J Telemed Telecare OnlineFirst, published on February 17, 2016 as doi:10.1177/1357633X16632968
RESEARCH/Original article
Education and training to support the use of clinical telehealth: A review of the literature
Journal of Telemedicine and Telecare 0(0) 1–10 ! The Author(s) 2016 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X16632968 jtt.sagepub.com
S Edirippulige1 and NR Armfield1,2
Abstract Introduction: Despite a growing literature base, substantial investment, and policy changes within governments, the integration of telehealth into routine clinical care has been limited. The availability of appropriate systematic education and training for practitioners has been highlighted as necessary for strong adoption. However, the availability and nature of telehealth-related education and training for practitioners is not understood. By reviewing the literature, we aimed to describe the delivery of education and training in telehealth, with particular focus on content, modes of delivery, types of institutions, and target clinician groups. Methods: We performed searches using PubMed, Scopus, Embase, Web of Science, PsycINFO, the Cochrane Library, and ERIC. We included studies that were focused on the delivery of telehealth-related academic or vocational education and training. We extracted information pertaining to country, programs and their participants, and tabulated the results. Results: Altogether 388 articles were identified, of which nine studies were selected for final review. Programs from five countries were represented and articles were spread across telemedicine and clinically oriented journals. Education and training in telehealth has been provided as both university level and vocational courses using conventional classroom based delivery methods and e-learning. Reported curriculum items included terminology, clinical applications, the evidence-base, and technological aspects. Conclusions: Published evidence in peer-reviewed literature on telehealth education and training is limited. According to this review, a number of topics relating to telehealth have been covered by existing education programs both within tertiary and professional development levels. Keywords Telehealth, telemedicine, education, training, curriculum, modes of delivery Date received: 6 November 2015; Date accepted: 23 January 2016
Introduction Despite a large literature base, and some formal evidence, to support the use of telehealth in a few well-established areas, such as radiology and dermatology, a substantial work is still needed for the field to mature.1 Nonetheless, many governments and health systems have made attempts to introduce telehealth services, a few of which have become large and well-integrated, such as the Ontario Telemedicine Network in Canada2 and Veteran’s Affairs Telehealth in the USA.3 The interest in telehealth to improve health care services is global. A number of European countries have implemented various telehealth projects; and some countries have conducted large research studies to establish an evidence base.4,5 Global organizations such as the World Health Organization (WHO) have been promoting telehealth, particularly in low and middle income countries in Asia, Africa, and Latin America, as a new way to address critical health challenges.6–8
Some governments have made important policy changes to encourage and incentivize the use of telehealth. For example, the Australian federal government introduced reimbursement for certain video-based consultations involving general practitioners, specialists, Aboriginal health workers, nurse practitioners, and midwives.9 In the USA, 46 states and Washington DC provide reimbursement for some videobased consultations under their Medicaid programs and this supports the healthcare costs of those on low incomes and those living with certain disabilities.10 Alongside the increase in use of telehealth, a flourishing industry of medical, technology, and clinical service
1 2
Centre for Online Health, The University of Queensland, Australia Centre for Children’s Health Research, Australia
Corresponding author: Sisira Edirippulige, Centre for Online Health, Building 33, Princess Alexandra Hospital, Queensland 4102, Australia. Email: [email protected]
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businesses has grown. The size of the market is difficult to estimate reliably. One group of analysts have suggested that it could be as large as USD$43.4 billion by 2019;11 while those in another group were more conservative in their estimate of USD$36.3 billion by 2020.12 Despite substantial investments and policy changes, the extent of adoption of telehealth is often less than expected;13 a review of activity since the 2011 introduction of reimbursement for telehealth in Australia found that only 35,565 (0.24%) of total eligible consultations have been conducted using video-based telehealth.14 While the barriers to adoption are wide-ranging, in this paper we focus specifically on skills development. Because using telehealth implies a change in practice, it should be supported by appropriate education for current and future practitioners. The literature suggests that education and training (E&T) in telehealth is needed and valued,15–18 although the area has not been formally reviewed. Therefore, the key objective of this study is to review the literature published in peer review literature relating to the provision of E&T in telehealth for current and future practitioners. Our main interest was to understand the types of education available, content of E&T, methods of delivery, types of target groups, and types of providers. The review also assessed the quality of studies included in the study.
Table 1. Search strategy. Search strategy step 1
2
3
4
Search terms Telehealth (a) MeSH Terms: telehealth OR telemedicine OR eHealth (b) Free text keywords: telehealth OR tele-health OR telemedicine OR ‘‘online health’’ OR ‘‘on-line health’’ OR ehealth OR e-health OR ehealth Education (a) MeSH Terms: education OR curriculum (b) Free text keywords: education OR training OR curriculum OR course OR qualification OR competency OR skill OR workforce Limits Published in the English language; abstract available; Publication date between January 2004– December 2014 1 AND 2 AND 3
MeSH: medical subject heading.
Methods Search strategy Computerized literature searches were performed by one author (SE) using PubMed, Scopus, Embase, Web of Science, PsycINFO, the Cochrane Library, and the Institute of Education Sciences Education Resources Information Center (ERIC). For PubMed searches, medical subject heading (MeSH) terms and free text keywords were used. For all other databases, equivalent free text keywords searches were conducted. The search terms were determined by discussion amongst the authors and were grouped into two main themes: (a) telehealth and (b) education. In addition to the computerized searches, a hand search of the table of contents of three international telemedicine/telehealth related journals, namely: Journal of Telemedicine and Telecare (JTT); Telemedicine Journal and eHealth (TJeH); and the Journal of Medical Internet Research (JMIR) was conducted to identify any further articles. The search strategy is described in Table 1. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) as the reporting guideline for this review.
Inclusion and exclusion criteria We included articles that focused specifically on the delivery of telehealth-related academic education at undergraduate or postgraduate level together with vocational continuing professional development (CPD). Articles describing patient education, the use of telehealth for education (rather than education about
telehealth itself), or technical aspects were excluded. Papers relating to education in health or medical informatics were also excluded, unless they had a focus specifically on telehealth. We also excluded papers which aimed to assess the level of knowledge and skills of practitioners in telehealth. Similarly, studies examining the educational needs of practitioners in telehealth were also excluded. Since the focus of this study was to examine the reported published evidence in peer-reviewed literature, we did not include literature reported in grey literature. The searches were constrained to articles published in the English language, between 2004–2014, for which abstracts were available. We elected to review the literature for the most recent 10 years, because the rapid changes in technology in recent years and the use of such technology in health care delivery may reflect the current status of telehealth E&T which is the focus of this study. We excluded review papers, however all relevant papers contained within reviews were considered for inclusion.
Data extraction and analysis All papers were reviewed independently by each author (SE and NRA). Disagreements were resolved by discussion. Characteristics of each study (aim, country, target group, number of participants, mode, type, level, length, provider, type of evaluation, results) were extracted. The information was then tabulated. Subsequently, the content, topics, and learning activities were explored in detail and tabulated.
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Table 2. Joanna Briggs Institute Qualitative Appraisal and Review Instrument (JBI QARI) critical appraisal checklist for interpretive and critical research. Criteria
Yes (1)
Not clear (0)
No (–1)
C1. Is there congruity between the stated philosophical perspective and the research methodology? C2. Is there congruity between the research methodology and the research question or objectives? C3. Is there congruity between the research methodology and the representation and the methods used to collect data? C4. Is there congruity between the research methodology and the representation and analysis of data? C5. Is there congruity between the research methodology and the interpretation of results? C6. Is the research ethical according to current criteria or for recent studies, and is there evidence of ethical approval by an appropriate body? C7. Do the conclusions drawn in the research report flow from the analysis, or interpretation, or the data?
The quality of studies was assessed using the Joanna Briggs Institute Qualitative Appraisal and Review Instrument (JBI QARI) Critical Appraisal checklist for Interpretive and Critical Research (Table 2). Any papers where authors of this review had authorship were reviewed and rated by two independent reviewers following the same methods.
Results The electronic searches identified 377 articles and an additional 11 were identified by the manual search. The abstracts of all 388 papers were reviewed with 30 meeting the inclusion criteria and 358 excluded. Based on full-text reading, a further 21 papers were excluded leaving a final set of nine studies for inclusion in this review (Figure 1).
Characteristics of studies Five countries were represented in the results. Australia, Brazil, UK, and USA each had two studies and Japan/ Pacific Islands had one study. Six studies were published in the last three years, while two studies were published in 2009 and one study in 2007. The studies were published
in a variety of scientific outlets: five studies were published in telemedicine/e-Health related journals (JTT, TJeH and JMIR), and the remaining four studies were published in more clinically oriented journals (BMC Medical Education, Journal of Applied Oral Science, Online Journal of Nursing Informatics and Journal of Medical Systems) (Table 3). Out of nine papers, eight studies aimed to evaluate some aspect of telehealth E&T. Seven studies set out to evaluate participants’ satisfaction and one study aimed to investigate the effect of a telehealth E&T program on students’ professional careers.18 Another study examined the feasibility of a short online course in telehealth for mental health professionals.20 The study published by Ishibashi et al. in 201124 aimed to describe the delivery of an e-Health education program to a group of participants from the Pacific Islands. All eight studies that evaluated aspects of telehealth E&T used either paper-based or online surveys for gathering information. Surveys consisted of questions with Likert scale responses and open-ended questions. In terms of results, seven studies presented outcomes of the evaluation. All seven studies indicated positive outcomes relating to participant satisfaction, relevance, feasibility, and learning outcomes. Two studies did not present results in the papers.21,24 In terms of the number of participants, all but two studies provided the numbers of study participants. Silva et al.21 and Ishibashi et al.24 did not present the number of participants. The total number of participants in the review was 1023. From a study design perspective, all of the studies were descriptive studies. Four studies used cross-sectional samples17,19,20,23 while the method of sample selection in other studies was unclear. According to the quality score, two studies were rated as seven,18,20 two as six,17,19 two as five23,25 and one as four.22 The quality rating for one study was –124 (Table 4).
Type and content of E&T Five studies described the delivery of short continuing professional studies19,20,23–25 while the remaining four described the delivery of formal university courses. From the perspective of telehealth subject matter, education components included topics relating to the definition and terminology of telehealth; clinical applications; evidence for clinical practice; design and implementation of telehealth; telehealth national strategies; and technology solutions (Table 5). In general, university courses were structured in a more traditional manner to incorporate both aspects of theoretical and practical knowledge whereas CPD courses focused on more specific practically oriented topics. In addition to theory and didactic learning, offerings included the development of hands-on practical skills and exposure to practical telehealth activities. One CPD course and one university undergraduate course incorporated a practical session within their E&T.18,24
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Figure 1. PRISMA Flow Chart.
How is education provided? Five studies used online platforms as the delivery mode19,20,22,23,25 while two studies used classroom-based face-to-face delivery methods.17,24 The remaining two studies used blended learning.18,21 The duration of telehealth courses varied: university courses were based on standard university semesters while the length of CPD courses differed widely. For example, the length of CPD courses in the review was one week, 10 weeks, three months, and six months. A range of learning activities was reported, including classroom-based lectures; brief presentations; asynchronous online presentations; live webcasts; online discussion forums, individual and group presentations; online and paper based assignments; and practical sessions. Both university courses and CPD courses have used the aforementioned learning activities. Only two studies used on-site practical sessions as learning activities in their E&T programs.17,24 The former was run as a part of a semesterbased university undergraduate course, the latter was a
professional development course provided to telehealth coordinators from the Pacific Islands. Studies reported the use of a range of learning platforms, tools, and equipment. These included live videoconferencing; animation techniques; chat room facilities; PowerPoint presentations; CD and DVD technology; and photographic equipment. Two studies identified their online learning platforms (Blackboard and Moodle).18,23 Only one study specified the course fees of students.23
Who provides telehealth education? Universities as well as other public and private organisations were responsible for the delivery of telehealth E&T. In most cases, universities offered telehealth courses within their formal degree programs. However, as our review showed, universities were also responsible for delivering telehealth CPD courses.20,23,24 Telehealth CPD courses were also delivered by professional organisations such as health departments, or the Veterans’ Health Administration (VHA).20,24,25
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Brazil
Australia
Australia
TJeH
JMIR
JTT
Dos Santos et al., 201419
Edirippulige et al., 201217
Edirippulige et al., 201218
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USA
J Appl Oral Sci
OJNI
JMIR
J Med Syst
Silva et al. 201121
Gallagher-Lepak et al. 200922
Jones et al., 200923
Ishibashi et al., 201124
UK
Brazil
BMC Med Ed
Ashurst et al. 201220
UK
Country
Journal
Author, Year
To describe an e-Health training course
To develop, deliver and evaluate an international PG module in e-Health
To describe development and delivery of distance course at five campuses in the University of Wisconsin
To evaluate a telehealth course offered for four years
To assess feasibility of short online courses (3) in telehealth for mental health professionals
To investigate the impact of an e-Health education on subsequent professional careers.Also to understand the satisfaction about postgraduate study
To assess students’ perceptions about an eHealth practicum
To evaluate participants’ satisfaction of a distance learning telehealth training course in Latin America
Study aim
Table 3. Characteristics of included studies.
Not specified
Professionals in health and medicine, public health, diagnostic imaging informatics, clinical governance, nurse, private sector informatics, a head of hospital IT department, librarian, journalist
UG nursing students
UG and PG students in Audiology, Speech and Dentistry
Trainees in clinical psychology from UK and USA
Doctors, nurses, allied health professionals, medical educators, health planner, telehealth project officer, e-Health coordinator, medial photographer
University undergraduate students (allied health, psychology, health sciences)
Telehealth coordinators from health ministries of 15 Latin American states
Target group
Not specified
16 participants from 6 countries
26
Not specified
On site, CPD; 3 months
Online; CPD; 2.5 hour live sessions weekly for 10 weeks
Online; part of nursing program; university semester
Blended learning; UG and PG levels; university semester based
Online; short CPD; 1 week
Blended learning; Postgraduate; length varies according to program
39
23
Classroom based practical session; part of one semester course; undergraduate; 1 day session
Online; CPD; 6 months
Mode, type, level, length
66
353
n
University
University
University
University
University
University
University
Latin American universities, Caribbean Information Centre on Health Sciences, health departments
Provider
Not specified
Cross-sectional descriptive study; satisfaction survey
Descriptive study; 45 item Informatics and computer selfassessment survey
Not specified
Cross-sectional descriptive study; Pre and post questionnaire
Descriptive study; survey questionnaire
Cross-sectional descriptive study; survey questionnaire
Cross-sectional descriptive study; Satisfaction survey
Study design and type of evaluation
Not presented
(continued)
12/16 Students found the course useful or very useful
Overall gain scores showed improvement at post-test in all six competency categories.
Not specified
Internet self-efficacy showed some improvement (3.2–3.5); general Internet confidence (6.4–7.8)
83% Of respondents perceived that eHealth education helped in their career development. 77% had worked e-Health related job since graduation. Satisfaction regarding eHealth education was high
89% Agreed they obtained e-Health practical skills, 95%: practicum was relevant to the course
71% Of enrolled completed basic modules, 44%: full telehealth training; 80% rated the course as excellent
Results
Edirippulige and Armfield 5
Descriptive study; survey
Results Study design and type of evaluation
Online; CPD; length not specified
VHA
Provider
>500
Mode, type, level, length
TJeH Kobb et al., 200825
USA
provided to persons in Pacific Island nations Japan/ Pacific Islands
To evaluate VHA’s telehealth education program
telehealth employees
n Target group Study aim Country Journal Author, Year
Table 3. Continued
CPD: continuing professional development; JMIR: Journal of Medical Internet Research; JTT: Journal of Telemedicine and Telecare; PG: postgraduate; TJeH: Telemedicine Journal and eHealth; VHA: Veterans’ Health Administration.
Journal of Telemedicine and Telecare 0(0) 87% Of respondents indicated they had 50% or greater performance increase in both the objectives outlined by the course and in their actual job duties. The top 5 skills acquired: Roles and duties, marketing strategies, program implementation, and patient selection methodology. Top 5 aspects of the course: Content relevant to job, co-workers’ supportive of applying skills, supportive environment, supportive work schedule, supervisor supportive
6
Who is the education provided to? Target groups included undergraduate and postgraduate students studying at universities, and various professional groups. Two studies described E&T for undergraduate students17,22 while one study related to the delivery to postgraduate students.18 Another study targeted the delivery of telehealth education to both postgraduate and undergraduate students.21 The background of undergraduate students was diverse including: physiotherapists; speech pathologists; occupational therapists; and students of a bachelor of health sciences degree. Postgraduate level telehealth courses targeted health professionals such as medical doctors, registered nurses, medical educators, and telehealth service coordinators. CPD courses targeted a range of professionals including: health policy makers; telehealth service coordinators; medical doctors; engineers; clinical psychology trainees; nurses; public health professionals; private sector informatics professionals; and information technology professionals.
Discussion While the enthusiasm for using telehealth as a new way of delivering health services is continuing, the lack of its integration into health systems has been a constant concern. Several studies have emphasized the importance of E&T as a key consideration.15–18 According to Ehnfors et al. the single largest dilemma for nurses and other health professionals is the identification of future core competencies that will be required to work in a technology-infused health care environment. With the introduction of new technology in health care, care processes must be re-evaluated and hence new competencies and skills may be require.26 Educational theorists have emphasized the value of systematic instruction to deliver information and knowledge through which domain-specific problem solving skills are developed.27–29 Educational research in various domains have provided ample evidence to suggest that education is effectively used to develop these skills that are later translated into practical utility.30,31 We found a very limited number of studies in the field. Only nine studies reported the formal delivery of programs. Compared to other aspects of telehealth research (e.g. feasibility, clinical efficacy, effectiveness, economics etc.) E&T-related research has been paid scant attention. Studies included in this review were all descriptive studies examining aspects such as E&T methods, perceptions of participants, and feasibility. This review showed that research relating to telehealth E&T has taken place in only a few countries. It is surprising that Canada, countries in Scandinavian region, Europe, or Africa where telehealth activities are substantive were not represented at all. This could be explained in many ways: it may be due to lack of telehealth E&T; or lack of interest in research relating to telehealth E&T. This may also be due to the lack of interest in reporting about E&T programs.
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Table 4. Assessment of the quality of studies. Study 19
Dos Santos et al., 2014 Edirippulige et al., 201217 Edirippulige et al., 201218 Ashurst et al., 201220 Silva et al., 201121 Gallagher-Lepak et al., 200922 Jones et al., 200923 Ishibashi et al., 201124 Kobb et al., 200825
C1
C2
C3
C4
C5
C6
C7
Total
1 1 1 1 1 1 1 0 1
1 1 1 1 0 1 1 0 1
1 1 1 1 0 1 1 0 1
1 1 1 1 0 1 1 0 1
1 1 1 1 0 1 1 0 1
0 0 1 1 –1 –1 –1 0 –1
1 1 1 1 0 0 1 –1 1
6 6 7 7 0 4 5 –1 5
Table 5. Details of curriculum. Study
Main topics in telehealth education and training
Dos Santos et al., 201419
Topics: development of telehealth action, a general focus; Design and implementation of projects; Scenarios: Detailed discussion of the use of telehealth resources in primary care and presentation of some experiences; national experiences; the countries report and their experiences on the national scene.
Edirippulige et al., 201217
Topics: standards-based VC for e-Health consultations, Internet and webcam-based VC for e-Health consultations, Consultations using a custom-based neonatal intensive care teleconsultation system, techniques of digital photography for e-Health.
Edirippulige et al., 201218
Theoretical aspects relating to e-Health, topics pertained to technological solutions and evidence for clinical practice of eHealth. Range of other topics including ethical, privacy and confidentiality aspects of e-Health, global e-Health policies, strategies for implementation and barriers and enablers. Topics: (i) computerised cognitive behavioural therapy for depression, (ii) discussion forums, (iii) lifestyle change intervention websites, (iv) webcast group therapy, (v) videophone, (vi) email, (vii) computer-patient interviews, (viii) Map of Medicine, (ix) patient access to their online medical records, (xi) groups who would benefit from Internet, (xii) implementations and requirements for supporting Internet uses Topics: basic and advanced informatics applied to health, innovations in communication, interactive telehealth consultations, tele-education, second opinion using ICT, telehealth policy.
Ashurst et al., 201220
Silva et al., 201121
Learning activities, learning material, and other specific information Activities: participation in live lectures, asynchronous discussion forums, group activities, use of three dimensional modelling and animation and video, discussion of case studies, developing national telehealth plan Material: Illuminate live conferencing, discussion forums, three dimensional modelling resources, animation and video. Activities: practical activities required students to complete practical tasks, including role play of clinical interactions using telehealth. Reinforcement of learning objectives by debrief by supervising staff member. Clinical photography sessions, site visits. Material: PPT, VC equipment, clinical photography equipment. Activities: follow weekly online lectures, participation in online discussion forums, individual and group work, completion of assessment tasks. Material: PPT, discussion forum, VC and other relevant e-Health equipment for practical sessions. Activities: Participation in webcast live lecture sessions, discussion forums, group activities. Material: Webcast technology, Discussion forum, email. LMS: unspecified online portal.
Activities: attendance in lectures, seminars, panel discussions and workshops, complete distance activities. Material: virtual hearing assessments technology, CD, DVD. (continued)
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Table 5. Continued Study
Main topics in telehealth education and training
Gallagher-Lepak et al., 200922
Topics: place of telehealth in nursing, terminology, definitions, privacy, commercial aspects, legal ethical, social aspects, remote monitoring.
Jones et al., 200923
Topics: the use of computers by patients, patient access to medical records, different forms of elearning for patients and professionals, research methods n e-Health, Geographic information systems (GIS) and telehealth.
Ishibashi et al., 201124
Topics: software solutions relating to e-Health for collection, accumulation, analysis and expression of information, image and movie production, database search, interactive multimedia programs for e-Health communication, specific telehealth disciplines example, telecardiology, WHO, ITU activities in e-Health, policies and funding for ehealth, Japan’s ODA and international health. Home telehealth.
Kobb et al., 200825
Learning activities, learning material, and other specific information Activities: attendance in online lectures, complete required course reading and tasks relating to ‘Health Buddy’ a remote monitoring device, participation in discussion forums, group discussions, completion of assessment tasks. Material: remote monitoring system ‘Health Buddy’, discussion forum, scientific papers. Activities: participation in live sessions, discussion forums and chat rooms, single or groups presentations, conduct recommended reading. Material: Webcasting technology, PPT, chat rooms, handouts and reading material, video technology for presentations. Cost: £220. Activities: attendance in classroom based lectures, complete hands on exercises, undertake self-practice exercises. Material: technologies pertained to practical sessions, handouts, PPT presentations.
Not specified.
LMS: PPT: Powerpoint; VC: videoconferencing; WHO; World Health Organization; ITU: International Telecommunications Union; ODA: Official Development Assistance.
In fact, there seem to be some education programs in telehealth taking place in various places. For example, there are some American Telemedicine Association (ATA) accredited telemedicine training programs in the USA. The Centre for Health and Technology at the University of California and the Telemedicine Learning Center at San Diego have been providing education for a number of years.32,33 There are some private providers who offer online telemedicine education in the UK.34 A recent report indicated that several medical schools in France have introduced telemedicine in their medical curriculum.35 The Australian Centre for Rural and Remote Medicine (ACRRM) has been providing online telehealth modules for clinicians and practice managers.36 This review found that there are two main types of E&T: formal university courses and CPD. These are traditional methods of providing E&T in any field and are not unique to telehealth. While higher education establishments such as universities provide more structured and conventional education focusing on degree qualifications, CPD is are generally used for providing short professional skills to practitioners. We found that online learning was the most common approach for both university level and CPD courses. The flexibility and other advantages offered by online delivery methods may explain this choice. Online education may be particularly attractive for busy practitioners who would choose to take up short CPD courses for developing
knowledge and skills. However, it also seems that practicing telehealth requires certain hands-on skills. Feedback of the participants of a telehealth practicum shows that the practical sessions helped them to develop specific skills that were relevant for practice. Also the observation of real-life telehealth consultations may be an effective way to gain exposure to the modality. Therefore, it is important to consider the value of developing practical skills through E&T too. In that sense, blended learning options may be appropriate for telehealth E&T. The education components covered a wide range of topics, involved participants in different learning activities, using diverse techniques and learning materials. However it is unclear whether the design of curricula, learning activities, and techniques were driven by the specific needs of the participants. The target groups of telehealth E&T in the higher education sector have included nurses and allied health professionals. However, it is also essential to educate future medical practitioners for telehealth, and this appears not to have occurred. The likely best way to provide appropriate knowledge and skills to future medical professionals would be to incorporate telehealth education as a standard component in the medical curriculum. There may be a number of reasons for lack of interest in telehealth E&T. There are no widespread and wellestablished professional careers in the field and this does not attract sufficient interest within the education sector to
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develop and offer telehealth education programs. Lack of careers may also result in low demand from students who may fear limited professional prospects.
Conclusions The lack of E&T to provide systematic knowledge and skills has been highlighted as a key issue. This review suggests that there is very limited published evidence relating to the delivery of telehealth E&T. Compared with research into clinical aspects and technology in telehealth, E&T has so far been paid scant attention. Integration of telehealth involves a significant change in traditional practice, therefore requires a systematic change management approach. The provision of relevant knowledge, skills, and competencies to current and future telehealth practitioners is an important way to address this transition. Declaration of conflicting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Armfield NR, Edirippulige SK, Bradford N, et al. Telemedicine–is the cart being put before the horse? Med J Aust 2014; 200: 530–533. 2. Ontario Telemedicine Network. OTN: About us, http:// www.otn.ca/ (accessed 5 December 2015). 3. US Department of Veterans Affairs, VA Telehealth Services, http://www.telehealth.va.gov/about/ (accessed 9 February 2016). 4. Steventon A, Bardsley M, Billings J, et al. Effect of telehealth on use of secondary care and mortality: Findings from the Whole System Demonstrator cluster randomised trial. Br Med J 2012; 344: e3874. 5. Zanaboni P, Knarvik U and Wootton R. Adoption of routine telemedicine in Norway: The current picture. Global Health Action 2014; 7: 1–14. 6. World Health Organization (WHO). Telemedicine: Opportunities and developments in member states, http:// www.who.int/goe/publications/goe_telemedicine_2010.pdf (2010, accessed 5 December 2015). 7. Beratarrechea A, Lee AG, Willner JM, et al. The impact of mobile health interventions on chronic disease outcomes in developing countries: A systematic review. Telemed J E Health 2014; 20: 75–82. 8. Wootton R. Telemedicine support for the developing world. J Telemed Telecare 2008; 14: 109–114. 9. Australian Government. Medical benefits schedule, http:// www.mbsonline.gov.au/telehealth (2014, accessed 5 December 2015). 10. Centre for Connected Health Policy, The National Telehealth Policy Resource Center, http://cchpca.org/whatis-telehealth (accessed 9 February 2016).
11. BCC Research. (2014). Global markets for tele-medicine technologies, http://www.bccresearch.com/market-research/ healthcare/telemedicine-technologies-report-hlc014g.html (2014, accessed 5 December 2015). 12. Telemedicine Market. Global industry analysis, size, share, growth, trends and forecast, 2014–2020, http:// www.transparencymarketresearch.com/pressrelease/teleme dicine-market.htm (2014, accessed 5 December 2015). 13. Zanaboni P and Wootton R. Adoption of telemedicine: From pilot stage to routine delivery. BMC Med Inform Decis Mak 2012; 12: 1. 14. Wade V, Soar J and Gray L. Uptake of telehealth services funded by Medicare in Australia. Aust Health Rev 2014; 38: 528–532. 15. Perle JG, Langsam LC, Randel A, et al. Attitudes toward psychological telehealth: Current and future clinical psychologists’ opinions of internet-based interventions. J Clin Psychol 2013; 69: 100–113. 16. Perle JG, Langsam LC and Nierenberg B. Controversy clarified: An updated review of clinical psychology and telehealth. Clin Psychol Rev 2011; 31: 1247–1258. 17. Edirippulige S, Smith AC, Armfield NR, et al. Student perceptions of a hands-on practicum to supplement an online eHealth course. J Med Internet Res 2012; 14: e182. 18. Edirippulige S, Armfield NR and Smith AC. A qualitative study of the careers and professional practices of graduates from an e-health postgraduate programme. J Telemed Telecare 2012; 18: 455–459. 19. Santos AD, Alves HJ, Nogueira JT, et al. Telehealth distance education course in Latin America: Analysis of an experience involving 15 countries. Telemed J E Health 2014; 20(8): 736–741. 20. Ashurst EJ, Jones RB, Williamson GR, et al. Collaborative learning about e-health for mental health professionals and service users in a structured anonymous online short course: Pilot study. BMC Med Educ 2012; 12: 37. 21. Silva ASCd, Rizzante FAP, Picolini MM, et al. Bauru School of Dentistry Tele-Health League: An educational strategy applied to research, teaching and extension among applications in tele-health. J Appl Oral Sci 2011; 19: 599–603. 22. Gallagher-Lepak S, Scheibel P and Gibson C. Integrating telehealth in nursing curricula: Can you hear me now. Online J Nurs Info 2009; 13: 1–16. 23. Jones RB, Maramba I, Boulos MNK, et al. Use of live interactive Webcasting for an International Postgraduate Module in eHealth: Case study evaluation. J Med Internet Res 2009; 11(4). 24. Ishibashi Y, Juzoji H, Kitano T, et al. ITU e-Health training program for Pacific Island Community with the support of the Sasakawa Peace Foundation. J Med Syst 2011; 35: 345–351. 25. Kobb RF, Lane RJ and Stallings D. E-learning and telehealth: Measuring your success. Telemed J E Health 2008; 14: 576–579. 26. Ehnfors M and Grobe SJ. Nursing curriculum and continuing education: Future directions. Int J Med Inform 2004; 73: 591–598. 27. Schoenfeld AH and Herrmann DJ. Problem perception and knowledge structure in expert and novice mathematical problem solvers. J Exp Psychol Learn Mem Cogn 1982; 8: 484. 28. Klauer KJ and Phye GD. Inductive reasoning: A training approach. Rev Educ Res 2008; 78: 85–123.
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29. Sternberg RJ and Frensch PA. Complex problem solving: Principles and mechanisms. Mahawah, United States: Psychology Press, 2014. 30. Sugrue B. A Theory-based framework for assessing domainspecific problem-solving ability. Educ Meas: Issues and practice 1995; 14: 29–35. 31. Dunbar K and Fugelsang J. Scientific thinking and reasoning. In: Holyoak KJ and Morrison RG (eds) The Cambridge Handbook of Thinking and Reasoning. New York: Cambridge University Press, 2005, pp.705–725. 32. UC Davis Health System. Telehealth education program, http://www.ucdmc.ucdavis.edu/cht/education/telehealth/ courseinfo.html (2015, accessed 5 December 2015). 33. Telemedicine Learning Center, UC San Diego School of Medicine, http://telemedicine.ucsd.edu/ (accessed 9 February 2016).
34. Virtual College. An introduction to telemedicine, http:// www.virtual-college.co.uk/products/introduction_to_tele medicine.aspx (accessed 5 December 2015). 35. Updates from the ISfTeH Global Telemedicine & eHealth Network (October 2015), https://www.isfteh.org/files/ media/Global_Telemedicine_and_eHealth_Update_%28 October_2015%29.pdf (accessed 9 February 2016). 36. Australian College of Rural and Remote Medicine. Telehealth education, http://www.ehealth.acrrm.org.au/tele health-education (accessed 5 December 2015).
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RESEARCH/Original article
Education and training to support the use of clinical telehealth: A review of the literature
Journal of Telemedicine and Telecare 0(0) 1–10 ! The Author(s) 2016 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X16632968 jtt.sagepub.com
S Edirippulige1 and NR Armfield1,2
Abstract Introduction: Despite a growing literature base, substantial investment, and policy changes within governments, the integration of telehealth into routine clinical care has been limited. The availability of appropriate systematic education and training for practitioners has been highlighted as necessary for strong adoption. However, the availability and nature of telehealth-related education and training for practitioners is not understood. By reviewing the literature, we aimed to describe the delivery of education and training in telehealth, with particular focus on content, modes of delivery, types of institutions, and target clinician groups. Methods: We performed searches using PubMed, Scopus, Embase, Web of Science, PsycINFO, the Cochrane Library, and ERIC. We included studies that were focused on the delivery of telehealth-related academic or vocational education and training. We extracted information pertaining to country, programs and their participants, and tabulated the results. Results: Altogether 388 articles were identified, of which nine studies were selected for final review. Programs from five countries were represented and articles were spread across telemedicine and clinically oriented journals. Education and training in telehealth has been provided as both university level and vocational courses using conventional classroom based delivery methods and e-learning. Reported curriculum items included terminology, clinical applications, the evidence-base, and technological aspects. Conclusions: Published evidence in peer-reviewed literature on telehealth education and training is limited. According to this review, a number of topics relating to telehealth have been covered by existing education programs both within tertiary and professional development levels. Keywords Telehealth, telemedicine, education, training, curriculum, modes of delivery Date received: 6 November 2015; Date accepted: 23 January 2016
Introduction Despite a large literature base, and some formal evidence, to support the use of telehealth in a few well-established areas, such as radiology and dermatology, a substantial work is still needed for the field to mature.1 Nonetheless, many governments and health systems have made attempts to introduce telehealth services, a few of which have become large and well-integrated, such as the Ontario Telemedicine Network in Canada2 and Veteran’s Affairs Telehealth in the USA.3 The interest in telehealth to improve health care services is global. A number of European countries have implemented various telehealth projects; and some countries have conducted large research studies to establish an evidence base.4,5 Global organizations such as the World Health Organization (WHO) have been promoting telehealth, particularly in low and middle income countries in Asia, Africa, and Latin America, as a new way to address critical health challenges.6–8
Some governments have made important policy changes to encourage and incentivize the use of telehealth. For example, the Australian federal government introduced reimbursement for certain video-based consultations involving general practitioners, specialists, Aboriginal health workers, nurse practitioners, and midwives.9 In the USA, 46 states and Washington DC provide reimbursement for some videobased consultations under their Medicaid programs and this supports the healthcare costs of those on low incomes and those living with certain disabilities.10 Alongside the increase in use of telehealth, a flourishing industry of medical, technology, and clinical service
1 2
Centre for Online Health, The University of Queensland, Australia Centre for Children’s Health Research, Australia
Corresponding author: Sisira Edirippulige, Centre for Online Health, Building 33, Princess Alexandra Hospital, Queensland 4102, Australia. Email: [email protected]
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businesses has grown. The size of the market is difficult to estimate reliably. One group of analysts have suggested that it could be as large as USD$43.4 billion by 2019;11 while those in another group were more conservative in their estimate of USD$36.3 billion by 2020.12 Despite substantial investments and policy changes, the extent of adoption of telehealth is often less than expected;13 a review of activity since the 2011 introduction of reimbursement for telehealth in Australia found that only 35,565 (0.24%) of total eligible consultations have been conducted using video-based telehealth.14 While the barriers to adoption are wide-ranging, in this paper we focus specifically on skills development. Because using telehealth implies a change in practice, it should be supported by appropriate education for current and future practitioners. The literature suggests that education and training (E&T) in telehealth is needed and valued,15–18 although the area has not been formally reviewed. Therefore, the key objective of this study is to review the literature published in peer review literature relating to the provision of E&T in telehealth for current and future practitioners. Our main interest was to understand the types of education available, content of E&T, methods of delivery, types of target groups, and types of providers. The review also assessed the quality of studies included in the study.
Table 1. Search strategy. Search strategy step 1
2
3
4
Search terms Telehealth (a) MeSH Terms: telehealth OR telemedicine OR eHealth (b) Free text keywords: telehealth OR tele-health OR telemedicine OR ‘‘online health’’ OR ‘‘on-line health’’ OR ehealth OR e-health OR ehealth Education (a) MeSH Terms: education OR curriculum (b) Free text keywords: education OR training OR curriculum OR course OR qualification OR competency OR skill OR workforce Limits Published in the English language; abstract available; Publication date between January 2004– December 2014 1 AND 2 AND 3
MeSH: medical subject heading.
Methods Search strategy Computerized literature searches were performed by one author (SE) using PubMed, Scopus, Embase, Web of Science, PsycINFO, the Cochrane Library, and the Institute of Education Sciences Education Resources Information Center (ERIC). For PubMed searches, medical subject heading (MeSH) terms and free text keywords were used. For all other databases, equivalent free text keywords searches were conducted. The search terms were determined by discussion amongst the authors and were grouped into two main themes: (a) telehealth and (b) education. In addition to the computerized searches, a hand search of the table of contents of three international telemedicine/telehealth related journals, namely: Journal of Telemedicine and Telecare (JTT); Telemedicine Journal and eHealth (TJeH); and the Journal of Medical Internet Research (JMIR) was conducted to identify any further articles. The search strategy is described in Table 1. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) as the reporting guideline for this review.
Inclusion and exclusion criteria We included articles that focused specifically on the delivery of telehealth-related academic education at undergraduate or postgraduate level together with vocational continuing professional development (CPD). Articles describing patient education, the use of telehealth for education (rather than education about
telehealth itself), or technical aspects were excluded. Papers relating to education in health or medical informatics were also excluded, unless they had a focus specifically on telehealth. We also excluded papers which aimed to assess the level of knowledge and skills of practitioners in telehealth. Similarly, studies examining the educational needs of practitioners in telehealth were also excluded. Since the focus of this study was to examine the reported published evidence in peer-reviewed literature, we did not include literature reported in grey literature. The searches were constrained to articles published in the English language, between 2004–2014, for which abstracts were available. We elected to review the literature for the most recent 10 years, because the rapid changes in technology in recent years and the use of such technology in health care delivery may reflect the current status of telehealth E&T which is the focus of this study. We excluded review papers, however all relevant papers contained within reviews were considered for inclusion.
Data extraction and analysis All papers were reviewed independently by each author (SE and NRA). Disagreements were resolved by discussion. Characteristics of each study (aim, country, target group, number of participants, mode, type, level, length, provider, type of evaluation, results) were extracted. The information was then tabulated. Subsequently, the content, topics, and learning activities were explored in detail and tabulated.
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Table 2. Joanna Briggs Institute Qualitative Appraisal and Review Instrument (JBI QARI) critical appraisal checklist for interpretive and critical research. Criteria
Yes (1)
Not clear (0)
No (–1)
C1. Is there congruity between the stated philosophical perspective and the research methodology? C2. Is there congruity between the research methodology and the research question or objectives? C3. Is there congruity between the research methodology and the representation and the methods used to collect data? C4. Is there congruity between the research methodology and the representation and analysis of data? C5. Is there congruity between the research methodology and the interpretation of results? C6. Is the research ethical according to current criteria or for recent studies, and is there evidence of ethical approval by an appropriate body? C7. Do the conclusions drawn in the research report flow from the analysis, or interpretation, or the data?
The quality of studies was assessed using the Joanna Briggs Institute Qualitative Appraisal and Review Instrument (JBI QARI) Critical Appraisal checklist for Interpretive and Critical Research (Table 2). Any papers where authors of this review had authorship were reviewed and rated by two independent reviewers following the same methods.
Results The electronic searches identified 377 articles and an additional 11 were identified by the manual search. The abstracts of all 388 papers were reviewed with 30 meeting the inclusion criteria and 358 excluded. Based on full-text reading, a further 21 papers were excluded leaving a final set of nine studies for inclusion in this review (Figure 1).
Characteristics of studies Five countries were represented in the results. Australia, Brazil, UK, and USA each had two studies and Japan/ Pacific Islands had one study. Six studies were published in the last three years, while two studies were published in 2009 and one study in 2007. The studies were published
in a variety of scientific outlets: five studies were published in telemedicine/e-Health related journals (JTT, TJeH and JMIR), and the remaining four studies were published in more clinically oriented journals (BMC Medical Education, Journal of Applied Oral Science, Online Journal of Nursing Informatics and Journal of Medical Systems) (Table 3). Out of nine papers, eight studies aimed to evaluate some aspect of telehealth E&T. Seven studies set out to evaluate participants’ satisfaction and one study aimed to investigate the effect of a telehealth E&T program on students’ professional careers.18 Another study examined the feasibility of a short online course in telehealth for mental health professionals.20 The study published by Ishibashi et al. in 201124 aimed to describe the delivery of an e-Health education program to a group of participants from the Pacific Islands. All eight studies that evaluated aspects of telehealth E&T used either paper-based or online surveys for gathering information. Surveys consisted of questions with Likert scale responses and open-ended questions. In terms of results, seven studies presented outcomes of the evaluation. All seven studies indicated positive outcomes relating to participant satisfaction, relevance, feasibility, and learning outcomes. Two studies did not present results in the papers.21,24 In terms of the number of participants, all but two studies provided the numbers of study participants. Silva et al.21 and Ishibashi et al.24 did not present the number of participants. The total number of participants in the review was 1023. From a study design perspective, all of the studies were descriptive studies. Four studies used cross-sectional samples17,19,20,23 while the method of sample selection in other studies was unclear. According to the quality score, two studies were rated as seven,18,20 two as six,17,19 two as five23,25 and one as four.22 The quality rating for one study was –124 (Table 4).
Type and content of E&T Five studies described the delivery of short continuing professional studies19,20,23–25 while the remaining four described the delivery of formal university courses. From the perspective of telehealth subject matter, education components included topics relating to the definition and terminology of telehealth; clinical applications; evidence for clinical practice; design and implementation of telehealth; telehealth national strategies; and technology solutions (Table 5). In general, university courses were structured in a more traditional manner to incorporate both aspects of theoretical and practical knowledge whereas CPD courses focused on more specific practically oriented topics. In addition to theory and didactic learning, offerings included the development of hands-on practical skills and exposure to practical telehealth activities. One CPD course and one university undergraduate course incorporated a practical session within their E&T.18,24
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Figure 1. PRISMA Flow Chart.
How is education provided? Five studies used online platforms as the delivery mode19,20,22,23,25 while two studies used classroom-based face-to-face delivery methods.17,24 The remaining two studies used blended learning.18,21 The duration of telehealth courses varied: university courses were based on standard university semesters while the length of CPD courses differed widely. For example, the length of CPD courses in the review was one week, 10 weeks, three months, and six months. A range of learning activities was reported, including classroom-based lectures; brief presentations; asynchronous online presentations; live webcasts; online discussion forums, individual and group presentations; online and paper based assignments; and practical sessions. Both university courses and CPD courses have used the aforementioned learning activities. Only two studies used on-site practical sessions as learning activities in their E&T programs.17,24 The former was run as a part of a semesterbased university undergraduate course, the latter was a
professional development course provided to telehealth coordinators from the Pacific Islands. Studies reported the use of a range of learning platforms, tools, and equipment. These included live videoconferencing; animation techniques; chat room facilities; PowerPoint presentations; CD and DVD technology; and photographic equipment. Two studies identified their online learning platforms (Blackboard and Moodle).18,23 Only one study specified the course fees of students.23
Who provides telehealth education? Universities as well as other public and private organisations were responsible for the delivery of telehealth E&T. In most cases, universities offered telehealth courses within their formal degree programs. However, as our review showed, universities were also responsible for delivering telehealth CPD courses.20,23,24 Telehealth CPD courses were also delivered by professional organisations such as health departments, or the Veterans’ Health Administration (VHA).20,24,25
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Brazil
Australia
Australia
TJeH
JMIR
JTT
Dos Santos et al., 201419
Edirippulige et al., 201217
Edirippulige et al., 201218
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USA
J Appl Oral Sci
OJNI
JMIR
J Med Syst
Silva et al. 201121
Gallagher-Lepak et al. 200922
Jones et al., 200923
Ishibashi et al., 201124
UK
Brazil
BMC Med Ed
Ashurst et al. 201220
UK
Country
Journal
Author, Year
To describe an e-Health training course
To develop, deliver and evaluate an international PG module in e-Health
To describe development and delivery of distance course at five campuses in the University of Wisconsin
To evaluate a telehealth course offered for four years
To assess feasibility of short online courses (3) in telehealth for mental health professionals
To investigate the impact of an e-Health education on subsequent professional careers.Also to understand the satisfaction about postgraduate study
To assess students’ perceptions about an eHealth practicum
To evaluate participants’ satisfaction of a distance learning telehealth training course in Latin America
Study aim
Table 3. Characteristics of included studies.
Not specified
Professionals in health and medicine, public health, diagnostic imaging informatics, clinical governance, nurse, private sector informatics, a head of hospital IT department, librarian, journalist
UG nursing students
UG and PG students in Audiology, Speech and Dentistry
Trainees in clinical psychology from UK and USA
Doctors, nurses, allied health professionals, medical educators, health planner, telehealth project officer, e-Health coordinator, medial photographer
University undergraduate students (allied health, psychology, health sciences)
Telehealth coordinators from health ministries of 15 Latin American states
Target group
Not specified
16 participants from 6 countries
26
Not specified
On site, CPD; 3 months
Online; CPD; 2.5 hour live sessions weekly for 10 weeks
Online; part of nursing program; university semester
Blended learning; UG and PG levels; university semester based
Online; short CPD; 1 week
Blended learning; Postgraduate; length varies according to program
39
23
Classroom based practical session; part of one semester course; undergraduate; 1 day session
Online; CPD; 6 months
Mode, type, level, length
66
353
n
University
University
University
University
University
University
University
Latin American universities, Caribbean Information Centre on Health Sciences, health departments
Provider
Not specified
Cross-sectional descriptive study; satisfaction survey
Descriptive study; 45 item Informatics and computer selfassessment survey
Not specified
Cross-sectional descriptive study; Pre and post questionnaire
Descriptive study; survey questionnaire
Cross-sectional descriptive study; survey questionnaire
Cross-sectional descriptive study; Satisfaction survey
Study design and type of evaluation
Not presented
(continued)
12/16 Students found the course useful or very useful
Overall gain scores showed improvement at post-test in all six competency categories.
Not specified
Internet self-efficacy showed some improvement (3.2–3.5); general Internet confidence (6.4–7.8)
83% Of respondents perceived that eHealth education helped in their career development. 77% had worked e-Health related job since graduation. Satisfaction regarding eHealth education was high
89% Agreed they obtained e-Health practical skills, 95%: practicum was relevant to the course
71% Of enrolled completed basic modules, 44%: full telehealth training; 80% rated the course as excellent
Results
Edirippulige and Armfield 5
Descriptive study; survey
Results Study design and type of evaluation
Online; CPD; length not specified
VHA
Provider
>500
Mode, type, level, length
TJeH Kobb et al., 200825
USA
provided to persons in Pacific Island nations Japan/ Pacific Islands
To evaluate VHA’s telehealth education program
telehealth employees
n Target group Study aim Country Journal Author, Year
Table 3. Continued
CPD: continuing professional development; JMIR: Journal of Medical Internet Research; JTT: Journal of Telemedicine and Telecare; PG: postgraduate; TJeH: Telemedicine Journal and eHealth; VHA: Veterans’ Health Administration.
Journal of Telemedicine and Telecare 0(0) 87% Of respondents indicated they had 50% or greater performance increase in both the objectives outlined by the course and in their actual job duties. The top 5 skills acquired: Roles and duties, marketing strategies, program implementation, and patient selection methodology. Top 5 aspects of the course: Content relevant to job, co-workers’ supportive of applying skills, supportive environment, supportive work schedule, supervisor supportive
6
Who is the education provided to? Target groups included undergraduate and postgraduate students studying at universities, and various professional groups. Two studies described E&T for undergraduate students17,22 while one study related to the delivery to postgraduate students.18 Another study targeted the delivery of telehealth education to both postgraduate and undergraduate students.21 The background of undergraduate students was diverse including: physiotherapists; speech pathologists; occupational therapists; and students of a bachelor of health sciences degree. Postgraduate level telehealth courses targeted health professionals such as medical doctors, registered nurses, medical educators, and telehealth service coordinators. CPD courses targeted a range of professionals including: health policy makers; telehealth service coordinators; medical doctors; engineers; clinical psychology trainees; nurses; public health professionals; private sector informatics professionals; and information technology professionals.
Discussion While the enthusiasm for using telehealth as a new way of delivering health services is continuing, the lack of its integration into health systems has been a constant concern. Several studies have emphasized the importance of E&T as a key consideration.15–18 According to Ehnfors et al. the single largest dilemma for nurses and other health professionals is the identification of future core competencies that will be required to work in a technology-infused health care environment. With the introduction of new technology in health care, care processes must be re-evaluated and hence new competencies and skills may be require.26 Educational theorists have emphasized the value of systematic instruction to deliver information and knowledge through which domain-specific problem solving skills are developed.27–29 Educational research in various domains have provided ample evidence to suggest that education is effectively used to develop these skills that are later translated into practical utility.30,31 We found a very limited number of studies in the field. Only nine studies reported the formal delivery of programs. Compared to other aspects of telehealth research (e.g. feasibility, clinical efficacy, effectiveness, economics etc.) E&T-related research has been paid scant attention. Studies included in this review were all descriptive studies examining aspects such as E&T methods, perceptions of participants, and feasibility. This review showed that research relating to telehealth E&T has taken place in only a few countries. It is surprising that Canada, countries in Scandinavian region, Europe, or Africa where telehealth activities are substantive were not represented at all. This could be explained in many ways: it may be due to lack of telehealth E&T; or lack of interest in research relating to telehealth E&T. This may also be due to the lack of interest in reporting about E&T programs.
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Table 4. Assessment of the quality of studies. Study 19
Dos Santos et al., 2014 Edirippulige et al., 201217 Edirippulige et al., 201218 Ashurst et al., 201220 Silva et al., 201121 Gallagher-Lepak et al., 200922 Jones et al., 200923 Ishibashi et al., 201124 Kobb et al., 200825
C1
C2
C3
C4
C5
C6
C7
Total
1 1 1 1 1 1 1 0 1
1 1 1 1 0 1 1 0 1
1 1 1 1 0 1 1 0 1
1 1 1 1 0 1 1 0 1
1 1 1 1 0 1 1 0 1
0 0 1 1 –1 –1 –1 0 –1
1 1 1 1 0 0 1 –1 1
6 6 7 7 0 4 5 –1 5
Table 5. Details of curriculum. Study
Main topics in telehealth education and training
Dos Santos et al., 201419
Topics: development of telehealth action, a general focus; Design and implementation of projects; Scenarios: Detailed discussion of the use of telehealth resources in primary care and presentation of some experiences; national experiences; the countries report and their experiences on the national scene.
Edirippulige et al., 201217
Topics: standards-based VC for e-Health consultations, Internet and webcam-based VC for e-Health consultations, Consultations using a custom-based neonatal intensive care teleconsultation system, techniques of digital photography for e-Health.
Edirippulige et al., 201218
Theoretical aspects relating to e-Health, topics pertained to technological solutions and evidence for clinical practice of eHealth. Range of other topics including ethical, privacy and confidentiality aspects of e-Health, global e-Health policies, strategies for implementation and barriers and enablers. Topics: (i) computerised cognitive behavioural therapy for depression, (ii) discussion forums, (iii) lifestyle change intervention websites, (iv) webcast group therapy, (v) videophone, (vi) email, (vii) computer-patient interviews, (viii) Map of Medicine, (ix) patient access to their online medical records, (xi) groups who would benefit from Internet, (xii) implementations and requirements for supporting Internet uses Topics: basic and advanced informatics applied to health, innovations in communication, interactive telehealth consultations, tele-education, second opinion using ICT, telehealth policy.
Ashurst et al., 201220
Silva et al., 201121
Learning activities, learning material, and other specific information Activities: participation in live lectures, asynchronous discussion forums, group activities, use of three dimensional modelling and animation and video, discussion of case studies, developing national telehealth plan Material: Illuminate live conferencing, discussion forums, three dimensional modelling resources, animation and video. Activities: practical activities required students to complete practical tasks, including role play of clinical interactions using telehealth. Reinforcement of learning objectives by debrief by supervising staff member. Clinical photography sessions, site visits. Material: PPT, VC equipment, clinical photography equipment. Activities: follow weekly online lectures, participation in online discussion forums, individual and group work, completion of assessment tasks. Material: PPT, discussion forum, VC and other relevant e-Health equipment for practical sessions. Activities: Participation in webcast live lecture sessions, discussion forums, group activities. Material: Webcast technology, Discussion forum, email. LMS: unspecified online portal.
Activities: attendance in lectures, seminars, panel discussions and workshops, complete distance activities. Material: virtual hearing assessments technology, CD, DVD. (continued)
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Table 5. Continued Study
Main topics in telehealth education and training
Gallagher-Lepak et al., 200922
Topics: place of telehealth in nursing, terminology, definitions, privacy, commercial aspects, legal ethical, social aspects, remote monitoring.
Jones et al., 200923
Topics: the use of computers by patients, patient access to medical records, different forms of elearning for patients and professionals, research methods n e-Health, Geographic information systems (GIS) and telehealth.
Ishibashi et al., 201124
Topics: software solutions relating to e-Health for collection, accumulation, analysis and expression of information, image and movie production, database search, interactive multimedia programs for e-Health communication, specific telehealth disciplines example, telecardiology, WHO, ITU activities in e-Health, policies and funding for ehealth, Japan’s ODA and international health. Home telehealth.
Kobb et al., 200825
Learning activities, learning material, and other specific information Activities: attendance in online lectures, complete required course reading and tasks relating to ‘Health Buddy’ a remote monitoring device, participation in discussion forums, group discussions, completion of assessment tasks. Material: remote monitoring system ‘Health Buddy’, discussion forum, scientific papers. Activities: participation in live sessions, discussion forums and chat rooms, single or groups presentations, conduct recommended reading. Material: Webcasting technology, PPT, chat rooms, handouts and reading material, video technology for presentations. Cost: £220. Activities: attendance in classroom based lectures, complete hands on exercises, undertake self-practice exercises. Material: technologies pertained to practical sessions, handouts, PPT presentations.
Not specified.
LMS: PPT: Powerpoint; VC: videoconferencing; WHO; World Health Organization; ITU: International Telecommunications Union; ODA: Official Development Assistance.
In fact, there seem to be some education programs in telehealth taking place in various places. For example, there are some American Telemedicine Association (ATA) accredited telemedicine training programs in the USA. The Centre for Health and Technology at the University of California and the Telemedicine Learning Center at San Diego have been providing education for a number of years.32,33 There are some private providers who offer online telemedicine education in the UK.34 A recent report indicated that several medical schools in France have introduced telemedicine in their medical curriculum.35 The Australian Centre for Rural and Remote Medicine (ACRRM) has been providing online telehealth modules for clinicians and practice managers.36 This review found that there are two main types of E&T: formal university courses and CPD. These are traditional methods of providing E&T in any field and are not unique to telehealth. While higher education establishments such as universities provide more structured and conventional education focusing on degree qualifications, CPD is are generally used for providing short professional skills to practitioners. We found that online learning was the most common approach for both university level and CPD courses. The flexibility and other advantages offered by online delivery methods may explain this choice. Online education may be particularly attractive for busy practitioners who would choose to take up short CPD courses for developing
knowledge and skills. However, it also seems that practicing telehealth requires certain hands-on skills. Feedback of the participants of a telehealth practicum shows that the practical sessions helped them to develop specific skills that were relevant for practice. Also the observation of real-life telehealth consultations may be an effective way to gain exposure to the modality. Therefore, it is important to consider the value of developing practical skills through E&T too. In that sense, blended learning options may be appropriate for telehealth E&T. The education components covered a wide range of topics, involved participants in different learning activities, using diverse techniques and learning materials. However it is unclear whether the design of curricula, learning activities, and techniques were driven by the specific needs of the participants. The target groups of telehealth E&T in the higher education sector have included nurses and allied health professionals. However, it is also essential to educate future medical practitioners for telehealth, and this appears not to have occurred. The likely best way to provide appropriate knowledge and skills to future medical professionals would be to incorporate telehealth education as a standard component in the medical curriculum. There may be a number of reasons for lack of interest in telehealth E&T. There are no widespread and wellestablished professional careers in the field and this does not attract sufficient interest within the education sector to
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develop and offer telehealth education programs. Lack of careers may also result in low demand from students who may fear limited professional prospects.
Conclusions The lack of E&T to provide systematic knowledge and skills has been highlighted as a key issue. This review suggests that there is very limited published evidence relating to the delivery of telehealth E&T. Compared with research into clinical aspects and technology in telehealth, E&T has so far been paid scant attention. Integration of telehealth involves a significant change in traditional practice, therefore requires a systematic change management approach. The provision of relevant knowledge, skills, and competencies to current and future telehealth practitioners is an important way to address this transition. Declaration of conflicting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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