie
nt a
nd p
rofe
ssio
nal u
ser
exp
erie
nces
of s
imp
le t
eleh
ealth
fo
r hy
per
tens
ion,
med
icat
ion
rem
ind
ers
and
sm
okin
g ce
ssat
ion:
a
serv
ice
eval
uatio
n
BM
J O
pen
Sat
isfie
d: p
ositi
ve p
atie
nt s
atis
fact
ion
ind
icat
ors
Effe
ctiv
e: im
pro
vem
ents
wer
e m
ade
over
Fl
oren
ce, a
nd u
sers
too
k an
act
ive
app
roac
h to
ac
hiev
e th
eir
goal
s, p
atie
nts
felt
emp
ower
ed
Tele
mon
itorin
g an
d
med
icat
ion
rem
ind
ers
Sat
isfa
ctio
n w
ith t
he s
ervi
ce
app
eare
d o
ptim
al w
hen
pat
ient
s w
ere
care
fully
sel
ecte
d
(sel
ectio
n b
ias)
, str
ong
sam
ple
(n
=17
07)
2014
Tab
ak e
t al
25A
tel
ehea
lth p
rogr
am fo
r se
lf-m
anag
emen
t of
CO
PD
ex
acer
bat
ions
and
pro
mot
ion
of a
n ac
tive
lifes
tyle
: a p
ilot
rand
omiz
ed c
ontr
olle
d t
rial
Inte
rnat
iona
l Jou
rnal
of
Chr
onic
Ob
stru
ctiv
e P
ulm
onar
y D
isea
se
Sat
isfie
d: s
atis
fact
ion
was
hig
her
with
the
co
ntro
l gro
up t
han
the
tele
heal
th g
roup
Effe
ctiv
e: b
ette
r cl
inic
al m
easu
res
in t
he
tele
heal
th g
roup
Web
-bas
ed a
nd
smar
tpho
ne
app
licat
ion
with
an
activ
ity c
oach
Str
ong
stud
y d
esig
n, s
mal
l sa
mp
le s
ize
(n=
19)
2014
Kim
et
al26
Cos
ts o
f mul
tidis
cip
linar
y p
aren
tera
l nut
ritio
n ca
re p
rovi
ded
at
a d
ista
nce
via
mob
ile t
able
ts
Jour
nal o
f Par
ente
ral
and
Ent
eral
Nut
ritio
nS
atis
fied
: eas
y to
use
, ver
y co
nven
ient
Effe
ctiv
e: o
utco
mes
sim
ilar
to in
-clin
ic v
isits
Effi
cien
t: c
ost
$916
.64
per
pat
ient
Tele
pho
ne w
ith
sem
istr
uctu
red
in
terv
iew
s
Goo
d s
amp
le s
ize
(n=
20 v
isits
for
45 p
atie
nts)
2014
Can
cela
et
al27
Wea
rab
ility
ass
essm
ent
of a
w
eara
ble
sys
tem
for
Par
kins
on's
d
isea
se r
emot
e m
onito
ring
bas
ed
on a
bod
y ar
ea n
etw
orko
f sen
sors
Sen
sors
Sat
isfie
d: o
vera
ll sa
tisfa
ctio
n hi
gh, b
ut s
ome
conc
ern
over
pub
lic p
erce
ptio
ns a
bou
t th
e w
eara
ble
sen
sors
Effe
ctiv
e: fo
r re
mot
e m
onito
ring,
wea
rab
le
syst
ems
are
high
ly e
ffect
ive
Rem
ote
mon
itorin
g b
ased
on
a b
ody
area
ne
twor
kof s
enso
rs
An
exte
nsio
n of
the
Bod
y A
rea
Net
wor
k se
nsor
s (li
mite
d
pop
ulat
ion)
, goo
d s
amp
le s
ize
(n=
32)
2014
Cas
ey e
t al
28P
atie
nts'
exp
erie
nces
of u
sing
a
smar
tpho
ne a
pp
licat
ion
to
incr
ease
phy
sica
l act
ivity
: the
S
MA
RT
MO
VE
qua
litat
ive
stud
y in
p
rimar
y ca
re
Br
J G
en P
ract
Sat
isfie
d: g
ood
usa
bili
tyE
ffect
ive:
tra
nsfo
rmed
rel
atio
nshi
ps
with
ex
erci
se
Sm
artp
hone
ap
plic
atio
nS
mal
l sam
ple
siz
e (n
=12
)
Janu
ary
2014
Tsai
et
al29
Influ
ence
s of
sat
isfa
ctio
n w
ith
tele
care
and
fam
ily t
rust
in o
lder
Ta
iwan
ese
peo
ple
Inte
rnat
iona
l Jou
rnal
of
Env
ironm
enta
l R
esea
rch
and
Pub
lic
Hea
lth
Sat
isfie
d: u
ser
satis
fact
ion
very
hig
h E
ffect
ive:
use
r p
erce
ptio
n of
hig
h q
ualit
yTe
lem
onito
ring,
web
-b
ased
, tel
epho
neFo
cus
was
on
old
er u
sers
and
th
eir
fam
ilies
, con
veni
ence
sa
mp
le, g
ood
siz
e (n
=60
)
2014
Oliv
eira
et
al30
Tele
med
icin
e in
Ale
ntej
oTe
lem
edic
ine
and
e-
Hea
lthS
atis
fied
: pos
itive
imp
act
on p
atie
nt e
xper
ienc
eE
ffici
ent:
ave
rage
tim
e an
d c
ost
of a
tel
e-ap
poi
ntm
ent
is 9
3 m
in fo
r te
leco
nsul
tatio
n an
d
9.31
pou
nds
vers
us 1
90 m
in a
nd 2
5.32
pou
nds
for
a fa
ce-t
o-fa
ce
Tele
pho
neP
artic
ipan
ts a
re o
lder
and
less
ed
ucat
ed t
han
the
rest
of t
he
pop
ulat
ion
of P
ortu
gal (
age
and
ed
ucat
ion
bia
s)
2013
Min
atod
ani e
t al
31H
ome
tele
heal
th: f
acili
tato
rs,
bar
riers
, and
imp
act
of n
urse
su
pp
ort
amon
g hi
gh-r
isk
dia
lysi
s p
atie
nts
Tele
med
icin
e an
d
e-H
ealth
Sat
isfa
ctio
n: p
atie
nts
rep
orte
d h
igh
leve
ls o
f sa
tisfa
ctio
n w
ith R
CN
sup
por
t b
ecau
se o
f th
e fe
edb
ack
on id
entifi
catio
n of
cha
nges
in
thei
r he
alth
sta
tus,
enh
ance
d a
ccou
ntab
ility
, se
lf-ef
ficac
y an
d m
otiv
atio
n to
mak
e he
alth
b
ehav
iour
chan
ges
Effe
ctiv
e: t
hrou
gh t
eleh
ealth
, gre
ater
sel
f-aw
aren
ess,
sel
f-ef
ficac
y an
d a
ccou
ntab
ility
E
ffici
ent:
feed
bac
k w
as m
ore
effic
ient
Tele
mon
itorin
g w
ith
nurs
e su
pp
ort
Lim
ited
pop
ulat
ion,
goo
d s
amp
le
size
(n=
33)
Tab
le 1
C
ontin
ued
Con
tinue
d
on March 14, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016242 on 3 A
ugust 2017. Dow
nloaded from
7Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242
Open Access
Dat
eA
utho
rT
itle
Jour
nal
Sum
mar
y/re
leva
nce
Tech
nolo
gy
used
Po
tent
ial b
ias,
sam
ple
siz
e,
mis
cella
neo
us c
om
men
ts
2013
Akt
er e
t al
32M
odel
ling
the
imp
act
of m
Hea
lth
serv
ice
qua
lity
on s
atis
fact
ion,
co
ntin
uanc
e an
d q
ualit
y of
life
Beh
avio
ur &
In
form
atio
n Te
chno
logy
Sat
isfie
d: s
atis
fact
ion
is r
elat
ed t
o se
rvic
e q
ualit
y, c
ontin
uanc
e in
tent
ions
and
qua
lity
of li
fe
Effe
ctiv
e: m
Hea
lth s
houl
d d
eliv
er h
ighe
r-or
der
, so
ciet
al o
utco
mes
Sm
artp
hone
ap
plic
atio
nS
elec
tion
bia
s
2014
Hun
g et
al33
Pat
ient
sat
isfa
ctio
n w
ith n
utrit
ion
serv
ices
am
ongs
t ca
ncer
p
atie
nts
trea
ted
with
aut
olog
ous
stem
cel
l tra
nsp
lant
atio
n:
a co
mp
aris
on o
f usu
al a
nd
exte
nded
car
e
Jour
nal o
f Hum
an
Nut
ritio
n an
d D
iete
tics
Sat
isfie
d: h
ighe
r us
e w
as in
dic
ativ
e of
hig
her
satis
fact
ion
Effe
ctiv
e: h
ighe
r us
e w
as c
linic
ally
imp
orta
nt t
o ou
tcom
es
Tele
pho
neS
mal
l sam
ple
siz
e (n
=18
)
Dec
emb
er 2
015
Bui
s et
al34
Use
of a
tex
t m
essa
ge
pro
gram
to
rais
e ty
pe
2 d
iab
etes
ris
k aw
aren
ess
and
pro
mot
e he
alth
beh
avio
r ch
ange
(par
t II)
: ass
essm
ent
of p
artic
ipan
ts'
per
cep
tions
on
effic
acy
Jour
nal o
f Med
ical
In
tern
et R
esea
rch
Sat
isfie
d: 6
7.1%
rep
orte
d v
ery
high
sat
isfa
ctio
nE
ffect
ive:
txt
4hea
lth m
essa
ges
wer
e cl
ear,
incr
ease
d d
isea
se li
tera
cy a
nd m
ore
cons
ciou
s of
die
t an
d e
xerc
ise
Effi
cien
t: lo
w p
artic
ipan
t co
sts
Text
mes
sagi
ngM
ichi
gan
and
Cin
cinn
ati o
nly
(geo
grap
hica
lly li
mite
d),
stro
ng
sam
ple
(n=
159)
2013
Hou
ser
et a
l35Te
lep
hone
follo
w-u
p in
prim
ary
care
: can
inte
ract
ive
voic
e re
spon
seca
lls w
ork
Stu
die
s in
Hea
lth
Tech
nolo
gy a
nd
Info
rmat
ics
Sat
isfie
d: s
tron
g sa
tisfa
ctio
n re
por
ted
for
the
inte
ract
ive
voic
e re
spon
se s
yste
m, I
VR
SE
ffect
ive:
pat
ient
s fe
lt in
form
ed
Tele
pho
neS
mal
l sam
ple
of t
hose
who
re
ceiv
ed t
he c
all I
VR
S, s
mal
l sa
mp
le s
ize
(n=
19)
2013
Kai
ry e
t al
36Th
e p
atie
nt's
per
spec
tive
of
in-h
ome
tele
reha
bili
tatio
n p
hysi
othe
rap
y se
rvic
es fo
llow
ing
tota
l kne
e ar
thro
pla
sty
Inte
rnat
iona
l Jou
rnal
of
Env
ironm
enta
l R
esea
rch
and
Pub
lic
Hea
lth
Sat
isfie
d: f
eelin
g an
ong
oing
sen
se o
f sup
por
t E
ffect
ive:
tai
lore
d c
halle
ngin
g p
rogr
amm
es
usin
g te
lere
hab
ilita
tion
Effi
cien
t: im
pro
ved
acc
ess
to s
ervi
ces
with
re
duc
ed n
eed
for
tran
spor
tatio
n, e
asy
to u
se
Vid
eoco
nfer
enci
ngC
onve
nien
ce s
amp
le, s
ingl
e ca
se,
smal
l sam
ple
siz
e (n
=6)
2013
Bis
hop
et
al37
Ele
ctro
nic
com
mun
icat
ion
imp
rove
s ac
cess
, but
bar
riers
to
its w
ides
pre
ad a
dop
tion
rem
ain
Hea
lth A
ffai
rsS
atis
fied
: eas
ier
acce
ss t
o an
d b
ette
r co
mm
unic
atio
n w
ith p
rovi
der
E
ffect
ive:
pat
ient
s w
ith r
epea
t is
sues
of a
co
nditi
on a
re a
ble
to
rese
t th
e tr
eatm
ent
for
the
mos
t re
cent
ep
isod
e E
ffici
ent:
it t
akes
ab
out
1 m
in p
er e
mai
l, an
d it
im
pro
ves
the
effic
ienc
y of
an
offic
e vi
sit
Em
ail a
nd
vid
eoco
nfer
enci
ngN
ew Y
ork
City
onl
y, s
tron
g re
sist
ance
to
chan
ge c
ited
(g
eogr
aphi
cally
lim
ited
), st
rong
sa
mp
le (n
=63
0)
2013
Pie
tta
et a
l38S
pan
ish-
spea
king
pat
ient
s'
enga
gem
ent
in in
tera
ctiv
e vo
ice
resp
onse
(IV
R) s
upp
ort
calls
for
chro
nic
dis
ease
sel
f-m
anag
emen
t:
dat
a fr
om t
hree
cou
ntrie
s
Jour
nal o
f Te
lem
edic
ine
and
Te
leca
re
Sat
isfie
d: 8
8% p
atie
nts
rep
orte
d ‘v
ery
satis
fied
’, 11
% ‘m
ostly
sat
isfie
d’
Effe
ctiv
e: 1
00%
pat
ient
s fe
lt th
e in
tera
ctiv
e vo
ice
resp
onse
: IV
R w
ere
help
ful,
77%
rep
orte
d
imp
rove
d d
iet,
80%
rep
orte
d im
pro
ved
sy
mp
tom
mon
itorin
g, 8
0% r
epor
ted
imp
rove
d
med
icat
ion
adhe
renc
e
Tele
pho
ne73
% w
omen
, ave
rage
6.1
yea
rs o
f ed
ucat
ion
(age
and
ed
ucat
ion
bia
s), s
tron
g sa
mp
le (n
=26
8)
2013
Gun
d e
t al
39A
ran
dom
ized
con
trol
led
stu
dy
abou
t th
e us
e of
eH
ealth
in t
he
hom
e he
alth
car
e of
pre
mat
ure
infa
nts
BM
C M
edic
al
Info
rmat
ics
and
D
ecis
ion
Mak
ing
Sat
isfie
d: p
aren
ts fe
lt th
at t
he S
kyp
e ca
lls
wer
e b
ette
r th
an r
egul
ar fo
llow
-up
, and
it o
ften
re
pla
ced
an
in-h
ome
visi
tE
ffect
ive:
sam
e or
bet
ter
outc
omes
bec
ause
the
p
aren
ts d
id n
ot h
ave
to b
ring
infa
nts
inE
ffici
ent:
Nur
ses
took
<10
min
of w
ork
time
dai
ly t
o an
swer
que
stio
ns
Vid
eoco
nfer
enci
ngR
and
omis
atio
n us
edS
emis
truc
ture
d in
terv
iew
s w
ere
only
use
d fo
r 16
fam
ilies
, sm
all
sam
ple
s (n
=13
, 12,
9)
Tab
le 1
C
ontin
ued
Con
tinue
d
on March 14, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016242 on 3 A
ugust 2017. Dow
nloaded from
8 Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242
Open Access
Dat
eA
utho
rT
itle
Jour
nal
Sum
mar
y/re
leva
nce
Tech
nolo
gy
used
Po
tent
ial b
ias,
sam
ple
siz
e,
mis
cella
neo
us c
om
men
ts
2013
ter
Huu
rne
et a
l40W
eb-b
ased
tre
atm
ent
pro
gram
usi
ng in
tens
ive
ther
apeu
tic c
onta
ct fo
r p
atie
nts
with
eat
ing
dis
ord
ers:
b
efor
e-af
ter
stud
y
Jour
nal o
f Med
ical
In
tern
et R
esea
rch
Sat
isfie
d: h
igh
satis
fact
ion
Effe
ctiv
e: s
igni
fican
t im
pro
vem
ents
in e
atin
g d
isor
der
psy
chop
atho
logy
, bod
y d
issa
tisfa
ctio
n,
qua
lity
of li
fe, a
nd p
hysi
cal a
nd m
enta
l hea
lth;
bod
y m
ass
ind
ex im
pro
ved
for
obes
ity g
roup
on
ly
Effi
cien
t: t
ask
com
ple
tion
rate
was
80%
for
the
youn
ger
grou
p a
nd 6
4.6%
for
the
old
er
grou
p
Web
-bas
edN
ot a
ll p
artic
ipan
ts r
epor
ted
the
sa
me
dia
gnos
es, s
tron
g p
re–p
ost
des
ign,
str
ong
sam
ple
(n=
89)
2012
Chu
n an
d
Pat
ters
on41
A u
sab
ility
gap
bet
wee
n ol
der
ad
ults
and
you
nger
ad
ults
on
inte
rfac
e d
esig
n of
an
Inte
rnet
-b
ased
tel
emed
icin
e sy
stem
Wor
kS
atis
fied
: on
a se
ven-
poi
nt s
cale
, sat
isfa
ctio
n sc
ores
wer
e 3.
41 y
oung
er a
nd 3
.54
old
er,
alth
ough
the
re w
as e
qua
l dis
satis
fact
ion
with
th
e d
esig
n of
the
sys
tem
Web
-bas
edS
mal
l sam
ple
siz
e (n
=16
)
2012
Lee
et a
l42Th
e V
ISY
TER
Tel
ereh
abili
tatio
n sy
stem
for
glob
aliz
ing
phy
sica
l th
erap
y co
nsul
tatio
n: is
sues
an
d c
halle
nges
for
tele
heal
th
imp
lem
enta
tion
Jour
nal o
f Phy
sica
l Th
erap
y E
duc
atio
nS
atis
fied
: rep
orte
d a
s hi
gh a
nd v
ery
high
Effe
ctiv
e: in
crea
ses
acce
ss w
here
pro
xim
ity is
an
issu
eE
ffici
ent:
link
s m
ultip
le p
rovi
der
s to
geth
er fo
r te
leco
nsul
tatio
n
Vid
eoco
nfer
enci
ngLi
mite
d s
cop
e fo
r co
nclu
sion
s,
pat
ient
s in
Mex
ico,
pro
vid
ers
in t
he U
SA
(cul
tura
l bia
s), s
mal
l sa
mp
le (n
=3)
2012
Sai
fu e
t al
43E
valu
atio
n of
hum
an
imm
unod
efici
ency
viru
s an
d
hep
atiti
s C
tel
emed
icin
e cl
inic
s
The
Am
eric
an J
ourn
al
of M
anag
ed C
are
Sat
isfie
d: 9
5% r
epor
ted
hig
hest
leve
l of
satis
fact
ion
Effe
ctiv
e: 9
5% r
epor
ted
a p
refe
renc
e fo
r te
lem
edic
ine
vers
us in
-per
son
visi
t E
ffici
ent:
rep
orte
d a
sig
nific
ant
red
uctio
n in
hea
lth v
isit-
rela
ted
tim
e, m
ostly
due
to
dec
reas
ed t
rave
l
Vid
eoco
nfer
enci
ngVe
tera
ns in
Los
Ang
eles
, C
alifo
rnia
, onl
y, c
onve
nien
ce
sam
ple
(geo
grap
hica
lly li
mite
d),
stro
ng s
amp
le (n
=43
)
2012
Lua
and
Nen
i44Fe
asib
ility
and
acc
epta
bili
ty o
f m
obile
ep
ilep
sy e
duc
atio
nal
syst
em (M
EE
S) f
or p
eop
le w
ith
epile
psy
in M
alay
sia
Tele
med
icin
e an
d
e-H
ealth
Sat
isfie
d: 7
4% r
epor
ted
ver
y or
qui
te u
sefu
l E
ffect
ive:
exc
elle
nt m
odal
ity fo
r ed
ucat
ion,
d
rug-
taki
ng r
emin
der
and
clin
ic a
pp
oint
men
t re
min
der
Text
mes
sagi
ngG
ood
mix
of g
end
ers,
hom
o-et
hnic
sam
ple
: 92.
2% M
alay
(r
acia
l bia
s), m
edia
n ag
e 25
(age
an
d t
echn
olog
y b
ias—
you
nger
m
ay a
lread
y b
e m
ore
rece
ptiv
e to
tec
hnol
ogy)
, goo
d s
ize
sam
ple
(n
=51
)
2012
Fink
elst
ein
et a
l45D
evel
opm
ent
of a
rem
ote
mon
itorin
g sa
tisfa
ctio
n su
rvey
and
its
use
in a
clin
ical
tria
l with
lung
tr
ansp
lant
rec
ipie
nts
Jour
nal o
f Te
lem
edic
ine
and
Te
leca
re
Sat
isfie
d: 9
0% o
f the
sub
ject
s w
ere
satis
fied
w
ith t
he h
ome
heal
th t
eleh
ealth
ser
vice
Effe
ctiv
e: fr
eque
ncy
of c
omm
unic
atio
n in
crea
sed
Rem
ote
mon
itorin
gLi
mite
d p
opul
atio
n
2011
Gib
son
et a
l46C
onve
rsat
ions
on
tele
men
tal
heal
th: l
iste
ning
to
rem
ote
and
ru
ral F
irst
Nat
ions
com
mun
ities
Rur
al a
nd R
emot
e H
ealth
Sat
isfie
d: 4
7% p
ositi
ve r
esp
onse
, 21%
neu
tral
, 32
% n
egat
ive
Effe
ctiv
e: in
crea
sed
com
fort
in t
he t
hera
peu
tic
situ
atio
n, in
crea
sed
use
fuln
ess
Effi
cien
t: in
crea
sed
acc
ess
to s
ervi
ces
Vid
eoco
nfer
enci
ngFi
rst-
natio
ns c
omm
uniti
es o
nly
(lim
ited
pop
ulat
ion)
, str
ong
sam
ple
(n=
59)
Tab
le 1
C
ontin
ued
Con
tinue
d
on March 14, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016242 on 3 A
ugust 2017. Dow
nloaded from
9Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242
Open Access
Dat
eA
utho
rT
itle
Jour
nal
Sum
mar
y/re
leva
nce
Tech
nolo
gy
used
Po
tent
ial b
ias,
sam
ple
siz
e,
mis
cella
neo
us c
om
men
ts
2010
Doo
renb
os e
t al
47S
atis
fact
ion
with
tel
ehea
lth fo
r ca
ncer
sup
por
t gr
oup
s in
rur
al
Am
eric
an In
dia
n an
d A
lask
a N
ativ
e co
mm
uniti
es
Clin
ical
Jou
rnal
of
Onc
olog
y N
ursi
ngS
atis
fied
: par
ticip
ants
rep
orte
d h
igh
leve
ls
of s
atis
fact
ion
with
sup
por
t gr
oup
s vi
a vi
deo
conf
eren
ceE
ffect
ive:
res
ults
of t
his
des
crip
tive
stud
y ar
e co
nsis
tent
with
oth
er r
esea
rch
that
sho
ws
the
need
for
sup
por
t gr
oup
s as
par
t of
ove
rall
ther
apy
for
canc
er s
urvi
vors
Voic
e te
leco
nfer
ence
fo
r gr
oup
mee
tings
All
par
ticip
ants
wer
e w
omen
(g
end
er b
ias)
, rur
al c
are
only
, p
artic
ipan
ts w
ere
mem
ber
s of
A
mer
ican
Ind
ian
or A
lask
an
Nat
ive
(lim
ited
pop
ulat
ion)
, str
ong
sam
ple
siz
e (n
=90
0)
2010
Bre
en e
t al
48Fo
rmat
ive
eval
uatio
n of
a
tele
med
icin
e m
odel
for
del
iver
ing
clin
ical
neu
rop
hysi
olog
y se
rvic
es
par
t II:
the
ref
errin
g cl
inic
ian
and
p
atie
nt p
ersp
ectiv
e
BM
C M
edic
al
Info
rmat
ics
and
D
ecis
ion
Mak
ing
Sat
isfie
d: t
elen
euro
phy
siol
ogy
imp
rove
d
satis
fact
ion
with
wai
ting
times
, ava
ilab
ility
of
resu
lts a
nd im
pac
t on
pat
ient
man
agem
ent
Effe
ctiv
e: t
elep
hysi
olog
y an
d c
ontr
ol g
roup
s w
ere
equa
lly a
s an
xiou
s ab
out
thei
r p
roce
dur
e,
tele
phy
siol
ogy
can
imp
rove
acc
ess
to C
N
serv
ices
and
exp
ert
opin
ion
Effi
cien
t: r
educ
ed t
rave
l bur
den
and
nee
d fo
r ov
erni
ght
jour
neys
Tele
neur
ophy
siol
ogy
whi
ch in
clud
ed a
n E
EG
Rem
ote-
rura
l pop
ulat
ion
of
Nor
ther
n Ire
land
, sm
all s
amp
le o
f p
hysi
cian
s (n
=9
phy
sici
ans,
116
p
atie
nts)
2010
Eve
rett
and
Ker
r49Te
lehe
alth
as
adju
nctiv
e th
erap
y in
insu
lin p
ump
tre
ated
pat
ient
s: a
p
ilot
stud
y
Pra
ctic
al D
iab
etes
In
tern
atio
nal
Sat
isfie
d: p
atie
nts
rep
orte
d m
ore
und
erst
and
ing,
insi
ght
and
con
trol
by
view
ing
dat
a an
d e
asy
acce
ss t
o he
alth
pro
fess
iona
lE
ffect
ive:
inte
rven
tion
grou
p d
emon
stra
ted
im
pro
ved
dia
bet
es c
ontr
olE
ffici
ent:
hea
lth p
rofe
ssio
nal t
ime
was
<
10 m
in e
ach
day
to
revi
ew d
ata
and
was
in
corp
orat
ed in
to c
urre
nt w
orkl
oad
Tele
mon
itorin
g an
d
text
mes
sagi
ngE
ach
user
’s h
ome
was
vis
ited
to
set
up
and
dem
onst
rate
the
sy
stem
(goo
d c
ontr
ol fo
r va
lidity
), sm
all s
amp
le (n
=16
)
2010
Gar
dne
r-B
onne
au50
Rem
ote
pat
ient
mon
itorin
g: a
hu
man
fact
ors
asse
ssm
ent
Hum
an F
acto
rs
Hor
izon
sS
atis
fied
: the
inte
rven
tion
dev
ice
was
intu
itive
to
use
Effe
ctiv
e: t
eleh
ealth
gro
up s
how
ed c
linic
al
imp
rove
men
tsE
ffici
ent:
eco
nom
ic a
naly
sis
show
ed s
avin
gs
in t
he C
OP
D t
elem
onito
ring
grou
p, s
oftw
are
issu
es c
ause
d m
any
inte
rven
tions
by
med
ical
st
aff w
hich
con
sum
ed t
ime
Rem
ote
mon
itorin
gM
edic
al li
tera
cy b
ecam
e an
issu
e w
hen
the
dev
ice
aske
d p
atie
nts
if th
eir
read
ings
wer
e no
rmal
, sm
all s
amp
le s
ize
(n=
27 c
ontr
ol,
n=19
inte
rven
tion)
2010
She
in e
t al
51P
atie
nt s
atis
fact
ion
with
Te
lere
hab
ilita
tion
asse
ssm
ents
for
whe
eled
mob
ility
and
sea
ting
Ass
istiv
e Te
chno
logy
Sat
isfie
d: h
ighe
r sa
tisfa
ctio
n w
ith
tele
reha
bili
tatio
n E
ffici
ent:
gre
at t
ime
savi
ngs
in t
rave
l
Vid
eoco
nfer
enci
ng89
.6%
Cau
casi
an, a
vera
ge a
ge
was
55,
(rac
ial a
nd a
ge b
ias)
, go
od s
amp
le (n
=32
)
CN
, Clin
ical
Neu
rop
hysi
olog
y; C
OP
D, C
hron
ic O
bst
ruct
ive
Pul
mon
ary
Dis
ease
; IV
RS
, Int
erac
tive
Voic
e R
esp
onse
Sys
tem
; PA
P, P
ositi
ve A
irway
s P
ress
ure;
RC
N, R
emot
e C
are
Nur
se; V
A, V
eter
ans
Affa
irs.
Tab
le 1
C
ontin
ued
on March 14, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016242 on 3 A
ugust 2017. Dow
nloaded from
10 Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242
Open Access
Table 2 Affinity matrix
Factor Article reference number Frequency
Improved outcomes 8 9 11 13 15–18 20–26 31–33 38–41 47 50 24
Preferred modality 8 9 11 14 15 19 22 26 34 43 44 46 12
Ease of use 18 19 23 26 28 36–38 46 49 50 11
Low cost or cost savings 10 14 16 20 21 23 26 34 50 9
Improved communication 24 27 31 36 37 39 42 45 49 9
Travel time 10 12 20 30 36 43 48 51 8
Improved self-management 13 21 23 28 31 32 48 7
Quality 16 19 29 32 40 5
Increased access 19 42 46 48 4
Increased self-awareness 31 34 35 38 4
Decreased wait times 16 43 48 49 4
Fewer miles driven 10 14 20 51 4
Decreased in-person visits 12 39 43 3
Improved self-efficacy 13 23 31 3
Good modality for education 15 34 44 3
Low time to manage 37 39 49 3
Improved medication adherence 13 38 44 3
Decreased readmissions 9 21 2
Fewer missed appointments 44 1
119
occurrences (55%): improved outcomes,8 9 11 13 15–18 20–26 31–33
38–41 47 50preferred modality,8 9 11 14 15 19 22 26 34 43 44 46 ease of use,18
19 23 26 28 36–38 46 49 50low cost or cost savings,10 14 16 20 21 23 26 34 50 and improved communication.24 27 31 36 37 39 42 45 49
dIscussIOnSummary of evidenceTelehealth has the potential to extend the boundaries of providers’ practices by overcoming the barrier of prox-imity. Along with the introduction of a new modality of care comes change, and the literature mentioned various reactions to this change. One study identified heavy resis-tance to change,29 37 while others mentioned an embrace of the change.29 48 Older patients, in general, do not embrace change, but recent studies have identified a generational acceptance of technology and mHealth in general.55
Our findings from this systematic review and narrative analysis identify some issues that are salient in the liter-ature. To help overcome provider resistance to change to telehealth, it should be noted that over the last 7 years 20% of the factors of effectiveness in the litera-ture were improved outcomes. Providers and patients should embrace telehealth modalities because of its ease of use,18 19 23 26 28 36–38 46 49 50 its tendency to improve outcomes8 9 11 13 15–18 20–26 31–33 38–41 47 50 and communica-tion,24 27 31 36 37 39 42 45 49 and its low cost.10 14 16 20 21 23 26 34 50 It can decrease travel time10 12 20 30 36 43 48 51 and increase
communication with providers. Telehealth can provide a high-quality service, increase access to care,19 42 46 48 increase self-awareness31 34 35 38 and item powers patients to manage their chronic conditions.13 21 23 28 31 32 48 Health-care organisations should embrace telehealth because it decreases missed appointments,44 is a good modality for education,15 34 44 decreases wait times,16 43 48 49 decreases readmissions9 21 and improves medication adher-ence.13 38 44 But most importantly, policymakers need to help legislation catch up with the technology by enabling additional means of reimbursement for telehealth because the modality improves outcomes,8 9 11 13 15–18 20–26
31–33 38–41 47 50 which improves public health.
comparisonThe results of our review and narrative analysis are consis-tent with other reviews. Health outcomes have been identified as a factor of effectiveness in chronically ill patients in multiple studies.56 Improvements have been identified for both physical and behavioural conditions. The review by de Jong et al, did not identify a significant decrease in use.56 This review also focused on interven-tions that used asynchronous communication, like email and text messages, with an older population. Our study included both asynchronous and synchronous interven-tions with all ages.
We were able to locate a study from 2011 that also evaluated telehealth and patient satisfaction.57 The researchers used secondary data analysis as the basis
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for their study. Their study focused on patient satis-faction and home telehealth in US Veterans. Similar to the de Jong review, this study focused on an older population ranging from 55 to 87, while our analysis included younger age groups. Its focus on US Veterans while ours included this group as only part of our popu-lation. Our approach can equate to a greater external validity to our analysis. The Young et al review found that its participants were extremely satisfied with the care coordination/home telehealth programme. The US Veterans in this review embraced the new modality. The researchers found a decrease in use associated with the telehealth modality.limitationsWe identified several limitations in the conduct of our literature review and narrative analysis. Selection bias is possible within this study; however, our group consensus methods will have mitigated against this risk. Publi-cation bias is another risk, particularly as we did not extend our search to the grey literature. Limiting our search to only two databases could easily have omitted valid articles for our review. We controlled for inter-rater reliability through the initial focus study of the topic followed by several consensus meetings held along the iterative process. By continuing to review our findings, we follow the example of other reviews and narrative analyses.52–55
The final limitation that we identified was the young age of the telehealth modality of care. It has existed since the early 1990s, but compared with traditional medicine, it is quite young. Because it is technologically based, we chose to only look at the last five years, which could also limit our findings, but the rapid advancement of a tech-nologically based modality drives a more recent sample to make current observations and conclusions.
cOnclusIOnsOverall, it was found that patient satisfaction can be associated with the modality of telehealth, but factors of effectiveness and efficiency are mixed. We found that patients’ expectations were met when providers delivered healthcare via videoconference or any other telehealth method. Telehealth is a feasible option for providers who want to expand their practices to remote areas without having to relocate or expand their footprint of their prac-tice. As telehealth continues to be developed, special care should be given to incorporate features that enable acceptance and reimbursement of this modality.basic definitionsPatient satisfaction: The U.S. Center for Medicare and Medicaid Services defines this term as the patient’s perspective of care which can be objective and meaningful to create comparisons of hospitals and other healthcare organisations.58
Effective: Successful or achieving the results that you want.59 Usually associated with outcomes.
Efficient: Performing or functi8oning in the best possible manner with the least waste of time and effort; having and using requisite knowledge, skill and industry.60
Acknowledgements The authors acknowledge Texas State University for using their library database for their research.
contributors CK directed the initial research, served as lead author, mediated discussions about the merit of abstracts/articles, integrated the input from all team members and helped refine the figure and tables to provide continuity and flow. NK contributed the initial draft of the introduction and integrated her viewpoints into the methods, discussion and worked with JV on the in-text citations. BR contributed the initial draft of the abstract and integrated her viewpoints into the methods, discussion (benefits). LT created the initial draft of figure 1 (literature review process) and the initial draft of benefits and barriers charts. JV integrated her viewpoints into the methods, the initial draft of the discussion (barriers) section and worked with NK on the in-text citations. MB served as an expert in research in U.S. Veterans due to his research in this area, and he contributed meaningful contribution to the formation of analysis and conclusion.
competing interests None declared
Provenance and peer review Not commissioned; externally peer reviewed.
data sharing statement All data are freely available.
Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/
© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
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