Review
Telemedicine across borders: A systematic review of factors that hinder or support implementation

https://doi.org/10.1016/j.ijmedinf.2012.08.003Get rights and content

Abstract

Purpose

Innovative technologies to deliver health care across borders have attracted both evangelists and sceptics. Our aim was to systematically identify factors that hinder or support implementation of cross-border telemedicine services worldwide in the last two decades.

Methods

Two reviewers independently searched ten databases including MEDLINE and EMBASE, in June 2011 including citations from 1990 onwards when at least an abstract was available in English. We also searched ELDIS and INTUTE databases and Internet search engines to identify grey literature. We included studies which (a) described the use of telemedicine to deliver cross-border healthcare and, or (b) described the factors that hinder or support implementation of cross-border telemedicine services. All study designs were included. Two reviewers independently assessed titles and abstracts of articles identified. Papers were allocated to one of four reviewers who extracted relevant data and validated it. We took a qualitative approach to the analysis, conducting a narrative synthesis of the evidence.

Results

6026 records were identified of which 5806 were excluded following screening of titles and abstracts. We assessed 227 full text articles, excluding 133 because they were fatally flawed or did not meet the inclusion criteria, producing a final sample of 94. They involved 76 countries worldwide, most involving collaborations between high and low or middle income countries. Most described services delivering a combination of types of telemedicine but specialties most represented were telepathology, telesurgery, Emergency and trauma telemedicine and teleradiology. Most link health professionals, with only a few linking professionals directly to patients. A main driver for the development of cross-border telemedicine is the need to improve access to specialist services in low and middle income countries and in underserved rural areas in high income countries. Factors that hinder or support implementation clustered into four main themes: (1) legal factors; (2) sustainability factors; (3) cultural factors; and (4) contextual factors.

Conclusions

National telemedicine programmes may build infrastructure and change mindsets, laying the foundations for successful engagement in cross-border services. Regional networks can also help with sharing of expertise and innovative ways of overcoming barriers to the implementation of services. Strong team leadership, training, flexible and locally responsive services delivered at low cost, using simple technologies, and within a clear legal and regulatory framework, are all important factors for the successful implementation of cross-border telemedicine services.

Highlights

► Cross-border telemedicine services aim to improve access to specialist services. ► Successful initiatives are simple, build on national ones, have strong leadership. ► They are supported or hindered by legal, sustainability, cultural, and contextual factors.

Introduction

Technological advances have rendered international borders increasingly porous [1], with implications for the delivery of health care [2]. For example, the ability to transmit high definition digital images across the world has enabled British hospitals to have access to specialist radiology services at night by using radiologists in Australia, while other British hospitals have outsourced large parts of their radiology services to other parts of the European Union where medical salaries are lower [3], [4], [5]. Initiatives such as these have proven controversial and, even within the European Union, the legal situation is ambiguous [6]. Despite this, the global telemedicine market is expected to grow from US$9.8 billion in 2010 to US$23 billion in 2015 [7].

For the present purposes we have defined telemedicine across borders as the delivery of health care services at a distance, involving at least two countries, using information and communication technologies. This includes two groups of applications, those linking a patient with a health professional, such as home telemonitoring for chronic disease management, and applications linking two health professionals, such as teleradiology [8].

As noted above, international collaborations using telemedicine to deliver cross-border health care services present many opportunities but also very substantial challenges [8]. Telemedicine has the potential to bring benefits to health systems and patients by facilitating timely access to cost-effective, high quality health care services, particularly in low and middle income countries and rural and remote areas of high income countries. The European Commission (EC) identified potential benefits of telemedicine at three levels: (i) at the individual level where health outcomes and quality of life could be improved, for example through home monitoring of patients with chronic conditions, (ii) at the health system level, where shortage of health professionals, for example in rural areas, could be improved, and (iii) at the societal level, where with an expanding global market, telemedicine could make substantial contributions to the European economy [8]. However, implementation faces technical challenges due to lack of interoperability between information technology systems, regulatory and legislative challenges due to the nature of work across health systems, and cultural challenges associated with work across societal and geographical boundaries [8], [9], [10].

Consequently, despite considerable enthusiasm in some quarters in engaging in telemedicine collaborations across borders, so far it is unclear to what extent such collaborations are actually meeting a real need or whether they are a solution in search of a problem [11]. There are two key parts in resolving this issue. The first is to describe the scale and nature of existing collaborations; the second is to identify what factors either enable or impede them [8]. This systematic review explores these issues, describing the range and diversity of cross-border telemedicine services implemented worldwide over the last two decades and synthesising the evidence around factors that hinder or support their implementation.

Section snippets

Search strategy

The full search strategy as it was developed in MEDLINE is available in supplementary material. In brief, two reviewers (VS and RH) independently searched ten databases including MEDLINE, EMBASE, the Cochrane Library, IBSS, CINAHL, Africa Wide Information, EconLit, Global Health, Web of Science and ZETOC in June 2011 and included citations from 1990 onwards when at least an abstract was available in English. We derived a search strategy that included MeSH terms and free text for two search

Results

The systematic search identified 6026 records of which 5806 were excluded following screening of titles and abstracts. We assessed 227 articles in full text for eligibility and excluded 133 of these because they were fatally flawed (n = 25) or did not meet the inclusion and exclusion criteria, producing a final sample of 94. Fig. 1 shows the progress of studies through the review, presented here in an adapted PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow-diagram

Main findings

This is the first and most comprehensive systematic review seeking to map cross-border telemedicine services and explore the factors that hinder or support their implementation. Most studies were descriptive in their approach and had many methodological weaknesses, which increase the risk of bias. We identified programmes involving at least 76 countries worldwide, with the majority delivered through collaborations between high income and low or middle income countries. The USA stands out as

Funding

This project was undertaken within the European Union 7th Framework Programme EU Cross Border Care Collaboration (EUCBCC), Contract no: 242058. The funder played no role in the design of the study, the interpretation of the findings, the writing of the paper, or the decision to submit.

Authors’ contributions’

All authors contributed to the writing of this report. VS, AA, HL-Q, JC and MM contributed to the conception and the study design. VS and RH developed the search strategy and conducted the database searches. JC and HL-Q advised on the development of the search strategy. VS and RH applied the inclusion and exclusion criteria and HL-Q resolved disagreements. VS, HL-Q, AA and RH conducted the data extraction and validation. VS and HL-Q led on the data analysis but all authors contributed to this.

Conflict of interest statement

All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declared: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

Summary points

What is already known about the subject

Acknowledgements

Jane Falconer, LSHTM librarian helped us to develop the search strategy. Lucinda Cash-Gibson, at Imperial College London, obtained some of the full text articles. Marina Karanikolos, Johanna Hanefeld, Nora Doering and Amina Sugimoto for reviewing the papers in Russian, German, Dutch and Japanese for us, respectively.

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