Usability Issues among End Users of Telehealth

Introduction

Background of the Review

There is an increase in global aging populations and age-associated chronic diseases, and this increase has prompted a growing need for access to healthcare. Telehealth, a concept which embroils the distribution of information and health-associated services through telecommunication technologies and electronic data has been advancing to meet the need of access to healthcare (Hoffman, 2012). When using telehealth technologies, patient information can be shared, retrieved, stored and gathered by manifold disciplines as a way to enhance safety and quality in the delivery of patient care. As the needs of healthcare services are augmenting, information technology is also advancing to meet the demands of global populations. Telehealth technologies were started to enhance healthcare access and to lower the financial burden (Karim et al., 2013). Telehealth is growing continuously to provide healthcare globally. It is used as a way of assessing, diagnosing, planning, implementing and evaluating data over distances and time.

According to Hoffman (2012) who carried out research using 281 out of 1976 articles to assess the benefits and ethical issues to using information technology in healthcare, the use of information technology in healthcare has several positive outcomes for end users. For instance, Hoffman discovered that telemedicine for home services and internet-based psychotherapy led to reduced mortality, enhanced safety from falls and improved medication compliance among end users. His study also recognized that elderly patients welcomed novel surveillance and technology of telehealth as it reduced their insecurities and fear. A study by Watanabe et al. (2012) revealed that the end users were highly satisfied with the features of the virtual clinic that they were using. About 6.8% of the study’s respondents mentioned that they felt discomfort using telehealth format or technology. Also, 19 of 44% of the physicians who took part in the study agreed that their patients were getting a valuable and easy time using telehealth services. Watanabe et al. (2012) also discovered that video conferencing is advantageous for home hospice nursing visits, education for patients and oncology consultations.

Although a lot of research has been done on the advantages of telehealth technologies in a bid to tout telehealth and encourage its wide adoption, few studies have investigated the usability issues associated with telehealth among end users (Watanabe at al., 2013: Karim et al., 2013: Timpano, 2013). It is because of this reason that this review sought to identify and report on the alleged usability issues of among end users of telehealth. The purpose of this review was to assess data that support issues to using telehealth technologies. This information can be utilized by healthcare providers to adjust existing practices and implement new programs in an effort to improve the delivery of healthcare services for worldwide populations. Perception of using telehealth technologies by end users as well as healthcare providers can be used to improve the system design of telehealth technologies.

Aim and Objective

The main aim of the study was to identify issues associated with the usability of telehealth among its end users. The objective of the study was to critically synthesize relevant literature to summarize the major issues among end users of telehealth.

Literature Review

Even though there are many benefits to using telehealth, there are usability issues among the end users of telehealth technologies. Watanabe et al. (2012) discovered that some end users had to travel long distanced to visit the healthcare facilities offering telehealth services for pain management. Another problem associated with telehealth and identified in the study was that patient appointment took a long time to enter into the telehealth system as opposed to the traditional handwritten system. Wade, Shaw, and Cartwright (2012) discovered that inaccurate readings are one of the usability issues facing end users of telehealth technologies. The reading errors can have adverse negative effects for the end users. It is hazardous because it offers false information to medical staff who may make wrong medical prescriptions that can eventually harm a patient. Non-reporting of telehealth technology readings withholds crucial information required for health practitioners to develop a plan of care for patients and may result in negative effects on the patients.

Hoffman (2012) proposes that the enactment of technology can be age discriminating by advancing inequalities and differences. It is not fair for family members to be expected to learn how to use telehealth technology since this added responsibility can change family ties. Additionally, the Hoffman study posits that tracking and monitoring telehealth devices can infringe the confidentiality, surveillance, autonomy, and privacy of an individual. Novitzky et al. (2015) suggest that introduction, use, and development of telehealth technologies prompt adverse issues. The end users of telehealth technologies often have distinctive requirements and needs which may not be immediately obvious to the researchers and developers of telehealth technologies. In this line of thinking the study by Novitzky et al. (2015) highlights the significance of user involvement in R&D of telehealth to avoid issues of mismatch of the functions of telehealth devices with the needs of the end users. Furthermore, users can refuse a new telehealth device if their input was not considered in the R&D process of developing the device.

Another usability issue of telehealth identified by Novitzky et al. (2015) is the increasing dependence on telehealth devices that reduces the autonomy of the end users. This issue involves end users being overly dependent on a telehealth system that they may wait for the system to report a complication on their behalf, instead of reporting it directly to their healthcare providers. The dependence on the pseudo –intelligence offered by telehealth technologies means that while they improve the provision of health services, they can reduce the autonomy of individuals. As a consequent, the technologies can also intensely invade the validity of informed consent given by patients at the more advanced stages of their usage of the technologies (Hoffmann, 2012).

Wade, Shaw, and Cartwright (2012) identify the problems of using telehealth devices as being the need for apparent value in using the devices and the associated costs. The study discovered that barriers to the sustained usage of telehealth technologies included issues with lack of service support, inadequate funding and technological problems. Additionally, the healthcare service infrastructure should align itself to support the usage of telehealth devices because the service can become a hindrance to the successful enactment of a telehealth system. The belief that usual healthcare service would be sufficient inhibits the adoption of telehealth technologies. Such a belief is a potential inhibitor to the sustainable utilization of telehealth devices (Wade, Shaw, and Cartwright, 2012).

Methodology

Research Design

The literature review was the methodology adopted for the project because it enables researchers to place each article in the context of its contribution to comprehending the research problem being investigated (Dunne, 2011). The research approach used in this review was secondary data approach were articles selected and reviewed to achieve the aim of the research. The literature review facilitated the assessment of the current state of research on the topic of usability issues among end users of telehealth. The secondary research approach involves the summary, synthesis, and collation of existing studies contained in journal articles and books.

Databases

The databases that were used to search articles in this review included Medical Complete, MEDLINE, and ProQuest-Health. The key phrases that were utilized in identifying relevant articles from the medical databases include:

• Telehealth end users
• Usability issues of telehealth
• Usability issues of telehealth among end users

Ten searches of the databases generated 50 articles, and this number was reduced using the selection criteria.

Selection Criteria

Selection criteria are used to choose research studies for literature reviews based on the research question of the review. The criteria are known as exclusion and inclusion criteria. The inclusion and exclusion criteria are the most suitable was of reducing the number of originally identified data sources while maintaining the relevance and accuracy of the review (Matthews & Ross, 2014). The PICO model was utilized in developing the inclusion and exclusion criteria for the articles that were identified in the databases to reduce the high number to a manageable number. The model is utilized in evidence practice to help answer the question of a study. In the model P refers to the population or problem of the study, I refers to an intervention or indicator, C refers to comparisons and O refer to the projected outcome of the study (Santos et al., 2007). The PICO framework for this review involved variables as shown in Table 1.

Table 1: PICO Model for the Research Question

P-problem	Lack of adequate information on usability issues of telehealth technology
I – indicator	Usability issues among end users
C-comparison	Comparisons drawn from reports and studies of usability issues of telehealth among end users
O- outcome	Create awareness of usability issues of telehealth technology

 

Inclusion criteria are the features of study that have to be present for the study to be qualified for inclusion in systematic literature reviews. Exclusion criteria are the features of a study that eliminate it inclusion in systematic literature reviews. The exclusion and inclusion criteria that were established using the PICO model to filter the data sources and eliminate sources that did not reflect that review’s objective are discussed in Table 2.

Table 2: Inclusion and Exclusion Criteria

PICO Elements	Exclusion Criteria	Inclusion Criteria
P-problem	Studies that do not address the usability issues among end users of telehealth.	Studies that address the usability issues among end users of telehealth.
I – indicator	Studies addressing usability issues of telehealth among caregivers	Studies addressing usability issues of telemedicine among end users
C-comparison	Studies with caregivers using telehealth technologies	Studies with end users of telehealth technologies who are patients
O- outcome	Studies not documenting the experience of end users of telehealth	Studies documenting the experience of end users of telehealth and effects of telehealth technologies on the patients

 

The studies that met the inclusion criteria were eight, and they were reviewed to achieve the objective of the research. The rationale for selecting these studies is that they reflected the objective of the review hence they would augment the quality and accuracy of this review.

Research Ethics

When conducting a literature review, researchers are supposed to be concerned about the ethical questions of how they will ensure that they treat the secondary data sources fairly and accurately and also whether the data sources raise any ethical issues that need to be addressed. Since the data sources for this review were freely available on online databases, the permission for review, analysis and further use was implied. Nevertheless, the ownership of the original source was acknowledged in this reviewed to avoid issues of plagiarism. Also, the researcher did not include studies that raised ethical questions in the research, for instance by not getting informed consent from the participants.

Results

Study	Purpose	Subject/settings	Methods	Major findings	Limitations
Hoffman, B. (2013). Ethical challenges with welfare technology: A review of the literature, Science and Engineering Ethics, 19:2, 389-406. Doi: http://dx.doi. org/10.1007/s11948-011-9348-1 2.	To identify welfare technologies and potential ethical challenges	A search was done in HTA, DARE SveMed, Cochrane Systematic Reviews, Ovid PsycINFO, Ovid EMBASE and Ovid MEDLINE databases.	Systematic literature review	Telehealth raises fundamental usability issues concerning privacy, confidentiality, autonomy, and surveillance. Some of the issues include alienation, conflicting goals, lack of respect for privacy and confidentiality of end users and also guarantee to equal access and just distribution for end users.	The reviewed studies were subject to remarkable variability in quality and significance to the question of issues among end users of telehealth
Karim, R., Zakaria, N., Zulkifley, M., Mustafa, M., Sagnap, I, Later, N. (2013). Telepointer technology in telemedicine: A review, Biomedical Engineer Online 12:21. Doi: http://dx.doi.org/10.1186/1475- 925X-12-21 3.	To provide an overview of modern advancement of telepointer technology in telehealth	Recent publications on telepointer technology were searched on online databases.	Systematic literature review	The lack of real-time positioning accuracy was the major usability issue of telepointer technology in telehealth.	Unreliable coding of variables across the reviewed studies limited their use for detecting heterogeneity
Timpano, F., Bonanno, L., Bramanti, A., Spadaro, L., Bramanti, P. Lanzafame, P. (2013). Tele-health and neurology: What is possible? Neurological Science, 34:12, 2263-70. Doi: http://dx.doi.org/10.1007/s 10072-012-1285-5 5.	To avail a narrative review of which investigates the probable future fields of applications that are significant in healthcare practices offered to patients with neurological illness	The study involved the manual search of published conference proceedings and abstracts search on PubMed online database and consultations with researchers in neurological science.	Quasi-randomized controlled clinical trial	The usability issue of telehealth identified in the study is the concern of dealing with sensitive patient data and their treatment.	The identification of interaction and trends was because data was not constant  across the reviewed studies
Wade, R., Shaw, K., Cartwright, C. (2012). Factors affecting provision of successful monitoring in home telehealth, Gerontology, 58:4, 371-7. Doi: http://dx. doi.org/10.1159/000335033 7.	To assess the acceptance and usage issues about telehealth products that are used by frail older clients of Transition Care Program	The study took place at the homes of the clients of transition care program.	Quasi-randomized controlled clinical trial	The revealed usability issues of telehealth included equipment failure, lack of follow-up by staff and lack of compliance of patients.	Lack of consistency in the contact rate of participants from staff affected the results of the study. Staff did not regularly record their reasons for not following up reading failures when they occurred
Watanabe, S., Fairchild, A., Pituskin, E., Borgersen, P., Hanson, J., Fassbender, K. (2013). Improving access to specialist multidisciplinary palliative care consultation for rural cancer patients by videoconferencing: Report of a pilot project, Supportive Care in Cancer, 21:4, 1201-7. doi: http:// dx.doi.org/10.1007/s00520-012-1649-7	To evaluate the feasibility of utilizing video-conferencing to offer specialist multidisciplinary palliative care and radiotherapy consultation to cancer patients in rural areas.	The study took place in local telehealth facilities of rural northern Alberta.	Quasi-randomized controlled clinical trial	The identified usability issues of telehealth included limited awareness of the technology among patients, delays in implementation of telehealth projects and technical hardships.	The study’s major limitation was lack of a control group. Another limitation was the small number of patients available to participate in the project. Follow-up data were not extracted in all cases. Also, the tools utilized in collection physician and patient satisfaction data were not validated.
Wade, R., Cartwright, C., & Shaw, K. (2015). Carers’ perceptions of the impact of home telehealth monitoring on the provision of care and sustainability of use. Australasian Journal on aging, 34(2), 109-114.	To report the perceptions of carers about the effect of home telehealth on the provision of care and sustainability of home telehealth utilization.	The study took place at the homes of the clients of transition care program.	Quasi-randomized controlled clinical trial	Usability issues of inaccurate readings, missing information and delayed information from care-giver’s error.	The limited number of studies looking at safety issues in telehealth. Small sample size due to low participation and eligibility rates. There was no measurement of the degree of burden of care experienced by the carers
Novitzky, P., Smeaton, A. F., Chen, C., Irving, K., Jacquemard, T., O’Brolcháin, F., … & Gordijn, B. (2015). A review of contemporary work on the ethics of ambient assisted living technologies for people with dementia. Science and engineering ethics, 21(3), 707-765.	To evaluate ethical issues involved in the clinical application, clinical experimentation, as well as research and development and of ambient, assisted living technologies for individuals with dementia and associated  stakeholders	Computer science, engineering, sociological legal and medical databases were searched for secondary sources	Systematic literature review	Usability issues of telehealth identified in the study include not involving the end-users in the R&D of telehealth technologies, ill-understanding of end users’ needs in implementing telehealth, as well as informed consent in the use of these technologies	Lack of consideration of suitable scoring and weights when combining the reviewed studies

 

Conclusion

The research design adopted for this paper was a literature review where sources were obtained from Medical Complete, MEDLINE and ProQuest-Health online databases. The researcher used the PICO model to develop an inclusion and exclusion criteria. The criteria were then utilized in reducing the number of originally identified sources to five. The reviewed articles demonstrated evidence of usability issues of using telehealth technologies. Some of the issues were ethical in nature while others involved the functionalities and equipment of telehealth systems. The usability issues that were ethical in nature included issues to do with autonomy, privacy, and confidentiality of end users. Technical issues involved failure of telehealth equipment and lack of real-time positioning accuracy. Other issues included limited knowledge regarding the usage of telehealth technologies and inaccurate readings of devices among end users.

References

Dunne, C. (2011). The place of the literature review in grounded theory research. International Journal of Social Research Methodology, 14(2), 111-124.

Hoffman, B. (2013). Ethical challenges with welfare technology: A review of the literature, Science and Engineering Ethics, 19:2, 389-406. Doi: http://dx.doi. org/10.1007/s11948-011-9348-1 2.

Karim, R., Zakaria, N., Zulkifley, M., Mustafa, M., Sagnap, I, Later, N. (2013). Telepointer technology in telemedicine: A review, Biomedical Engineer Online 12:21. Doi:http://dx.doi.org/10.1186/1475- 925X-12-21 3.

Matthews, B., & Ross, L. (2014). Research methods. Pearson Higher Ed.

Novitzky, P., Smeaton, A. F., Chen, C., Irving, K., Jacquemard, T., O’Brolcháin, F., … & Gordijn, B. (2015). A review of contemporary work on the ethics of ambient assisted living technologies for people with dementia. Science and engineering ethics, 21(3), 707-765. https://doi.org/10.1007/s11948-014-9552-x

Santos, C. M. D. C., Pimenta, C. A. D. M., & Nobre, M. R. C. (2007). The PICO strategy for the research question construction and evidence search. Revista latino-americana de enfermagem, 15(3), 508-511.

Timpano, F., Bonanno, L., Bramanti, A., Spadaro, L., Bramanti, P. Lanzafame, P. (2013). Tele-health and neurology: What is possible? Neurological Science, 34:12, 2263-70. Doi: http://dx.doi.org/10.1007/s 10072-012-1285-5 5.

Wade, R., Cartwright, C., & Shaw, K. (2015). Carers’ perceptions of the impact of home telehealth monitoring on the provision of care and sustainability of use. Australasian journal on ageing, 34(2), 109-114. Doi: 10.1111/ajag.12139

Wade, R., Shaw, K., Cartwright, C. (2012). Factors affecting provision of successful monitoring in home telehealth, Gerontology, 58:4, 371-7. Doi: http://dx.doi.org/10.1159/000335033 7.

Watanabe, S., Fairchild, A., Pituskin, E., Borgersen, P., Hanson, J., Fassbender, K. (2013). Improving access to specialist multidisciplinary palliative care consultation for rural cancer patients by videoconferencing: Report of a pilot project, Supportive Care in Cancer, 21:4, 1201-7. Doi: http://dx.doi.org/10.1007/s00520-012-1649-7