Age and Ageing 2007; 36: 369–374
doi:10.1093/ageing/afm045
Published electronically 20 April 2007
 The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: [email protected]
REVIEW
The application of telemedicine to geriatric
medicine
MICHAEL BRIGNELL1 , RICHARD WOOTTON2 , LEN GRAY3
1
Western Health, Gordon St, Footscray, Victoria, Australia 3011, Australia
Centre for On-Line Health, The University of Queensland, Level 3, Centre Building, Royal Children’s Hospital, Herston, Brisbane,
Australia 4029, Australia
3 Academic Unit in Geriatric Medicine, The University of Queensland, Princess Alexandra Hospital, Ipswich Rd., Woolloongabba,
Brisbane, Queensland, Australia 4102, Australia
2
Address correspondence to: Len Gray. Tel: 61 7 32405327; Fax: 61 7 32405399. Email: [email protected]
Abstract
Background: telemedicine has the potential to improve access to the specialty of geriatric medicine, particularly in rural and
remote settings. While telemedicine is widely used in some specialities, this is not yet the case in geriatric medicine.
Objective: to review the current literature to identify proven and potential strategies for application of telemedicine in
geriatric medical practice.
Method: a comprehensive review of literature pertaining to the application of telemedicine in geriatric medicine and relevant
related sub-specialties was undertaken.
Results: a large number of small studies of limited quality, and a small number of robust studies including randomised trials,
were identified.
Conclusions: there is evidence to suggest that a variety of telemedicine techniques can be applied effectively and safely in
geriatric medicine across a variety of clinical settings. Patient satisfaction is generally reported as high. Howeve, caution is
advised due to the paucity of robust studies in the literature.
Keywords: telemedicine, geriatrics, elderly, remote consultation
Introduction
Geriatric medical expertise is not universally available, even in
industrialised countries. This is usually a result of inadequate
supply of practitioners or remoteness. In rural or remote
communities, there may be insufficient caseload to warrant
the full-time presence of a geriatrician. As a consequence,
this important capability is often not available.
Telemedicine strategies have been applied in response to
similar challenges in other medical disciplines. Telemedicine
has the possible advantage of being able to offer a service
at marginally increased cost, depending on volume, and
eliminating travel costs for the doctor and the patient
[1].
In this paper, the literature that supports acceptable,
reliable and cost-effective application of telemedicine
strategies to geriatric medicine is reviewed. Reports of
randomised clinical trials of telemedicine strategies with
substantial numbers of elderly are very few, and no papers
report by age subgroup. The wide variety of clinical areas
covered, and areas not covered, by these trials diminishes
the value of further analysis. In order to include lessons
learnt from closely associated health disciplines, a literature
search must be less restricted, but as a consequence,
less amenable to systematic analysis [2]. As concluded
by a 2002 review [3], the reports are of variable quality,
and their claims about utility and efficacy may not be
founded on strong evidence. Cost effectiveness has more
recently been addressed also in a systematic review which
concluded [4] that ‘good quality studies are still scarce’.
Due to the scarcity of reports specific to geriatric patients
and the large number of feasibility or pilot studies, this
review set aside the intended systematic approach and
draws on that broader search, adding reference to recent
reviews in telemedicine, and emphasises important themes
in modern geriatric medical practice in a commentary
narrative.
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M. Brignell et al.
The literature search
Practice environments
Reported experience of telemedicine and geriatric medicine
was sought from databases of health and related publications.
The search applied the terms telemedicine, telehealth, ehealth, telecare, teleconsulting or remote consultation (all
spellings) AND geriatric, aged over 65, ageing, elder and
elderly. References to publications after 1990 with an
abstract, in English, were collected. The search included,
PubMed, Medline, CINAHL, Psycinfo, Web of Science
and TIE (Telemedicine Information Exchange). The AMI
(Australasian Medical Index) was searched to include any
local publications possibly not included in the major
databases. The search was conducted in April 2005.
The extracted references were combined and duplicates
removed, resulting in 233 separate publications. These were
then reviewed in abstract form to ensure relevance and
categorised (MJB) according to the type of technology used,
clinical practice and level of evaluation. Three articles proved
not to be telemedicine, leaving 230 for further review. Fiftysix papers were reviews, or opinions, leaving 174 clinical
studies. They covered a wide range of clinical activity,
with variable relevance to clinical geriatrics. Elements of
a geriatric service were therefore considered separately to
seek out reported experience and evaluation. A further six
papers were accessed for background material, or as a result
of secondary following of cited references. Articles which
reported work in allied clinical practice, such as psychiatry
and neurology, which included older patients, and which
were considered relevant to geriatric medical practice, were
emphasised in the review.
The clinical papers were categorised according to whether:
When the broad field of geriatrics is considered, there
are patterns of clinical activity, which may be compared
with other disciplines. Important elements of hospital work,
which can be considered are inpatient management (hospital
or nursing home), consultation or triage for admission or
transfer purposes. Community work can involve chronic
disease or disability management, home visits, clinic/office
practice and care planning. Service planning involves
consideration of logistics, equity, efficacy and cost of clinical
processes and systems. When the literature is reviewed
with these elements in mind, many examples of reported
experience of telemedicine will have relevance. The following
is a discussion of these elements in order.
• the contact was in real time (156 reports) or ‘store and
forward’ (18 reports);
• objective patient data was transferred (101) or referred to
voice or video interaction only (73);
• the patient participated in the use of the technology (168),
or contact was between health workers only (6);
• control groups were compared (74);
• costs were reported (30);
• available technology (telephone or PC/internet) (45) or
specialised /purpose built equipment was used;
• patients used the technology in a clinical care setting (86)
or in their own home (85);
• whether substantial numbers of patients were involved
(n =>100) (61).
Of the 230 papers, 78 were published in one of the two major
journals of telemedicine. In papers reporting randomised
control trials with substantial numbers, 26 reports referred
specifically to the elderly. These included 17 reports of costs
from 11 separate clinical trials. In the following sections
related to pratice environments and issues, published papers
considered by the authors to be most important and relevant
are referenced.
370
Inpatient management
It is difficult to take full responsibility for hospital type care
from a distance. Many practitioners are unwilling to provide
care or advice without face-to-face contact. Most precedents
relate to extremes of urgency or remoteness. Specialists may
advise local health practitioners, however, having received
information about the patient. There is a widely established
practice of telephone conversation for informal advice in
many disciplines, which is not reported in detail in the
literature of telemedicine. Where more technology or a
formal telephone protocol is used, there are reports from
telemedicine projects serving a range of disciplines.
Consultation opinions about hospital patients are a routine
activity, which contributes to better outcomes. Medical
consultation for hospital patients by telemedicine from an
offsite location is less widely used, but has become routine
in electrocardiography and radiology, and is reported in
neurology [5], orthopaedics [6], minor injuries [7], wound care
[8], biopsy cytology [9], psychiatry [10], otorhinolaryngology
[11] and urolithiasis [12]. There are isolated examples of
remote reporting of objective data only, obtained and
transmitted in digital form in echocardiography [13, 14]
and polysomnography [15]. Offsite consultation for nursing
home residents has been reported by geriatric teams [16] and
psychiatry [17].
Because consultation work can be a major component of
hospital geriatric practice, it seems likely to be a focus for
telemedicine developments.
Triage by telemedicine for admission, or face-to-face
attendance, has been reported from neurosurgery [18] and
urology [12] (using teleradiology), geriatrics [16, 19] and
podiatry [20] in a nursing home, nurse practitioners in
family medicine [21] and medical assistance subscribers
using a help line [22]. Universally, these studies report that
a proportion of contacts can be managed without transfer,
and in the case of head injury, greater safety. When the
distances or hazards of transfer are greater, the likely utility
of telemedicine increases. A project in nursing homes in
Singapore proposed to use an electronic medical record, in
combination with videoconference, but no patient data was
reported [19]. A Hong Kong experience linking a community
Telemedicine and geriatric medicine
geriatric assessment team to a local nursing home to provide
management advice instead of a clinic or outreach visit,
resulted in 9% fewer ED attendances and 11% fewer utilised
hospital days [16]. Both studies reported on the introduction
of videoconference to an existing clinical relationship, where
workers from several disciplines were known to staff in the
same region, but stated that it enhanced clinical interaction
and support for the nursing home staff.
Providing non-urgent advice and opinions from allied
health practitioners has been reported from Australia where
videoconference links to nursing homes were used [23].
The outcomes were reported in terms of user satisfaction
and also adequacy of assessment, by five disciplines. The
workers were often uneasy about the clinical assessment, but
the opportunity to revise recommendations after seeing the
patient in person resulted in only minor changes to plans.
Ambulatory geriatrics
Office practice or ambulatory care would require the patient
to be introduced to the remote specialist by a local health
facility or worker. There are many reports of successful clinics
providing specialist advice by telemedicine. Detailed analysis
of patient outcomes, satisfaction levels [24, 25] and costs are
reported. Neurology clinic reports from Northern Ireland
demonstrate feasibility and efficacy, but that telemedicine
may generate more investigations [26]. In further work, they
were able to show that costs of the service were critically
dependent on the type of consultant, telecommunication
charges and the locally based health worker’s time. The
cost-efficiency emerged when the service was compared
with a broader usual care group, in ‘everyday practice’ [27],
and increased as the distance increased. A large randomised
trial of a virtual outreach consultation service [28] reported
excess costs which were attributable to the initial consultation
which included the patient and their local doctor, but patient
satisfaction was higher in the telemedicine group.
Some successes have been reported with assessment
of cognitive function [29] and psychiatric interview [30],
with clear parallels to wider geriatric practice. The use of
videoconference was reported as acceptable for patients
with mild dementia, but its utility is likely to decline as the
patient is less able to comprehend the interview, or has
significant sensory impairment. A specialist cognitive service
[29] was able to show that standardised screening tools
appear to perform reliably when used in video-conference to
diagnose dementia, but this selected patient group required a
clinician at the remote location, to enable specialist clinician
assessment. Telephone assessment of cognition has also been
validated in stroke follow-up [31].
Since cognitive function is an important component of
comprehensive geriatric assessment, these reports provide
valuable guidance, but the more impaired patients are less
likely to tolerate unfamiliar technology, unless supported by
skilled staff at the time, as in the nursing home experience.
When there is a possibility of cognitive impairment, the
capacity of the patient to cope with the technology becomes
a confounding factor. In an approach that is not reliant on a
remote clinician having direct interaction with the patient, the
assessment outcome is likely to be less affected by cognitive
impairment. The scope of assessment may be reduced, but
reliability is likely to be greater. ‘Store and forward’ strategies,
where a local clinician collects objective data and transmits
it for an opinion, have this advantage, without the patient
needing to adapt to the technology.
Community care
Chronic disease management has also been reported in a
number of studies, which have relevance to geriatrics. Here
the emphasis is often on direct links to patients’ homes,
without the intermediary health worker. Passive monitoring
of blood pressure with telephone transmission of recordings
to a clinic improved control in a randomised control trial
[32]. The control of heart failure, diabetes and chronic
respiratory disease have been improved by an integrated
approach, with non-invasive passive monitoring of various
physiological data, support of a nurse case manager and an
electronic medical record, resulting in less hospital bed and
emergency department use and greater patient satisfaction
[33]. Cost savings accrued largely from reduced hospital bed
use, although the patient groups were not pre-matched for
this variable. Since this randomised control trial involved
Veterans’ Administration high resource users who had a
mean age of 71 years (range 54–90), it is likely to be applicable
to geriatric practice, but access to the monitoring technology
may limit its widespread use. Those approaches which result
in improvements in both efficacy and cost of care seem likely
to revolutionise chronic disease management.
Ongoing care in the community has been augmented by
telephone, with improvements in heart failure and patient
satisfaction [34], and depression [35]. The addition of a video
link [36] to usual home care has been shown to be well
accepted [37] and cost-effective [38], not as an alternative
to community nurses, but as a means of safely reducing or
targeting their visits, after initial contact. Existing outreach
and case management services are likely to improve efficacy
and efficiency by introducing telehealth.
Technology issues
Different methods of data transfer have been compared in
ambulatory clinics in dermatology, psychiatry and community
care. Videoconferencing has been compared to review
of stored images [39] and the clinical results were less
satisfactory for the asynchronous technique in dermatology.
On the other hand, it is clearly cheaper than either video
conference or usual care, and less dependent on achieving
economies of scale. For these reasons, store and forward
strategies are attractive where the service is not substituting
for existing service, and setup costs are of paramount
concern. Some studies report purpose built equipment,
especially for in-home monitoring, costing US$10,000 per
client for mobile videoconference units [33]. The use
of standard telephone lines for transmission of simple
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M. Brignell et al.
measurements like blood pressure, pulse, weight, or blood
sugar, downloaded from a small device, or reported by
voice is now possible and clearly less expensive. An Internet
connection will also allow keyboard data entry or the use of
Web forms. As more patients already have Internet access
at home, set-up costs are further reduced. This also raises
the possibility of passive home monitoring via the Web, but
clinical reports are still only in the pilot phase.
Limited video or voice over the Internet can be expected
to become more readily available as connection speeds and
bandwidth improve; however, evidence from the United
Kingdom suggests that the cost of utilising ISDN lines can
represent a substantial proportion of a service budget [40].
Limitations
Inability to elicit physical examination findings [16] is
a frequently stated issue limiting the utility of remote
assessments. This was overcome in the neurology and
emergency department studies cited earlier in this review
by employing a junior doctor with the patient to elicit clinical
signs, under direct observation by the remote physician.
This strategy increases costs substantially over the use of
a nurse or other health worker to chaperone the process,
although these workers may become as effective as a junior
doctor in these tasks with specific training. In dermatology,
viewing only images and clinical notes appeared to result in
inefficiency, with increased review appointments [39]. Where
the clinical interaction is most dependent on physical contact
with the patient, remote assessment will remain problematic.
Clinician users of telemedicine systems often reported
dissatisfaction or uncertainty. An early report related this to
gender differences in the need for touch, or the personal
style of the physician [41]. There are no reports of significant
gender differences in satisfaction with telemedicine. The
higher degree of clinician uncertainty is predictable and may
be inevitable with a single episode of clinical contact, but
can be alleviated by ensuring that the ongoing management
responsibility and plans are clear. For doctors, the uncertainty
and reluctance may arise from less clinical control, and a
change in the power relationships when working remotely
with nurses [42]. The long-term links between clinicians of
all disciplines within a telemedicine system may be the
best source of greater clinical certainty, as they would
be in conventional local referral systems. These clinical
relationships are more difficult to establish over greater
distances, but the successful introduction of a service may
be enhanced by deliberate emphasis on the people as well
as the technology [43], until the service is well established,
and always emphasising the ongoing clinical relationship
between the patient and the local health worker. The use of
a combination of usual care and telemedicine strategies in a
longer course of treatment or community care should also
minimise any perceived limitations.
372
Implementation issues
The practice of telemedicine in geriatrics is not generally
considered to be ‘mainstream’. A qualitative analysis of
three UK studies [44] argued for stages in the normalising
of telemedicine which depend on local organisation policy
and politics in a way which is easily underestimated by its
proponents. For this reason alone, there are likely to be
difficulties in implementing strategies which have shown
promise in well conducted clinical trials. A recent review
recommends that to overcome the image that telemedicine
is for ‘early adopters’ and enthusiasts, research projects
should be linked to medical education where there is more
acceptance of remote learning. It is also suggested that
partnerships with health authorities will be essential to
ensure access to the infrastructure [45]. Clinicians may also
be reassured by the many reports of high satisfaction levels
from patient surveys, but levels are generally high and most
studies may be criticised on size and methods [46].
Learning by analogy
Given the scarcity of geriatricians, techniques which allow
brief clinical interaction without ongoing management may
be more practical. Remote consultation with a local health
professional is attractive for this reason.
Assembling objective data according to an agreed
protocol, and transmitting it in real time, or store-andforward, is likely to be more time efficient. It should also
enhance a consultation process by giving it more structure.
The full development of the dataset would become part of
an electronic medical record.
Minimising the demand for new technology beyond a PC
with web access and email software, assists in controlling
set-up costs. Both the equipment and the training will be less
costly as a result.
In the hospital setting, existing staff are more likely to
participate if the procedure is not too demanding of their
time, substitutes for existing less integrated activity and
provides a timely, clinically relevant response.
Conclusions
In areas where geriatrician expertise is currently unavailable,
telemedicine has the capacity to allow remote consultation,
which can be supported by a trained health worker locally,
using a protocol for comprehensive geriatric assessment. It
may be more feasible than relying on recruitment of a local
geriatrician but overall geriatrician numbers will continue to
limit the availability of expertise.
In chronic disease management, there are many reports of
improved efficacy and patient satisfaction when compared
with usual care. Geriatricians and other health workers can
expect increasing use of telemedicine in this area as an
enhancement of existing systems. It seems likely to improve
clinical relationships, treatment efficacy and productivity, but
further evaluation in the elderly is needed.
Telemedicine and geriatric medicine
A predictable limitation to the introduction of new
technology is start-up costs. When new systems can employ
existing technology in novel ways, this constraint is less
important. Since the PC, Internet and e-mail are available to
most health workers in industrialised countries, telemedicine,
using these modalities, is likely to be feasible and cost
effective.
Key points
•
•
•
•
•
Telemedicine can increase effectiveness and efficiency in
geriatric medicine.
Currently available technology may be all that is required.
Novel remote clinical roles and relationships may need to
be developed.
Local health workers will continue to be the backbone of
any system.
Evaluation of telemedicine in the care of the frail elderly
is required.
Conflicts of Interest
None
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Received 15 August 2006; accepted in revised form 25 January
2007