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A new peer reviewed journal focused on research and applications for the health artificial intelligence (AI) community.

Khaled El Emam, PhD,   Canada Research Chair in Medical AI, University of Ottawa; Senior Scientist, Children’s Hospital of Eastern Ontario Research Institute: Professor, School of Epidemiology and Public Health, University of Ottawa, Canada

Bradley Malin, PhD, Accenture Professor of Biomedical Informatics, Biostatistics, and Computer Science; Vice Chair for Research Affairs, Department of Biomedical Informatics: Affiliated Faculty, Center for Biomedical Ethics & Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA

JMIR AI is a new journal that focuses on the applications of AI in health settings. This includes contemporary developments as well as historical examples, with an emphasis on sound methodological evaluations of AI techniques and authoritative analyses. It is intended to be the main source of reliable information for health informatics professionals to learn about how AI techniques can be applied and evaluated. 

JMIR AI is indexed in DOAJ , PubMed and PubMed Central .

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Explore the latest research in the field of digital health, including innovations in health care technologies, patient and caregiver education, participatory medicine, biomedical engineering and medical informatics.

Journal of Medical Internet Research

The leading peer-reviewed journal for digital medicine and health and health care in the internet age. June 2024 - Journal Impact Factor: 5.8. Q1 journal in "Medical Informatics" and "Health Care Sciences & Services" categories.(Source: Journal Citation Reports™ 2024 from Clarivate™)

JMIR mHealth and uHealth

Focused on health and biomedical applications in mobile and tablet computing, pervasive and ubiquitous computing, wearable computing and domotics. June 2024 - Journal Impact Factor: 5.4. Q1 journal in "Health Care Sciences & Services" and "Medical Informatics" categories. (Source: Journal Citation Reports™ 2024 from Clarivate™)

Digital health technologies, apps, and informatics for patient education, medicine and nursing, preventative interventions, and clinical care / home care for elderly populations. June 2024 - Journal Impact Factor: 5.0. Q1 journal in "Geriatrics & Gerontology", "Gerontology" and "Medical Informatics" categories. (Source: Journal Citation Reports™ 2024 from Clarivate™)

JMIR Mental Health

A journal focused on Internet interventions, technologies, and digital innovations for mental health and behavior change. Official journal of the Society for Digital Psychiatry. June 2024 - Journal Impact Factor: 4.8. Q1 journal in "Psychiatry" category. (Source: Journal Citation Reports™ 2024 from Clarivate™)

JMIR Serious Games

A multidisciplinary journal on gaming and gamification including simulation and immersive virtual reality for health education/promotion, teaching, medicine, rehabilitation, and social change. June 2024 - Journal Impact Factor: 3.8. Q1 journal in "Health Care Sciences & Services" category. (Source: Journal Citation Reports™ 2024 from Clarivate™)

JMIR Public Health and Surveillance

A multidisciplinary journal that focuses on the intersection of public health and technology, public health informatics, mass media campaigns, surveillance, participatory epidemiology, and innovation in public health practice and research. June 2024 - Journal Impact Factor: 3.5. Q1 journal in "Public, Environmental & Occupational Health" category (Source: Journal Citation Reports™ 2024 from Clarivate™)

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• v.19(1); 2017 Jan

Internet Health Information Seeking and the Patient-Physician Relationship: A Systematic Review

Sharon swee-lin tan.

1 Center for Health Informatics, Department of Information Systems, National University of Singapore, Singapore, Singapore

Nadee Goonawardene

2 SMU -TCS iCity lab, Singapore Management University, Singapore, Singapore

Associated Data

Critical Appraisal Skills Programme (CASP) quality assessment for qualitative studies.

Quality assessment tool for quantitative studies.

With online health information becoming increasingly popular among patients, concerns have been raised about the impact of patients’ Internet health information-seeking behavior on their relationship with physicians. Therefore, it is pertinent to understand the influence of online health information on the patient-physician relationship.

Our objective was to systematically review existing research on patients’ Internet health information seeking and its influence on the patient-physician relationship.

We systematically searched PubMed and key medical informatics, information systems, and communication science journals covering the period of 2000 to 2015. Empirical articles that were in English were included. We analyzed the content covering themes in 2 broad categories: factors affecting patients’ discussion of online findings during consultations and implications for the patient-physician relationship.

We identified 18 articles that met the inclusion criteria and the quality requirement for the review. The articles revealed barriers, facilitators, and demographic factors that influence patients’ disclosure of online health information during consultations and the different mechanisms patients use to reveal these findings. Our review also showed the mechanisms in which online information could influence patients’ relationship with their physicians.

Conclusions

Results of this review contribute to the understanding of the patient-physician relationship of Internet-informed patients. Our main findings show that Internet health information seeking can improve the patient-physician relationship depending on whether the patient discusses the information with the physician and on their prior relationship. As patients have better access to health information through the Internet and expect to be more engaged in health decision making, traditional models of the patient-provider relationship and communication strategies must be revisited to adapt to this changing demographic.

Introduction

As the Internet becomes a ubiquitous part of individuals’ information lives, most people have access to and are becoming comfortable with using the Internet for their information needs [ 1 ]. In health care, the rapid proliferation of health information on the Internet has resulted in more patients turning to the Internet as their first source of health information [ 2 - 4 ] and acquiring knowledge on their health conditions before seeking a professional diagnosis. Patients are feeling more empowered [ 5 , 6 ] and are more inclined toward being involved in their health and health decision making [ 7 ]. This may thus change the way in which patients interact with and participate in consultations with their physicians and how they feel about their relationship with their physicians.

Notwithstanding the potential benefits of Internet health information seeking, some concerns have been raised about the plausible negative effects of Internet health information seeking on patients. First, as online health information content can range from being peer reviewed or professionally reviewed to personal blogs, opinions, or anecdotes of other patients, information quality can vary, and patients may not possess the necessary skills to evaluate medical information and relate it to their own health circumstances [ 8 - 10 ]. As a consequence, online information can lead to patients’ being misinformed, lead to distress, and increase the tendency toward self-diagnosis or self-treatment [ 9 ]. Internet-informed patients may have more questions and may request additional treatments or medications during consultations [ 11 ]. Hence, online information can add a new interpretive role to physicians’ responsibilities during consultations [ 12 , 13 ]. Second, when patients’ online findings do not align with physicians’ diagnosis or treatments, concerns have been raised as to how a patient’s appointment satisfaction and trust in the physician would be affected [ 2 , 8 , 14 ] and how conflicts or even arguments could occur between the physician and patient [ 12 ]. This may then result in dissatisfied patients who may seek a second opinion, change the physician, change their treatment plan [ 15 ], or self-medicate using recommendations found on the Internet [ 16 ].

As patients’ Internet health information seeking becomes more pervasive, the expectations and needs of Internet-informed patients in their interactions with their physicians are expected to change. Thus, it is pertinent to have a comprehensive understanding of the influence of online health information on the patient-physician relationship. To the best of our knowledge, no review has synthesized and analyzed how patients’ Internet health information seeking affects the patient-physician relationship. The closest reviews we have found are by McMullan [ 17 ] and Wald et al [ 18 ]. McMullan [ 17 ] examined physicians’ reactions to online information and identified 3 possibilities: (1) physicians could feel threatened by the information and respond defensively by asserting their “expert opinion,” (2) physicians and patients could collaborate in obtaining and analyzing the information, and (3) physicians could guide patients to reliable health information websites. Wald et al [ 18 ] reviewed the past literature to identify the advantages and disadvantages of Internet-acquired information, and the challenges to providing guidelines to health care providers for effective interaction with Internet-informed patients.

The focus of this review was to systematically review and synthesize the existing research on Internet health information-seeking behavior and its impact on the patient-physician relationship to give implications for future research and practice. Specifically, our review sought to understand how and in what ways the Internet information search behavior of patients prior to consultations would affect doctor-patient encounters and patients’ relationships with their doctors. Our research question was “How and in what ways does patients’ Internet health information-seeking behavior influence the patient-physician relationship?”

Search Procedure

We systematically searched PubMed to identify articles and citations from January 1, 2000 to October 1, 2015. We also searched articles from key medical informatics journals and information systems journals ( Journal of the American Medical Informatics Association , International Journal of Medical Informatics , Journal of Medical Internet Research , Journal of Health Communication , Information Systems Research , Management Information Systems Quarterly , and Journal of the Association for Information Science and Technology ) to include additional relevant studies.

The search strategy included all possible combinations of keywords under 3 broad themes: (1) online OR Internet OR Web, (2) wellness information OR health information, (3) search* OR seek*. Further, we used the Medical Subject Headings (MeSH) “patient-physician relations” and “Internet” to perform a separate search in PubMed. PubMed searches yielded 3872 records, while journal searches yielded 452 records. We removed duplicate articles and screened the remaining articles in 2 stages. The first stage involved screening titles and abstracts to identify and exclude irrelevant articles. The remaining articles were then subjected to a second stage of screening of their main content. Figure 1 depicts the flow of the article selection procedure.

Search procedure for empirical studies on Internet-informed patients’ relationship with their physicians.

We included articles that were in English and were empirical studies focused on the Internet health information-seeking behavior of health care consumers and aspects of the patient-physician relationship. We excluded nonempirical articles, which included review articles, content assessment studies of websites, and research commentaries.

Analysis Procedure

We conducted this systematic review to analyze published empirical studies on Internet-informed patients’ relationship with their physicians. The 19 articles selected were first assessed for research quality, and 2 researchers independently performed the quality assessment. We assessed intercoder consistency at the end. As the selected articles were mainly empirical cross-sectional studies, we used quality assessment tools that were able to assess the methodological quality, findings, and contribution of the research articles. We evaluated qualitative studies using the Critical Appraisal Skills Programme quality assessment tool [ 19 ], which consists of 10 questions that assess the quality of the research methodology and the contribution of the qualitative studies. We assessed quantitative studies using a customized coding scheme that consists of 14 questions adapted from 3 well-established quality assessment tools used for quantitative studies (US National Heart, Lung, and Blood Institute quality assessment tool for observational, cohort, and cross-sectional studies [ 20 ], and quality assessment criteria proposed by Young and Solomon [ 21 ] and Davids and Roman [ 22 ]). Multimedia Appendices 1 and 2 present the 2 quality assessment tools used in this review. We assessed the intercoder consistency to determine the inclusion of articles for the review. All articles met the quality rating except for 1 article (the rating was <0.7 after the agreement of both researchers), which we thus removed from the final analysis.

The remaining 18 articles were then manually coded by 2 researchers based on preidentified themes: (1) patients’ discussion of online information during consultation, and (2) implications for the patient-physician relationship. During the coding process, both researchers independently identified subthemes and then added them to the existing themes upon agreement. Any disagreements were discussed and resolved before the final subthemes were confirmed. The first category included themes related to characteristics of doctor-patient consultations that led patients to reveal their online findings during visits with their doctor, such as strategies for using and revealing online information, facilitators of and barriers to discussion of online findings during consultations, and demographic factors affecting the discussion of online information. The second category, implications for the patient-physician relationship, focused on the influence of the patients’ Internet research on their relationship with the doctor, and include subthemes such as patients’ perception of a positive or negative impact on the patient-physician relationship, patients’ sense of control, confidence, and empowerment during the consultation, patients’ perceived consultation effectiveness, and patient satisfaction.

Characteristics of Included Articles

Our initial PubMed and journal search returned over 4000 titles and citations. By applying the inclusion and exclusion criteria, we identified 744 records for further screening based on the title and abstract. Of these, we retained 316 articles for content screening, and then selected 19 peer reviewed journal articles that met the review criteria. Of the rejected articles, 228 focused on patients’ Internet health information seeking but did not address patient-physician relationship aspects. In 30 articles, the Internet was not the primary source of information. Of the remaining articles, 16 were not empirical studies, 11 were not about active information seeking, 5 were not available in full-text version, 3 were not in English, 2 focused only on postconsultation information seeking, and 2 focused on professional information seeking. Finally, we excluded 1 article among the 19 during the quality assessment procedure, leaving only 18 articles for the review. Of these 18 articles, 7 used surveys to gather data, 6 used interviews, 3 used semistructured interviews, and 2 used a mixed-methods approach. All articles were published within the period of 2003 to 2015 (see Table 1 and Table 2 for the complete list of articles and summaries) [ 3 , 4 , 7 , 12 , 15 , 23 - 35 ].

Summary of articles on Internet-informed patients’ relationship with their physicians.

Summary of findings of the articles.

Of the 18 articles, 6 focused primarily on the implications for the patient-physician relationship, 2 studied the discussion of online information with physicians, and the rest studied both themes.

Discussion of Online Information With Physicians

Of the 18 articles reviewed, 12 examined patients’ discussion of information they found on the Internet with their physicians. These studies examined this category along 4 themes: (1) strategies patients use to reveal their Internet information searches, (2) facilitators of and (3) barriers to the discussion of online findings, and (4) demographic factors affecting discussion of online findings. Table 3 summarizes the themes and subthemes related to patients’ discussion of online information with physicians covered by each study. are summarized in Table 3 .

Themes and subthemes on patients’ discussion of online information with physicians.

Strategies for Using and Revealing Online Information

A total of 3 articles examined strategies patients used to reveal their online findings during their doctor visits. These studies found 5 different strategies to be used by patients who brought online information to their consultations. These strategies were asking additional questions [ 4 , 12 ], making suggestions based on their online findings [ 12 ], directly disclosing online findings [ 12 ], verifying silently without asking any questions [ 4 , 12 ], and bringing printouts of online information [ 12 ]. Asking additional questions would allow patients to clarify contradictory points between their own view and the information from the physician. Making suggestions on different diagnostics and treatments would be helpful to patients in verifying their personal interpretations of online health information. Patients who preferred concealing their Internet search discussed online information without directly revealing that they had found the information on the Internet [ 4 , 12 , 26 ]. However, some patients preferred more accurate verification of their online findings by showing printouts of their Internet research to prompt discussions during consultations [ 12 ]. In fact, patients who directly disclosed online findings preferred critical appraisals from physician and appreciated their physician’s evaluations. Patients who silently verified their Internet search results did so to avoid interrupting the diagnosis process [ 12 ].

Facilitators of and Barriers to Discussion of Online Findings During Consultations

Silver [ 25 ] highlighted 3 facilitating factors that encouraged patients to discuss online health information with their physicians: (1) having a family member present at doctor visits, (2) doctor-initiated inquiries, and (3) encountering a treatment-related advertisement that suggested talking with a doctor. Having a family member present would help patients remember what to ask and made the context more comfortable to share online findings. Online advertisements or recommendations about certain medications and treatment options that contained information believed relevant to their own health condition prompted some patients to initiate a conversation with their physicians [ 25 ]. Further, some patients reported incidences of doctors’ positively encouraging patients to search the Internet for information [ 3 ]. These factors spurred patients to communicate their Internet research findings during consultations. In a study by Newnham et al [ 29 ], more than half of the patients who searched for online information prior to consultations had discussed information obtained in their search with their physician and had found their physician to be willing to discuss this information.

A total of 8 studies examined barriers to patients’ willingness to discuss their online findings with their physicians during consultations. The most common reason found was that patients were usually skeptical of how physicians would react to the knowledge they acquired through the Internet: patients were afraid doctors would perceive them as challenging doctors’ opinion if they directly revealed their online findings to their doctors [ 28 ]. Patients were mindful in ensuring that doctors played the central role during consultations [ 27 ]. They feared that revealing their knowledge gained from Internet searches would be an insult to professional health care providers [ 25 ] who could feel criticized or have an unchangeable preconceived view [ 27 ]. For example, Chiu [ 30 ] showed that patients cautiously made an effort not to offend doctors with their online findings. Patients expressed concerns over how physicians may perceive them as being “challenging” and “confrontational” if they discussed their health condition from a more informed point of view during consultations [ 28 ].

The second most common barrier for patients was the resistance or discouragement from physicians encountered when patients tried to discuss their Internet information research during consultations. Patients felt physicians’ resistance toward them when they tried to discuss with their physicians the health information they had found on the Internet on their conditions or even about day-to-day health management [ 3 , 7 ]. Patients also felt that some physicians reacted in a way that implicitly or explicitly discredited the patients’ ability to become informed via the Internet, presenting serious barriers to shared decision making during consultations, with the physicians asserting their authority by dismissing patient-acquired knowledge [ 7 , 26 ]. Patients felt that physicians were employing strategies to avoid online information-related dialogues or that they briefly answered patients’ queries with short answers to reclaim the traditional consultation model of one-way information provision. As a result, patients carefully observed their physicians before deciding whether to reveal their Internet research [ 25 , 30 ], and patients would only bring up their Internet health searches if they felt the situation was right.

A third major barrier was the fear of embarrassment [ 25 ]. Patients who identified this to be a barrier felt they did not possess the required skill set to evaluate online medical information. They had a lower level of confidence in the trustworthiness and the credibility of online information. They manifested a sense of being unsure of how to explain the information they found and how to relate it to their own condition, and hence did not want to mention it to their physicians.

Finally, other than the main barriers, some patients did not discuss their findings during consultations because they did not think the information was important enough and they searched the Internet just to be informed [ 15 ]. Other reasons for not revealing their online findings were a reluctance to interfere with physicians’ diagnostic process [ 12 ] and lack of time during doctor visits [ 12 ].

Demographic Factors Affecting Discussion of Online Information

The impact of patients’ demographic characteristics on their decision to discuss online health information with health care providers was studied in 4 studies. These studies examined demographic characteristics such as culture [ 30 ], sex [ 24 ], age, having children [ 31 ], health status [ 15 ], health literacy [ 24 ], and eHealth literacy [ 15 ]. Chiu [ 30 ] addressed the cultural influence on patient-physician encounters and patients’ Internet research. In a culture where the hierarchy of the patient-physician relationship is deemed to be like that of a son to a father, physicians have absolute authority to decide on the treatment, and patients must absolutely trust their doctors [ 36 ]. For such patients, even though online information empowered them with the knowledge to have a better discussion with doctors, they tended to do so cautiously, with an effort not to offend doctors and to assume greater responsibility in trying to understand their doctors’ advice with their knowledge gained from online health information.

The impact of sex was studied in a study by Chung [ 24 ], which showed that men were more likely than women to have a conversation regarding online health information with their physicians. Russ et al [ 31 ] showed that the average age of those who shared online information with doctors tended to be higher and they tended to have more children under the age of 18 years. Murray et al [ 15 ] found that people in poor health were more likely to talk to their physicians about online health information than were those in good health. Further, Chung [ 24 ] also showed that patients with low health literacy or who had trouble trusting online health information were not more likely to ask questions or to seek guidance during consultations. In contrast, Murray et al [ 15 ] showed that self-rated ability to critically appraise online health information was positively related to patients’ decision to discuss online information during consultations. Patients who rated themselves as excellent or very good at assessing the reliability of information on the Internet were more likely to take information to their physicians than were those who were not confident in assessing the reliability of Internet information [ 15 ].

Implications for the Patient-Physician Relationship

A total of 15 articles studied the implications of patients’ online health information seeking for the patient-physician relationship. Of these, 8 studies focused on the patients’ perceptions of positive and negative implications for the patient-physician relationship, while 10 studies examined the indirect effects on the patient-physician relationship (ie, patients’ sense of control, confidence, and empowerment, perceived consultation efficacy, and patient satisfaction). Table 4 summarizes the themes and subthemes related to implications for the patient-physician relationship covered by each study.

Themes and subthemes on implications of patient-physician consultation for the patient-physician relationship.

Patients’ Perception of Positive or Negative Impact on the Patient-Physician Relationship

Of the 18 studies, 8 examined the factors directly affecting the patient-physician relationship. In the studies we reviewed, a greater proportion of participants were found to believe that Internet health information seeking did not adversely affect their relationship with physicians [ 3 , 29 , 33 , 34 ]. In the study by Newnham et al [ 29 ], 40% of patients felt the patient-physician relationship was unaffected by information searching, 24% felt it improved the relationship, and only 8% felt it adversely affected the relationship. However, the articles we reviewed showed that the effect of online information on the patient-physician relationship depended on several factors.

First, 5 studies showed the effect of patients’ discussion of their online findings with physicians. AlGhamdi and Moussa [ 33 ] reported that 45% had searched the Internet for health information before coming to the clinic; 72.5% of those discussed the information with their doctors, and 71.7% of those who did so believed that this positively affected their relationship. Patients who perceived their information search to have improved their relationship with physicians saw the Internet as an additional resource that supported doctors’ advice and enhanced the relationship with doctors [ 3 ]. They valued their relationship with their doctors and expected doctors to be more welcoming toward their Internet health research [ 15 ]. The positive influence of online information was stronger when patients had an opportunity to discuss their online findings [ 31 , 33 , 34 ].

On the other hand, bringing up online information during consultations also resulted in conflicts between patients and physicians. Conflicts stemming from different interpretation of online health information led to intensive discussions with physicians and patients [ 12 ]. Further, when patients valued the information they found on the Internet above their physicians’, this information led patients to ignore physicians’ expertise [ 12 ].

Second, Murray et al [ 15 ] found that how physicians reacted to patients when they shared their online findings during consultations could determine the positive or negative effect on the relationship’s quality. When patients perceived physicians to be threatened by their bringing online information, 49% of the patients were seriously dissatisfied with the consultation and 4% believed their relationship was worsened [ 15 ]. Bringing information was found to have a positive effect when the physician did not appear challenged by the online information [ 7 , 12 , 15 ].

Third, 1 study we reviewed showed the effect of physicians’ communication skills when patients discussed their online findings. Patients felt that the relationship was strengthened when physicians displayed adequate communication skills in discussing patients’ queries [ 15 ].

Fourth, Schrank et al [ 27 ] showed the influence of the quality of the existing relationship with physicians when patients assessed their physicians’ reaction during the discussion of online information. Patients judged their physicians’ reactions as mostly positive when they had a good prior relationship, even when the doctors’ replies were evasive or openly critical of the patients’ Internet search [ 27 ].

Fifth, 2 studies examined the influence of patients’ demographic characteristics on their assessment of physicians’ reaction to online information [ 15 , 24 ]. Murray et al [ 15 ] showed that most patients felt their physicians reacted positively to online health information, but those who felt their physicians were challenged tended to be uninsured patients, who described themselves as excellent or very good at critically appraising information on the Internet. Further, Chung [ 24 ] showed that physicians’ reactions to online information was perceived as negative by patients who experienced poor health, and they also had more concerns about the quality of the health information they sought on the Internet.

Patients’ Sense of Control, Confidence, and Empowerment During Consultation

A total of 5 articles reviewed examined the effect of Internet health information search on patients’ empowerment, perceived confidence, and control during a consultation. Murray et al [ 15 ] showed that patients felt more in control and confident during the consultation as a result of bringing information to their physicians. Patients also felt more confident in their physicians’ diagnosis once they had discussed their online findings [ 4 , 15 , 32 ]. Further, Internet search behavior led patients to experience a sense of control and therefore enter into a comprehensive negotiation with their specialist [ 7 ].

Of the studies we reviewed, 3 found that online health information can empower patients [ 23 , 35 ] to play a more active role in their disease management. A study of prostate cancer patients showed how the Internet affected their decision-making ability. Online information empowered them “to do something” rather than “just being told what to do” by their specialist [ 7 ]. Internet search provided clarity in terms of treatment options and, as a result, diminished patients’ reliance on their specialists.

Although Internet information search was shown to shift the subjectively perceived hierarchy between the doctor and the patient [ 27 ], patients still valued traditional doctor-patient consultations as important to their understanding of online health information [ 27 ]. The patients’ sense of empowerment was dependent on how receptive providers and specialists were to the patients’ desire to take part in the decision-making process [ 7 ]. Doctors’ resistance toward discussing online findings was found to result in higher levels of anxiety, confusion, and frustration.

Patients’ Perceived Consultation Effectiveness

In the studies we reviewed, most patients felt that Internet health information seeking prior to consultations had improved their communication with doctors and the effectiveness of their consultations. First, participants who searched for online health information prior to their consultations felt better equipped to communicate with their physicians during the consultations [ 23 , 35 ]. They believed the patient-physician communication had improved because they could understand their doctors and the jargon they used better [ 30 ]. Kivits [ 4 ] also found that, by discussing information they had accessed on the Internet or setting questions in advance, patients were able to better understand and participate in consultation sessions with their doctors.

Second, patients who searched the Internet for information prior to the consultation felt more confident and comfortable with the doctor’s advice. Ybarra and Suman [ 32 ] showed that a majority of patients had felt more comfortable with information from health care providers because of their Internet searches. Patients felt more informed as they used the knowledge gained from Internet searches to check and complete the information received from doctors. Further, discussions with physicians were found to give patients greater clarity, orientation, and certainty [ 12 ]. On the other hand, when physicians exerted resistance to patients’ online information sharing during consultations, it created a barrier to receiving effective care from the physician [ 7 ].

Patient Satisfaction

Only 2 studies examined the influence of patient satisfaction on the patient-physician relationship. Russ et al [ 31 ] found that online information seekers felt they had received satisfactory information about their health from their physician when compared with nonseekers. The appointment satisfaction of physicians and patients was found to be significantly higher when online health information was discussed [ 28 ], even if the information was not explicitly stated to be from the Internet. Patients who shared online information felt that they received more attention from their physician, compared with nonsharers [ 31 ].

Principal Findings

Based on our review of the 18 empirical studies that examined patients’ Internet health information seeking and the implications for the patient-physician relationship, we found that a greater proportion of patients did not feel that their Internet health information-seeking activities had an adverse impact on the patient-physician relationship [ 3 , 29 , 33 , 34 ]. The recent proliferation of health information on the Internet has resulted in a shift in the traditional information balance [ 37 , 38 ], where patients are increasingly equipped with health information related to their conditions, eroding the prior exclusivity of health information among health professionals. However, our findings show that patients’ positive attitude toward physicians did not change unless physicians imposed restrictions on their online information sharing during consultations (eg, [ 3 , 7 , 26 ]). Patients went on the Internet mostly to be actively involved in the decision making related to their health. Patients still valued consultations with physicians [ 27 ], and their trust in physicians remained very high [ 26 , 27 ]. Patients used the information found on the Internet to help them prepare for their visit, ask better questions, and understand what the physicians told them. These were shown to empower patients to play a more active role in their disease management and to be more effective in understanding and communicating with their physicians [ 32 ]. Internet-informed patients were also more confident in and comfortable with their physicians’ advice [ 15 ].

In the studies we reviewed, some looked at how Internet health information seeking affected the patient-physician relationship, while others focused on how patients’ use of the online health information affected the patient-physician relationship. Although we identified 5 different types of strategies in the literature (including silently verifying information, bringing printouts, explicitly verifying information by asking questions, and asking extra questions without directly revealing their Internet search), most studies focused simply on whether patients discussed the online health information during physician consultations and the associated outcomes. Among these studies, evidence showed that patients experienced a better patient-physician relationship when they had the opportunity to discuss their online health information with their physicians, and their physicians were receptive to discussing the online information. However, if patients experienced resistance from their physicians to their discussion of online information, patients were found to become frustrated and anxious [ 7 ] and would withhold their discussion [ 3 , 7 ]. Conflicts arising from physicians and patients having different interpretations of the online information and when patients valued this information more also had adverse implications for the patient-physician relationship [ 12 ]. In general, we found more evidence of positive than of negative implications of discussing online health information.

As patients become better informed and like to be more actively involved in decision making about their health, traditional models of the patient-physician relationship need to be adapted to patients’ changing needs by incorporating their perspective into a relationship-centered medical paradigm [ 39 ]. In contrast to the physician-centric paternalistic models of care, a deliberative or participatory model has been recommended for encounters with Internet-informed patients [ 40 ], where physicians delineate the patients’ clinical situation and provide help in explaining and deciding on the available options [ 41 ]. Under this model of care, the physician acts as a teacher or a friend by engaging patients in a dialogue through the decision-making process [ 39 ].

Allowing or encouraging patients to discuss their Internet information searches with physicians is increasingly important, given that acquiring information on the Internet has the potential to misguide patients with inaccurate information and make them excessively anxious [ 8 ]. Therefore, the information patients wish to use in decision making ought to be verified to ensure that it is based on facts [ 40 ]. Additionally, not disclosing their Internet information searches could erode patients’ trust in their physicians if the diagnosis or the recommendations are different from their Internet research findings [ 2 ]. Our findings showed that enabling patients to communicate their Internet research was one of the key mechanisms to ensure that patients’ opinion was valued and to enhance physicians’ relationships with their Internet-informed patients. When physicians embrace openness to online information [ 7 , 12 , 15 , 24 ] and encourage patients to discuss the online information they have, patients’ perception of physician resistance and fear of embarrassment could be reduced and patients are more likely to discuss online information with their physicians.

Research Gaps

In interpreting our findings, we should take note of the various research gaps in the existing studies. First, these empirical studies were primarily based on cross-sectional surveys, focus groups, or interview data, or a combination of these. Most of the results are descriptive, making it difficult to ascertain the causal effect of Internet health information seeking on the patient-physician relationship. In order to quantify the causal relationship between influencing factors and the quality of the patient-physician relationship, future research could involve more quantitative approaches, such as field experiments or surveys carried out in multiple waves. Second, the studies we reviewed focused mainly on understanding the patients’ perspectives, and hence our conclusions are limited to their perspectives, which might differ from those of physicians. Future research should explore physicians’ perspectives on patients’ Internet health information-seeking behavior and how physicians’ communication strategies during consultations could affect the patient-physician relationship.

Limitations

We should also interpret our findings in the light of these limitations. First, the search criterion we used for retrieving the studies was initially broad to cover all the aspects that have been studied in relation to patients’ active Internet health information seeking. As there is no consistent terminology for the patient-physician relationship and its related dimensions, our main search query did not include MeSH terms. This may have resulted in missing out potentially relevant articles. However, we mitigated this limitation by performing a second round of search with a basic MeSH query. Second, we considered only articles that were in English. Therefore, we excluded several non-English articles from our review.

Results of this review contribute to the understanding of the influence of health information sought by patients on the Internet on the patient-physician relationship. In contrast to the belief that patients’ Internet research can erode the patient-physician relationship [ 2 ], our findings show that patients’ Internet health information seeking has the potential to improve the relationship [ 3 , 27 , 29 , 33 , 34 ]. Patients typically see the Internet as an additional resource that can help them to better understand doctors’ recommendations and advice [ 3 ]. Thus, it has the potential to change the structure of the traditional patient-physician relationship [ 27 , 38 ] from one where patients perceive health care providers as the sole custodians of medical information [ 42 ]. Further research needs to be carried out to understand the needs and wants of Internet-informed patients, how physicians can adapt to this shift, and how traditional patient-physician relationship models must be adapted to meet the changing health paradigm.

Acknowledgments

This research was supported by Ministry of Education Singapore grant no. R253-000-100-112.

Abbreviations

Multimedia Appendix 1

Multimedia appendix 2.

Conflicts of Interest: None declared.

JMIR Public Health and Surveillance

A multidisciplinary journal that focuses on the intersection of public health and technology, public health informatics, mass media campaigns, surveillance, participatory epidemiology, and innovation in public health practice and research..

Travis Sanchez, DVM, MPH, Emory University Rollins School of Public Health, USA

JMIR Public Health & Surveillance (JPHS, Editor-in-chief: Travis Sanchez, Emory University/Rollins School of Public Health) is a top-ranked (Q1)  Clarivate (SCIE, SSCI etc) , Scopus ,  PMC/PubMed ,  MEDLINE , CABI, and EBSCO/EBSCO essentials indexed, peer-reviewed international multidisciplinary journal with a unique focus on the intersection of  innovation and technology in public health , and includes topics like public health informatics, surveillance (surveillance systems and rapid reports), participatory epidemiology, infodemiology and infoveillance, digital disease detection, digital epidemiology, electronic public health interventions, mass media/social media campaigns, health communication, and emerging population health analysis systems and tools. In June 2024, JPHS received an impact factor of 3.5.   JMIR Public Health and Surveillance received a CiteScore of 13.7, placing it in the 97th percentile (#18 of 665) as a Q1 journal in the field of Public Health, Environmental and Occupational Health.

JPHS has an international author- and readership and welcomes submissions from around the world.

We publish  regular articles, reviews, protocols/system descriptions and viewpoint  papers on all aspects of public health, with a focus on innovation and technology in public health.  The main themes/topics covered by this journal can be found here.

Apart from publishing traditional public health research and viewpoint papers as well as reports from traditional surveillance systems, JPH was one of the first (if not the only) peer-reviewed journals to publish papers with surveillance or pharmacovigilance data from non-traditional, unstructured big data and text sources such as social media and the Internet ( infoveillance , digital disease detection), or reports on novel participatory epidemiology projects, where observations are solicited from the public.  

Among other innovations, JPHS is also dedicated to support rapid open data sharing and rapid open access to surveillance and outbreak data. As one of the novel features we plan to publish rapid  or even real-time  surveillance reports and open data. The methods and description of the surveillance system may be peer-reviewed and published only once in detail, in a  "baseline report" (in a JMIR Res Protoc or a JMIR Public Health & Surveill paper), and authors then have the possibility to publish data and reports in frequent intervals rapidly and with only minimal additional peer-review (we call this article type "Rapid Surveillance Reports"). JMIR Publications may even work with authors/researchers and developers of selected surveillance systems on APIs for semi-automated reports (e.g. weekly reports to be automatically published in JPHS and indexed in PubMed, based on data-feeds from surveillance systems and minimal narratives and abstracts).

Furthermore, during epidemics and public health emergencies, submissions with critical data will be processed with expedited peer-review to enable publication within days or even in real-time.

We also publish descriptions of open data resources and open source software. Where possible, we can and want to publish or even host the actual software or dataset on the journal website.

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Digital technologies have become more important in the health care sector in the past decades. This transition from conventional to digital health care has been accelerated by the impact of the COVID-19 pandemic, which poses the risk of creating a “digital divide,” inadvertently placing those who are older, economically disadvantaged, and have a lower level of education at a disadvantage.

Personality has an impact on the health-related quality of life (HRQoL) of older adults. However, the relationship and mechanisms of the two variables are controversial, and few studies have been conducted in older adults.

Traditional public health surveillance efforts are generally based on self-reported data. Although well validated, these methods may nevertheless be subjected to limitations such as biases, delays, and costs or logistical challenges. An alternative is the use of smart technologies (eg, smartphones and smartwatches) to complement self-report indicators. Having embedded sensors that provide zero-effort, passive, and continuous monitoring of health variables, these devices generate data that could be leveraged for cases in which the data are related to the same self-report metric of interest. However, some challenges must be considered when discussing the use of mobile health technologies for public health to ensure digital health equity, privacy, and best practices. This paper provides, through a review of major Canadian surveys and mobile health studies, an overview of research involving mobile data for public health, including a mapping of variables currently collected by public health surveys that could be complemented with self-report, challenges to technology adoption, and considerations on digital health equity, with a specific focus on the Canadian context. Population characteristics from major smart technology brands—Apple, Fitbit, and Samsung—and demographic barriers to the use of technology are provided. We conclude with public health implications and present our view that public health agencies and researchers should leverage mobile health data while being mindful of the current barriers and limitations to device use and access. In this manner, data ecosystems that leverage personal smart devices for public health can be put in place as appropriate, as we move toward a future in which barriers to technology adoption are decreasing.

The Coronavirus Disease 2019 (COVID-19) pandemic resulted in a massive disruption in access to care and thus passive, hospital and clinic-based surveillance programs. In 2020, the reported cases of Lyme disease were the lowest both across the United States and North Carolina in recent years. During this period, human contact patterns began to shift with higher rates of greenspace usage and outdoor activities, putting more people into contact with potential vectors and associated vector borne diseases. Lyme disease reporting relies on passive surveillance systems which was likely disrupted by changes in health care seeking behavior during the pandemic.

Understanding the factors contributing to mental well-being in youth is a public health priority. Self-reported enthusiasm for the future may be a useful indicator of well-being and has been shown to forecast social and educational success. Typically, cross-domain measures of ecological and health-related factors with relevance to public policy and programming are analyzed either in isolation or in targeted models assessing bivariate interactions. Here, we capitalize on a large provincial data set and machine learning to identify the sociodemographic, experiential, behavioral, and other health-related factors most strongly associated with levels of subjective enthusiasm for the future in a large sample of elementary and secondary school students.

Little is known about post–hospital health care resource use (HRU) of patients admitted for severe COVID-19, specifically for the care of patients with postacute COVID-19 syndrome (PACS).

With the development of science and technology and health literacy improvement, more studies have focused on frailty prevention by promoting medication adherence, emphasising the role of eHealth literacy. However, the association between eHealth literacy and medication adherence in frail older adults has not been well studied, and it is unknown whether there are urban-rural variances in their relationship.

Young men who have sex with men and young transgender women (YMSM-YTW) utilize online spaces to meet sexual partners with increasing regularity, and research shows that experiences of racism in these virtual spaces mimic the real world. Quantitative evidence to demonstrate that racial/ethnic minority YMSM-YTW utilize and meet sexual partners online and through mobile apps differently than White non-Hispanic YMSM-YTW is limited.

Drug users (DUs) are considered one of the high-risk groups for HIV infection and play a crucial role in the transmission of HIV. Under the emerging of new drugs, we aim to explore the drug using behaviors currently, HIV infections and the correlation between drug using behaviors and HIV infection risk among drug users from 2014-2021.

The COVID-19 pandemic prompted the launch of the US Department of Health and Human Services’ COVID-19 Public Education Campaign to boost vaccine confidence and uptake among adults, as vaccines are key to preventing severe illness and death.

Hand, Foot and Mouth Disease (HFMD) is a notable infectious disease predominantly affecting infants and children worldwide. Previous studies on HFMD have primarily focused on natural patterns, such as seasonality, but research on the influence of important social time points is lacking. Several studies have indicated correlations between birthdays and certain disease outcomes.

The COVID-19 pandemic highlighted gaps in the public health workforce’s capacity to deploy digital technologies, while upholding ethical, social justice and health equity principles. Existing public health competency frameworks have not been updated to reflect the prominent role digital technologies play in contemporary public health, and public health training institutions are seeking to integrate digital technologies in their curricula.

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Treatment of COVID-19 patients with a SARS-CoV-2-specific siRNA-peptide dendrimer formulation

Affiliations.

• 1 National Research Center (NRC) Institute of Immunology Federal Medical-Biological Agency (FMBA) of Russia, Moscow, Russia.
• 2 Pirogov Russian National Research Medical University, Moscow, Russia.
• 3 RUDN University, Moscow, Russia.
• 4 I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 5 Federal State Unitary Enterprise "The Saint Petersburg Scientific Research Institute of Vaccines and Serums and the Enterprise for the Production of Bacterial Preparations" of Federal Medical and Biologic Agency (FSUE SPbSRIVS FMBA of Russia), St. Petersburg, Russia.
• 6 North-West District Scientific and Clinical Center named after L.G. Sokolov Federal Medical and Biological Agency, St. Petersburg, Russia.
• 7 Federal Clinical Center of High Medical Technologies of the Federal Medical and Biological Agency of Russia, Moscow, Russia.
• 8 Federal Medico-biological Agency of Russia (FMBA Russia), Moscow, Russia.
• 9 Centre for Evaluation and Control of Finished Pharmaceutical Products, Federal State Budgetary Institution "Scientific Centre for Expert Evaluation of Medicinal Products" of the Ministry of Health of the Russian Federation, Moscow, Russia.
• 10 Centre for Strategic Planning of FMBA of Russia Federal State Budgetary Institution "Centre for Strategic Planning and Management of Biomedical Health Risks" of the Federal Medical Biological Agency, Moscow, Russia.
• 11 Medical University of Vienna, Vienna, Austria.
• 12 Karl Landsteiner University of Healthcare, Krems, Austria.
• PMID: 36721963
• DOI: 10.1111/all.15663

Background: Severe acute respiratory syndrome corona virus (SARS-CoV-2) infection frequently causes severe and prolonged disease but only few specific treatments are available. We aimed to investigate safety and efficacy of a SARS-CoV-2-specific siRNA-peptide dendrimer formulation MIR 19® (siR-7-EM/KK-46) targeting a conserved sequence in known SARS-CoV-2 variants for treatment of COVID-19.

Methods: We conducted an open-label, randomized, controlled multicenter phase II trial ( NCT05184127 ) evaluating safety and efficacy of inhaled siR-7-EM/KK-46 (3.7 mg and 11.1 mg/day: low and high dose, respectively) in comparison with standard etiotropic drug treatment (control group) in patients hospitalized with moderate COVID-19 (N = 52 for each group). The primary endpoint was the time to clinical improvement according to predefined criteria within 14 days of randomization.

Results: Patients from the low-dose group achieved the primary endpoint defined by simultaneous achievement of relief of fever, normalization of respiratory rate, reduction of coughing, and oxygen saturation of >95% for 48 h significantly earlier (median 6 days; 95% confidence interval [CI]: 5-7, HR 1.75, p = .0005) than patients from the control group (8 days; 95% CI: 7-10). No significant clinical efficacy was observed for the high-dose group. Adverse events were reported in 26 (50.00%), 25 (48.08%), and 28 (53.85%) patients from the low-, high-dose and control group, respectively. None of them were associated with siR-7-EM/KK-46.

Conclusions: siR-7-EM/KK-46, a SARS-CoV-2-specific siRNA-peptide dendrimer formulation is safe, well tolerated and significantly reduces time to clinical improvement in patients hospitalized with moderate COVID-19 compared to standard therapy in a randomized controlled trial.

Keywords: SARS-CoV-2; clinical trial; efficacy; safety; siRNA.

© 2023 The Authors. Allergy published by European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.

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This paper is in the following e-collection/theme issue:

Published on 24.11.2020 in Vol 22 , No 11 (2020) : November

Telemedicine in the United States: An Introduction for Students and Residents

Authors of this article:

• Maryam A Hyder 1   ; 
• Junaid Razzak 2 , MBBS, PhD  

1 Barnard College, New York, NY, United States

2 Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States

Corresponding Author:

Junaid Razzak, MBBS, PhD

Department of Emergency Medicine

Johns Hopkins School of Medicine

5801 Smith Ave

Baltimore, MD, 21209

United States

Phone: 1 410 735 6450

Email: [email protected]

Telemedicine refers to the delivery of medical care and provision of general health services from a distance. Telemedicine has been practiced for decades with increasing evidence proving its potential for enhanced quality of care for patients, reduction in hospital readmissions, and increase in savings for both patients and providers. The COVID-19 pandemic has resulted in a significant increase in the reliance on telemedicine and telehealth for provision of health care services. Developments in telemedicine should be structured as complements to current health care procedures, not with the goal of completely digitizing the entire health care system, but rather to use the power of technology to enhance areas that may not be working at their full potential. At the same time, it is also clear that further research is needed on the effectiveness of telemedicine in terms of both financial and patient benefits. We discuss the current and rapidly increasing knowledge about the use of telemedicine in the United States, and identify the gaps in knowledge and opportunities for further research. Beginning with telemedicine’s origins in the United States to its widespread use during the COVID-19 pandemic, we highlight recent developments in legislation, accessibility, and acceptance of telemedicine.

Introduction

The World Health Organization (WHO) defines digital health as the use of digital technologies for health purposes, a category that encompasses the increasing use of technologies for health services [ 1 ]. Related to digital health is telemedicine; telemedicine seeks to harness the growing role of technology to create more effective health care, and is part of a larger movement of digital health services. Table 1 [ 1 , 2 ] provides definitions of various terms used under the broad scope of digital health and their relationship to each other. These terms have some minor differences, but are important to recognize as relevant to the overall discussion of digital health. Our focus in this paper, however, is specifically telemedicine: its history, its uses, and its importance.

a According to the World Health Organization [ 1 ].

b The American Telemedicine Association considers telemedicine to be synonymous with telehealth [ 2 ].

In the United States, 76% of hospitals connect with patients using some form of telemedicine [ 3 ]. Kane and Gillis identified physicians practicing in radiology (39.5%), psychiatry (27.8%), and cardiology (24.1%) as the most frequent users of telemedicine [ 3 ].Telemedicine not only is effective for provider-patient interactions but also creates a more connected network between health care professionals. The specialties reported to most commonly use telemedicine to communicate with other health care professionals were emergency medicine (38.8%), pathology (30.4%), and radiology (25.5%) [ 3 ]. With increasing need for a multidisciplinary approach to care and patient-provider partnerships, telemedicine has helped further strengthen connections between patients, health care providers, and other stakeholders. In the face of the COVID-19 pandemic, the relevance of telemedicine has become even more acute. Use of telemedicine has been rapidly promoted, and laws on its coverage are rapidly changing.

Here we provide a background of the increasing use of telemedicine in the United States and emphasize its relevance for medical students and residents. Beginning with telemedicine’s origins in the United States to its widespread use during the COVID-19 pandemic, we highlight developments in legislation, accessibility, and acceptance of telemedicine. Omitted from this review are comprehensive descriptions of the technical aspects of telemedicine, as well as newer developments in technology such as artificial intelligence. This review is meant to be a starting point for students, and thus we omit more technical information for the sake of brevity and focus.

History of Telemedicine in the United States

In the United States, one of the early uses of telemedicine was established by the National Aeronautics and Space Association (NASA) in 1960, for monitoring astronauts in flight by physicians and medical teams during their mission Project Mercury [ 4 ]. NASA designated “medical monitors” to become well-versed in the astronauts’ medical history, while conducting research on the effect of the environment of outer space on the human body. Teams of medical observers were positioned at 18 sites across North America, Europe, Africa, and Australia. Their role was to observe and preserve the health of the astronauts by providing medical advice when needed and consistently evaluating their condition [ 4 ]. As NASA demonstrated, using telecommunications to establish contact between health care providers and patients can allow for greater availability of, and access to, health care beyond what was previously conceived as possible. Understanding this great potential that telemedicine holds for increased connectivity, the US National Library of Medicine, in 1966, designated US $42 million for multiple telemedicine projects spanning over 19 years targeted to medically isolated—rural, inner city, and suburban—areas [ 5 ].

Approaches to Telemedicine

Telemedicine use in various fields of medicine.

In the United States there are several successful and active models of telemedicine and telehealth, demonstrating their potential. In 2013, there were approximately 4 neurologists per 100,000 people in the country, caring for over 700,000 strokes per year [ 6 ]. To deal with the shortage of neurologists, several hospitals and offices implemented telemedicine measures specifically for stroke treatment, or telestroke. Telestroke refers to a common method used in emergency departments to access specialist neurologists, reducing the need for in-house experts. Using telemedicine, neurologists can communicate remotely with emergency physicians and patients with stroke and recommend treatment faster than previously available [ 6 ]. This is especially helpful for smaller, rural hospitals that do not have specific specialists for a vast range of conditions compared with larger urban medical centers [ 7 ]. Hospitals’ use of telestroke enables patients to go to their nearest hospital while still receiving the specialized emergency care they require, and thus all patients are given equal chances of survival [ 6 ].

Telemedicine has also been particularly useful in radiology, since nearly all radiology examinations produce digital content, known as teleradiology. In 2014, teleradiology was reported to account for more than half of all telemedicine services performed in the United States [ 8 ]. Images and reports collected from either in-person or telemedicine examinations can be transmitted to a remote radiologist, whose report can be sent to the patient’s physician or other health care providers. Particularly in areas where there is a shortage of radiologists, teleradiology supplements that shortage by eliminating the in-person meeting between patient and radiologist, as well as providing quicker readings and results to patients [ 9 ].

Even fields that traditionally have depended on face-to-face communications, such as psychiatry, have been able to provide care of comparable quality using telemedicine. As of 2016, a mere 43.1% of the 44.7 million Americans with any sort of mental illness had used mental health services in the United States [ 10 ]. Being able to provide care to more Americans with mental illness through telepsychiatry could have a profound effect. The University of Rochester in Rochester, NY, USA created a telepsychiatry program that is available from 8:30 AM to 5:00 PM, Monday through Friday, and is performing about 2000 telepsychiatry consultations per year [ 10 ]. A provider simply sends a request for a visit with a patient by computer, and the query is answered by a specialist at the university. The interface of communication is extremely simple, consisting of an iPad on a rolling stand for providers and a video camera for the patient. Nurses are also able to use the interface to record videos of patients in agitated states and securely send the videos to specialists, who can use a patient’s video and medical record to recommend treatment and calming techniques [ 10 ].

Telemedicine for Patients at Home

The implementation of certain at-home monitoring telemedicine and telehealth systems has also been successful. For example, Columbia University in New York, NY, USA created a home telemedicine unit through its Informatics for Diabetes Education and Telemedicine initiative [ 11 ]. This home telemedicine unit is capable of videoconferencing, medical data acquisition, sharing of collected data with physicians, web-based access to clinical data, and web access tailored to diabetes education. Data are transmitted through the existing telephone lines of each household, meaning no extra technological installment was needed. Each home telemedicine unit includes glucose and blood pressure monitors, alerts patients if any of their recorded values are abnormal, and indicates whether they should contact a physician [ 11 ]. Long-term outcome data are awaited to determine its full success.

At-home telehealth monitoring, especially for patients with chronic diseases, has proven to be beneficial for not only patients but also hospitals. The Patient Protection and Affordable Care Act requires the US Centers for Medicare & Medicaid Services to penalize readmissions to hospitals that occur within 30 days after discharge [ 12 ]. This provision incentivizes hospitals to find another way to communicate with and treat patients who may not require readmission, but simply medical attention. A study conducted by Partners HealthCare in 2014 [ 13 ] provided in-home monitoring to over 3000 patients with congestive heart failure. Their personal data—blood pressure, weight, heart rate, pulse—were recorded and uploaded daily to a monitoring system that used decision support software to alert patients and nurses of which patients needed attention. The data were transmitted securely through a telephone service to the internet. Over 6 years, hospital readmissions dropped by 44% for these patients, and the program generated savings of over US $10 million. This program led to a more efficient use of health human resources, as it allowed 3 to 4 nurses to care for 250 patients rather than the 4 to 6 patients they would be assigned to in a traditional hospital setting [ 13 ]. This example demonstrates the potential of telehealth to reduce health care costs, as well as unnecessary hospital admissions for patients, while also benefitting hospitals through reduced readmission penalties. In addition, this study highlights that telemedicine does not benefit one part of the system over another, but ideally works to create overall improvement in the health care system.

Similar results were seen in the implementation of a home health program for veterans, which used telemonitoring to help manage veterans with chronic illnesses, such as diabetes and depression. The Care Coordination/Home Telehealth program yielded high satisfaction from patients and produced a 19% reduction in the number of hospital visits as compared with their usual care [ 14 ]. The program generated savings of nearly US $2000 per patient, and even facilitated independent living of 36% of patients, who otherwise would have qualified for long-term residential care [ 14 ]. Through this increased access to knowledge, the goal of health care could be shifted from intervention to prevention, as increased education can promote healthier self-management.

Telemedicine as an Emergency Tool During the COVID-19 Pandemic

As COVID-19 continues to spread, many hospitals and physician practices have transitioned to telemedicine to conduct nonessential appointments [ 15 ]. A study of trends at NYU Langone Health (New York, NY, USA) showed an 80% decline in in-person visits and a 683% increase in telemedicine visits between March 2 and April 14, 2020 [ 15 ]. Most routine consultations could be conducted over the phone with both the patient and the physician at home, which is particularly useful for quarantined physicians. Telemedicine can also play an instrumental role in treating patients in hospitals. For example, Aurora Health, based in Wisconsin, modified emergency department procedures to allow for remote patient intake, which can accommodate faster testing [ 16 ]. As the number of COVID-19–infected patients increases, using computers and tablets for telemedicine can also reduce staff exposure in both ambulances and hospitals. Tablets can be effectively disinfected and allow patients to be safely isolated [ 16 ]. Electronic intensive care units (e-ICUs) dramatically increase the number of patients that health care workers can monitor at once, and as the numbers of hospitalized patients increase, e-ICU systems can help clinicians manage the load. Finally, developers Avera Health, based in South Dakota, are working on mobile home health care units for sick patients who are able to return home [ 16 ]. At-home systems provide patient evaluation without overwhelming an emergency room, allow physicians to assign sick patients to hospital beds through telemedicine, and even potentially facilitate at-home testing [ 16 ]. Great advancements in telemedicine are being made to help cope with this global pandemic and demonstrate how the emergence of telemedicine can shift the preparedness infrastructure of the health care system.

Health System Issues for Telemedicine

Reimbursement and the interest of health care payors and insurance providers.

The increasing use of telemedicine has led to increasing interest among payors to cover such services. Several insurance companies, and certain government-funded programs, have expanded their policies adjusting for telemedicine services. In 2018, Medicaid in several states broadened the scope of telehealth and telemedicine services for which they reimburse, thus reducing barriers for their use. For example, California approved reimbursement for substance use disorder services delivered through telehealth; Kentucky prohibited the requirement that a physician must be present with the recipient of health care for reimbursement; and Colorado expanded reimbursement to teledentistry [ 17 ].

In light of the current opioid epidemic in the United States, telemedicine can provide a newer and quicker avenue for crisis intervention, which is being recognized by payor groups. For example, Connecticut had previously prohibited prescription of controlled substances through telemedicine, but as of 2018 the state has made an exception for the prescription of drugs that treat opioid use disorder or substance use disorder [ 17 ]. Additionally, outside of government-funded health care, 31 states and the District of Columbia have enacted parity laws, requiring private insurers to reimburse providers for telehealth services [ 18 ]. This shows the impact telemedicine is making on the health care system. Furthermore, legislation currently being proposed is working toward making the practical use of telemedicine and telehealth even easier and more accessible for patients nationwide. Insurance reimbursement poses a large determinant in the acceptance of, and attitude toward, telemedicine. Government insurance reimbursement policies, in particular, have been shown to influence telemedicine adoption.

A survey conducted by the American Telemedicine Association in 2014 found that hospitals were not billing for telemedicine services because government payers would not pay for them, and neither would major private payers [ 19 ]. Furthermore, administrative rules differed for in-person versus telemedicine care, another barrier to reimbursement, and insurance companies ultimately followed the guidelines of their individual states, further hindering standardization of telemedicine billing. This study concluded that, if government payers change their policies to include reimbursement for telemedicine services, private payers are also more likely to change their policies [ 19 ]. Insurance reimbursement incentivizes telemedicine adoption for hospitals, and thus administrative and state-level rules would likely adjust as well. Finally, billing and coding processes for telemedicine services must also be better understood in order to enact change [ 19 ].

State governments have the power to decide whether they will cover telemedicine practices; and states are not required to submit an amendment to Medicaid if they decide to reimburse for telemedicine (in the same way as they do for in-person services). As of 2015, Medicaid reimbursed for telemedicine services in 46 of the 50 states [ 20 ]. Medicare, however, has created strict guidelines and instances for which it will reimburse telemedicine practices. To be eligible for Medicare reimbursement for a telemedicine service, a case must conform to a set of national guidelines; namely, the receiver of telemedicine service must be in a rural geographical location defined as either a Health Professional Shortage Area or a county outside of a Metropolitan Statistical Area [ 20 ]. These areas are defined by the Health Resources & Services Administration and can be found on their Medicare Telehealth Payment Eligibility Analyzer on their website [ 21 ]. As of July 2019, a small number of exceptions to this geographical requirement were enacted, including treating end-stage renal disease, stroke, and substance use disorder [ 22 ]. Since Medicare, in particular, serves elderly and disabled populations, telemedicine could alleviate the stress of needing to meet with a physician in person, but the lack of reimbursement deprives these populations of the benefits of telemedicine and telehealth.

In response to COVID-19, Medicare has temporarily expanded its services to cover telemedicine services outside of the prior designated sites and platforms through which one could qualify for reimbursement. As of March 6, 2020, Congress waived the Medicare requirements that limited provision of telehealth care to rural areas [ 23 ]. These services can be conducted from any hospital, office, or place of residence—a promising change in policy [ 24 ]. Finally, certain Medicare plans cover the cost of COVID-19 testing. These temporary expansions of coverage can, hopefully, become permanent and further promote the use of telemedicine.

Licensing and Use of Telemedicine

In the United States, there is not one standardized license a physician receives that is valid throughout the country, but rather a physician’s medical license is issued only for their state of practice. This poses an issue for interstate telemedicine practices, but in 2014 the Federation of State Medical Boards passed the Interstate Medical Licensure Compact to help facilitate interstate practice [ 20 ]. The compact allows a physician to apply through their home state medical board for eligibility of a medical license in another state. If the application is approved by their home state, no further verification is required and, after paying a fee to the requested state, they will be issued a medical license [ 20 ]. Such legal changes can allow telemedicine to become a “usual” part of the health system in the future. Given the enormity of the COVID-19 health care crisis, many state governments are reducing the licensing restrictions to ensure more effective use of physicians.

Technology and Usability

Concerns about the quality and security of medical records have previously hampered the adoption of telemedicine. In a study conducted by Resneck et al in 2016, medical residents posed as patients and submitted internet pictures to direct-to-consumer telemedicine websites and apps treating skin diseases. In terms of security concerns, they found that none of the websites asked for the patients’ ID to prove the photographs were not false [ 25 ]. Often clinicians were randomly assigned to patients, depriving patients of any autonomy in their choice of health care provider. In some cases patients were assigned to an international physician who did not have a license to practice medicine for their state. Even though the services diagnosed the conditions accurately based on images only, diagnoses were incorrect and missed major dermatologic conditions when a more detailed medical history was required for conditions such as secondary syphilis and eczema [ 25 ]. Maintaining quality is critical while attempting to expand access to care, and similar standards apply to care provided through telemedicine and to in-person care.

Important aspects of telemedicine and telehealth adoption are the ease of use and lack of technical prerequisites on the part of both patients and health care facilities, as well as reliability of new technologies. If telephone calls are not adequate as a means of making telemedicine visits, access to videoconferencing poses an accessibility barrier both for patients and for health care providers. On the patient side, access to the internet, video cameras, and software poses an issue; and for health care systems, installation of certain videoconferencing software may breach privacy governance policies [ 25 ]. In dealing with COVID-19, there is need for immediate conversion to telemedicine, and the time needed to develop new telemedicine platforms that mirror health care workflows is limited. Therefore, videoconference appointments must be monitored and controlled accordingly until access to more appropriate telemedicine software is available [ 26 ]. Keeping this in mind, COVID-19 testing must be integrated into telemedicine systems, so that after telemedicine appointments such patients are not immediately sent to the emergency room, further overwhelming hospital systems. For example, testing sites outside of the emergency room should be set up to accommodate telemedicine workflow, whether it be in other office spaces, in tents, or at the patient’s home with take-home tests [ 16 ].

Finally, despite significant improvement in the reliability and ease of use of technology, there remain a few of limitations, such as some loss of nonverbal communication between physician and patient. This includes, for example, a reassuring touch from a physician or a physician’s ability to smell alcohol on a patient’s breath and address alcohol consumption during the visit. These limitations could compromise the quality of health care in some cases from both the patient’s and physician’s point of view [ 27 ].

Acceptability by Patients and Providers

For telemedicine to ultimately be successful, it must be accepted by both patients and physicians. In 2016, a survey conducted in Austria asked patients and health professionals to rank what they perceived as the highest- and lowest-ranked benefit of and barrier to eHealth and telemedicine. With a demographic of 43.2% working in health professions and 56.8% in non–health professions, the overall highest-ranked benefit of eHealth was location-independent access to health care services, and the lowest-ranked benefit was better financing of health care. The highest-ranked barrier to eHealth was data security, and the lowest-ranked barrier was increase of administrative burden [ 28 ]. The highest-ranked benefit of telemedicine specifically was location-independent access to health care services, and the lowest-ranked benefit was better relationships between doctors and patients. For telemedicine, the highest- and lowest-ranked barriers were the same as those for eHealth [ 28 ].

This study also showed that acceptance of telemedicine may vary depending on socioeconomic factors. Participants were categorized by education level, gender, health profession or non–health profession, and digital age group. Digital age group was defined as 2 groups: digital natives, those who grew up in a digital world (defined by age ≤35 years); and digital immigrants, those who did not grow up in a digital world, but adopted the culture [ 28 ]. Participants were asked to evaluate their opinion on their knowledge of telemedicine, reliability of health information, reasonability of data exchange, consistent monitoring of patients with chronic disease, and consistent monitoring of all patients. Non–health professionals were 40% less likely to report high knowledge on telemedicine, but having a university degree led to 64% higher odds for high knowledge on telemedicine. The study also found that digital age was a determinant in evaluating the reliability of online health information: digital immigrants were 44% more likely than digital natives to find online information reliable [ 28 ]. These findings demonstrated that education on eHealth is crucial for widespread acceptance of eHealth among diverse populations. Since several digital natives were less likely to trust online information or telehealth services as reliable, education is needed even for digital users on not only general definitions of telemedicine and telehealth, but also their practical implementation and reliability.

For telemedicine and telehealth to be implemented successfully, patients must be educated about and comfortable with their use. Systems of informed consent are an essential part of this process, allowing patients to change their consent as they learn more about the technology being used and implemented—especially those with unintended but potential consequences. For example, a study implementing a voice-response telephone counseling system affected some participants in an unanticipated manner. Participants in this study were asked to call a telephone line daily and report their diet and exercise behavior, and most participants spent around 5 minutes per week speaking with the system [ 25 ]. Over the course of the study, patients began to form a relationship with the voice, referring to it with gender pronouns, or even naming their relationship as a friend, doctor, or mentor. Some reported the voice of the phone-line as condescending, leaving them with feelings of guilt after their call. After the study ended, some participants reported that they “missed the voice” of the system and continued to call the line [ 27 ]. Had patients been informed of the possibility that they could form a relationship—even if subconsciously—with this telephone line prior to the study, they would have been able to make an informed choice of whether to participate. This example helps elucidate the need for education about eHealth not only for medical professionals but also for those who will be interacting with it in order to promote acceptability.

Telemedicine and Telehealth in Special Groups

Patients with chronic illnesses.

Telemedicine and telehealth can play a large role in care for those with chronic diseases, if approved by both patient and provider. A study conducted in an amyotrophic lateral sclerosis (ALS) clinic held appointments with patients over live videoconferences in place of their regular visit and measured satisfaction surveys from both the patients and care providers. Patients had an overall high level of satisfaction with videoconferencing checkups. They commented that such specialized-care videoconferencing eliminated the need to drive long distances and allowed appointments to be conducted that would have ordinarily been missed or canceled due to bad weather [ 29 ]. A symptom of several chronic diseases, including ALS, is fatigue, and thus one of the most popular remarks about the appointments was that videoconferencing was less taxing for patients than their regular in-person visits. Overall, patients felt they received good and high-quality care comparable with an in-person visit. When asked for negative factors of the videoconference appointment, patients stated that they missed the personal physical gestures of reassurance from physicians, such as hugs, during their visits [ 29 ].

Elderly Patients

For elderly patients, doctor’s appointments often provide an outing; the videoconferencing appointment kept these patients at home, depriving them of an opportunity to mobilize [ 29 ]. Suggestions made by the patients included better coordination between clinical care and home care, and thus including a briefing between physician and home caregivers in the videoconference. Additionally, patients commented that the technology and software used may require improvements or replacements, as several patients experienced audio lags during their appointments [ 29 ].

Acceptance by Physicians

Geronimo et al [ 29 ] also surveyed physicians treating ALS patients for their perspective on the videoconferencing appointments. The most common remark was that patients seemed more comfortable throughout the visit. Additionally, the videoconferencing appointments increased the physicians’ understanding of their patients’ daily life and the kind of home care they were receiving [ 29 ]. The main concern, however, was the lack of physical examination, as well as physical contact for reassurance. This study indicated that, although telemedicine provides a convenient avenue for health care, it cannot completely replace the current system. Both patients and physicians felt comfortable and satisfied after their visits, but certain crucial elements of an in-person visit are irreplaceable, such as physical examinations and gestures. Acceptance of and attitudes toward this form of telemedicine also varied by geographical location. Rural clinicians especially appreciated the monitoring function of e-ICU systems, as it allowed them to be involved in providing care without being physically present [ 30 ].

Acceptance by Nurses

Acceptance depends not only on physicians and patients, but also on the other health care providers interacting with these systems, such as nurses. Health care providers working through various e-ICU systems were surveyed for their general attitudes toward its efficacy and sustainability. The survey found that providers who used the e-ICU more frequently had positive reactions, whereas those who used it less were more likely to have a negative view and to suggest that it imposes a greater burden on nurses [ 30 ]. Nurses—who often are responsible for monitoring a large load of patients, as well as coordinating inpatient and outpatients matters—felt the monitoring capabilities of telemedicine helped alleviate some of their stress and to dedicate their time effectively [ 30 ]. As this study illustrated, if used effectively, telemedicine can maintain high-quality health care while decentralizing stress on providers.

Future Directions

Table 2 outlines the key future strategies for improving the availability and quality of telemedicine and telehealth services based on a framework from the WHO [ 1 ].

Public policy must be compatible with increased eHealth implementation for telemedicine to be practiced regularly. Despite the exceptions to Medicare’s telehealth reimbursement policy, the current regulations prevent widespread adoption and use of eHealth and set a precedence for other large private insurers. The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) Act was introduced to the US Senate in 2017, but has yet to make progress. This act proposes the removal of the geographical restrictions under Medicaid and, if passed, would expand coverage of telemedicine services [ 18 ]. As a result, telemedicine services would be given the legitimacy of in-person visits in terms of Medicaid and may inspire other insurers to change their private policies.

a Based on World Health Organization recommendations [ 1 ].

State legislation is one of the largest determining factors in telemedicine adoption, and it has been shown that, in states that require private insurers to reimburse for telemedicine, adoption rates have increased [ 31 ]. For telemedicine to provide genuine and effective location-independent health care, a standardized licensing system or an equivalency system must also be established in the United States as a whole, or between states. There are several approaches to dealing with interstate licensing other than standardization across the country [ 20 ]. State governments can review each other’s board examinations and agree to mutually approve medical licensing between them. This solution gives states autonomy in controlling which physicians are eligible to practice telemedicine within their area, while also creating connections between physicians across the country. If legislation is passed legitimizing the role of telemedicine and telehealth in the American health care system, increased education and research on the area can lead to telemedicine being a prominent daily practice for physicians and patients alike.

Conclusions

We have reviewed the definitions, challenges, and potential future directions for telemedicine in the United States. It is no longer a question of whether eHealth has a role to play in health care delivery, rather it is a matter of making it happen. As we are learning during this COVID-19 pandemic, telemedicine and telehealth are critical to ensuring public health and are poised to become reliable and acceptable methods of seeking care for many conditions.

Acknowledgments

The views expressed in this paper are solely those of the authors and do not represent the view of Barnard College or of Johns Hopkins University.

Authors' Contributions

MAH conceptualized, researched, drafted, and edited the paper. JR reviewed drafts and helped finalize the paper. All authors approved the final version.

Conflicts of Interest

None declared.

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Abbreviations

Edited by G Eysenbach, G Fagherazzi; submitted 29.05.20; peer-reviewed by Z Su, J Fortuin; comments to author 13.07.20; revised version received 27.08.20; accepted 21.09.20; published 24.11.20

©Maryam A Hyder, Junaid Razzak. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 24.11.2020.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

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