Barriers to Telehealth

Original Editor - Arnold Fredrick D'Souza Top Contributors - Arnold Fredrick D'Souza and Kim Jackson

Introduction[edit | edit source]

Telehealth practice is increasing globally, partially in response to the sudden disruption brought upon by the COVID-19 pandemic.[1] Telehealth usage is not without significant barriers which might be specific to each setting.[2][3][4] These barriers need to be identified beforehand and may necessitate the development of individualized strategies to address them appropriately.[5]

Categories of Barriers to Telehealth Practice[edit | edit source]

Most barriers can be categorized under the following:

Ethical barriers[edit | edit source]

Due to widespread social media usage, there is generally a great awareness of data privacy and confidentiality issues associated with being online.[6] These issues are critical since it concerns health records and other private information related to treatment. These fears might discourage some from accepting telehealth as an alternative mode of availing healthcare services. Telehealth systems that incorporate data encryption and similar cyber-security measures must be employed.[7] Clinicians must seek informed consent from their clients before each telehealth consultation[8] and in a specific format.[9]

Economical barriers[edit | edit source]

Despite evidence to the contrary[10], the perceived cost is one of the important barriers preventing telehealth use. This is more prominent in low-resource settings. Investing in telehealth infrastructure such as broadband and other telehealth equipment in addition to personnel training is a concern for most.[11] These costs can be minimized by selecting the most appropriate telehealth delivery methods for the intervention, setting, and population. For example, clinicians can use SMS or other asynchronous methods instead of real-time videoconferencing, if suitable. The modern smartphone is a comparatively inexpensive and self-sufficient device for most telehealth use cases.[12]

Another area of concern is billing and financial reimbursement for telehealth services. The government or other regulatory bodies might provide guidance for billing for telehealth. Insurance coverage for telehealth services needs to be determined. In its absence, alternate means must be identified in consensus with the client before commencement.[13][14]

Regulatory barriers[edit | edit source]

Depending on the country and state (as in the case of the United States of America), telehealth practice may be under the purview of the law. Clinicians may need to obtain the mandated licence and meet other legal requirements as stipulated by law. In countries without clear legal requirements, the presiding professional body may have set certain guidelines in place that may assist clinicians in setting up their practice. The law may also impose strict data privacy requirements for patient safety.[13]

On the other hand, the internet could also enable quacks and other bad actors to defraud people for telehealth services. Patients should be educated to look up their service providers' credentials before accepting or paying for any telehealth intervention.[15]

Socio-cultural barriers[edit | edit source]

Before the COVID-19 pandemic, clinicians and patients' general perception and attitudes towards telehealth were usually negative to mixed, probably motivated in part by the perceived lack of contact. Older clinicians and patients may be resistant to change and express more skepticism with telehealth.[16][17] Although the acceptability might have increased after the pandemic, certain populations, especially in rural settings, might still express concerns about the use of telehealth for their healthcare needs. Increasing awareness through education can help mitigate these concerns.[18]

Technological barriers[edit | edit source]

These are usually associated with the technological requirements for conducting telehealth. They may include lack of broadband coverage or low bandwidth, lack of user-friendly telehealth hardware or software, and poor digital literacy.[19] Broadband coverage and speeds are set to improve soon. The rollout of 5G worldwide will make telehealth easier due to the exponentially higher data transfer speeds.[20] Globally, there has already been considerable improvement in internet accessibility in the past decade. Although, developing countries still have a long way to go in contrast to the rest of the world.[21] Clinicians must collaborate with engineers, and designers must develop telehealth devices and software applications keeping in mind the needs of the target population. Besides training clinicians and patient education, poor digital literacy can be overcome with good design.[22]

Educational barriers[edit | edit source]

This might stem from a lack of training related to telehealth practice. Telehealth was not a standard inclusion in curricula before the COVID-19 pandemic.[23] Clinicians need to be educated early, especially while training as healthcare students.[24]The early exposure through dedicated training will help build confidence and comfort in using telehealth in their future practice.

On the other hand, the literacy of the client (both traditional and digital) and their education level may pose a barrier due to the nature of telehealth. This may necessitate designing telehealth applications based on simplicity and ease-of-use, keeping in mind such limitations.[4]

Evidence-related barriers[edit | edit source]

Research related to telehealth is increasing due to the push for remote services provided by the COVID-19 pandemic. Telehealth is an effective alternative to in-person care in many medical conditions. Although, in specific applications, telehealth may still need further research before application in the community.[25] Evidence-based telehealth practice will help prevent patients from receiving sub-optimal care that may deter their continued engagement in the long term. Similarly, high-quality research on telehealth applications globally will also help convince skeptics and make telehealth practice more accessible to a larger population in a variety of different settings. An ever-growing body of evidence will also help generate funds for future research that will help establish telehealth further in the mainstream.

Additional material[edit | edit source]

Chapter 4 of 'The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary' discusses "seven deadly barriers" to telemedicine.[26]

[27]

The video above enumerates the barriers to telehealth practice and suggests two methods to address them. First, it suggests educating the client about the benefits of telehealth. Secondly, it describes a process called 'shared informed decision-making' as a possible solution to decide on telehealth for a client. It mentions a paper by Elwyn et al., 2012 as reference material for the same. Shared informed decision-making refers to the process of treatment selection on the basis of current level of evidence and the client's preferences. The client is allowed to make an informed choice on their treatment.[28]

[29]

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

References[edit | edit source]

  1. Seivert S, Badowski ME. The Rise of Telemedicine: Lessons from a Global Pandemic. 2021. INNOVATIONS.
  2. Gajarawala SN, Pelkowski JN. Telehealth benefits and barriers. The Journal for Nurse Practitioners. 2021 Feb 1;17(2):218-21.
  3. Bali S. Barriers to development of telemedicine in developing countries. InTelehealth. 2018. IntechOpen.
  4. 4.0 4.1 Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: A systematic review. J Telemed Telecare. 2018 Jan;24(1):4-12. doi: 10.1177/1357633X16674087.
  5. Zhai Y. A Call for Addressing Barriers to Telemedicine: Health Disparities during the COVID-19 Pandemic. Psychother Psychosom. 2021;90(1):64-66.
  6. Isaak J, Hanna MJ. User data privacy: Facebook, Cambridge Analytica, and privacy protection. Computer. 2018 Aug 14;51(8):56-9.
  7. Hall JL, McGraw D. For telehealth to succeed, privacy and security risks must be identified and addressed. Health Affairs. 2014 Feb 1;33(2):216-21.
  8. Langarizadeh M, Moghbeli F, Aliabadi A. Application of Ethics for Providing Telemedicine Services and Information Technology. Med Arch. 2017 Oct;71(5):351-355.
  9. Mondal H, Haldar R, Mondal S. Informed consent for telemedicine. J Family Med Prim Care. 2020 Oct 30;9(10):5402-5403.
  10. Kane A, Katebi C, Subramanian M. Telehealth Saves Money and Lives: Lessons From the COVID-19 Pandemic. 2021. The Progressive Policy Institute.
  11. Jang-Jaccard J, Nepal S, Alem L, Li J. Barriers for delivering telehealth in rural Australia: a review based on Australian trials and studies. Telemedicine and e-Health. 2014 May 1;20(5):496-504.
  12. Scott RE, Mars M. Telehealth in the developing world: current status and prospects. Smart Homecare Technology and TeleHealth. 2015 Feb 2;3:25-37.
  13. 13.0 13.1 Baker DC, Bufka LF. Preparing for the telehealth world: Navigating legal, regulatory, reimbursement, and ethical issues in an electronic age. Professional Psychology: Research and Practice. 2011 Dec;42(6):405.
  14. Gilman M, Stensland J. Telehealth and Medicare: payment policy, current use, and prospects for growth. Medicare & medicaid research review. 2013;3(4).
  15. Canady VA. Survey finds telehealth services raise the potential for fraud. Mental Health Weekly. 2020 Nov 9;30(43):3-4.
  16. Sahin E, Kefeli U, Cabuk D, Ozden E, Cakmak Y, Kaypak MA, Seyyar M, Uygun K. Perceptions and acceptance of telemedicine among medical oncologists before and during the COVID-19 pandemic in Turkey. Support Care Cancer. 2021 Dec;29(12):7497-7503.
  17. Holtz BE. Patients perceptions of telemedicine visits before and after the coronavirus disease 2019 pandemic. Telemedicine and e-Health. 2021 Jan 1;27(1):107-12.
  18. Alexander DS, Kiser S, North S, Roberts CA, Carpenter DM. Exploring community members' perceptions to adopt a Tele-COPD program in rural counties. Exploratory Research in Clinical and Social Pharmacy. 2021 Jun 1;2:100023.
  19. Triana AJ, Gusdorf RE, Shah KP, Horst SN. Technology literacy as a barrier to telehealth during COVID-19. Telemedicine and e-Health. 2020 Sep 1;26(9):1118-9.
  20. Siriwardhana Y, De Alwis C, Gür G, Ylianttila M, Liyanage M. The fight against the COVID-19 pandemic with 5G technologies. IEEE Engineering Management Review. 2020 Aug 18;48(3):72-84.
  21. Poushter J. Internet access is growing worldwide but remains higher in advanced economies. Pew Research Center Global Attitudes and Trends.
  22. Pires G, Lopes A, Correia P, Almeida L, Oliveira L, Panda R, et al. Usability of a telehealth solution based on TV interaction for the elderly: the VITASENIOR-MT case study. Universal Access in the Information Society. 2022 Jan 17:1-2.
  23. Savage DJ, Gutierrez O, Montané BE, Singh AD, Yudelevich E, Mahar J, et al. Implementing a telemedicine curriculum for internal medicine residents during a pandemic: the Cleveland Clinic experience. Postgrad Med J. 2021 Mar 10:postgradmedj-2020-139228.
  24. Pourmand A, Ghassemi M, Sumon K, Amini SB, Hood C, Sikka N. Lack of Telemedicine Training in Academic Medicine: Are We Preparing the Next Generation? Telemed J E Health. 2021 Jan;27(1):62-67.
  25. Seron P, Oliveros MJ, Gutierrez-Arias R, Fuentes-Aspe R, Torres-Castro RC, Merino-Osorio C, et al. Effectiveness of Telerehabilitation in Physical Therapy: A Rapid Overview. Phys Ther. 2021 Jun 1;101(6):pzab053.
  26. Board on Health Care Services; Institute of Medicine. The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary. Washington (DC): National Academies Press (US); 2012 Nov 20. 4, Challenges in Telehealth. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207146/
  27. MedBridge. Removing Patient Barriers to Telehealth - Jared Vagy | MedBridge [Internet]. Youtube.com. 2020 [cited 2 February 2022]. Available from: https://www.youtube.com/watch?v=pOjXJ5ASIhw
  28. Elwyn G, Durand MA, Song J, Aarts J, Barr PJ, Berger Z, et al. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017 Nov 6;359:j4891.
  29. Texas Medical Association. Telehealth Webinar: The Digital Divide: Addressing Patient Barriers - July 23, 2020 [Internet]. Youtube.com. 2022 [cited 2 February 2022]. Available from: https://www.youtube.com/watch?v=QgK3SYiLu9E