Designing Telemedicine Systems for Geriatric Patients: A Review of the Usability Studies

Abstract

Background:

One area where telemedicine may prove to be highly effective is in providing medical care to the geriatric population, an age group predicted to account for 20% of the population in the near future. However, even though telemedicine has certain advantages, the usability of these systems with this population merits investigation.

Materials and Methods:

This article reviews the literature published from 2000 to 2016 with the goal of analyzing the characteristics of usability-related studies conducted using geriatric participants and the subsequent usability challenges identified. Articles were found using Web of Knowledge and PubMed citation indexing portals using the keywords (1) Telemedicine* AND Geriatrics* (2) Telemedicine* AND Usability* (3) Telemedicine* AND Usability* AND Older Adults*.

Results:

A total of 297 articles were obtained from the initial search. After further detailed screening, 16 articles were selected for review based on the inclusion criteria. Of these, 60% of the studies focused on the overall usability of telemedicine systems; 6.25% focused on the usability of a telepresence robot; 12.5% compared a face-to-face medical consultation with the use of telemedicine systems, and 25% focused on the study of other aspects of telemedicine in addition to its usability. Findings reported in the studies included high patient satisfaction with telemedicine in 31.25%, whereas another 31.25% indicated a high acceptance of this method of medical consultation. Care coordination in 6.25% of the studies; confidence in telemedicine in 6.25%; trust, privacy, and reliability in 6.25%; and increased convenience when compared to personal visits in 18.75% were also reported.

Conclusions:

This review suggests limited research providing scientifically valid and reproducible usability evaluation at various stages of telemedicine system development. Telemedicine system designers need to consider the age-related issues in cognition, perception, and behavior of geriatric patients while designing telemedicine applications. Future directions for research were developed based on the limitations as well as other results found in this systematic review.

Introduction

Telemedicine, which is the exchange of medical information between locations through the use of electronic communication devices, is primarily used to improve healthcare services.¹ Its most significant feature, its dependence on communication technology, allows it to function as a surrogate to in-person meetings,¹ thus providing diagnosis, pretreatment and/or posttreatment to medical issues comparable to the conventional face-to-face method of medical practice.² The first reference to telemedicine, although primitive, was made in 1897 in a magazine article reporting the use of a telephone in a home setting in lieu of personal visits to the doctor.³ Another early application of telemedicine was seen during NASA's first manned space mission when vital signs were collected regularly from the astronauts to address concerns of ground-based physicians regarding the effects of the absence of gravity on the human body.¹ Today, patients use laptops, tablets, smartphones, and other such telecommunication devices⁴ for private real-time consultations with healthcare providers at distant hospitals and clinics concerning medical and pharmaceutical information.^3,5
–7

One area where telemedicine may prove to be highly effective is in providing medical care to the elderly,⁸ an age group that may soon account for 20% of the population; however, little research has focused on how effective care can be delivered to this population.⁹ Studies indicate that 92% of elderly are affected by at least one chronic health issue and in some cases two. In addition, they experience reduced mental ability due to dementia⁸ as well as reduced motor capabilities especially in fine motor coordination.¹⁰ Deteriorating health combined with poor motor skills, waiting in line at clinics and hospitals to be assessed by a doctor, or travelling long distances to a healthcare unit, thus, become arduous. One potential advantage of telemedicine is that it eliminates the travel necessary for more conventional treatment, travel that is expensive both in terms of personnel and finances.⁸ In addition, there is also a shortage of medical staff to handle the issues of the older population,¹¹ a situation compounded in rural areas by the cost of employing a full-time geriatrician, which may be impractical because of the reduced caseload.¹² These issues related to the healthcare of the elderly may be addressed by telemedicine.

The research conducted investigating the application of telemedicine to geriatric medical issues suggests it can be applied in various ways, including providing long-term care for chronic diseases, medical access to the elderly in the comfort of their homes, monitoring of vital signs and behavior, and increased access to physicians and other healthcare professionals in nursing homes.⁸ More importantly, the medical advice provided through telemedicine has been found to be of good quality, resulting in improved patient satisfaction.¹³ In addition, the use of telephone consultation and video conferencing in geriatrics has been found to be cost effective.

Even though telemedicine has advantages, the usability of these systems with the geriatric population requires investigation. While the technology implemented is readily available and widely used, the geriatric population may not be as able to navigate and use it as well as the younger generations. For example, understanding technology-related commands provided by a healthcare professional during a session may be problematic to users with minimal experience and familiarity with technology. Furthermore, the usability of telemedicine by the older population may also be affected by health-related issues, especially because system designers usually do not consider this age group to be potential users, and, therefore, focus little attention on the problems faced by them.¹⁴ However, the overall usability of telemedicine systems is important in creating a positive attitude toward the use of technology in general and in the increased adoption of these systems specifically.¹⁵

This article investigates the areas of usability that have been studied in the geriatric telemedicine setting. More specifically, it reviews articles with the goal of understanding (1) the characteristics of usability-related studies conducted with the geriatric population, (2) the aspects of usability explored in these articles and the instruments used to measure them, (3) the data analysis methods used, (4) the impact of the usability of geriatric telemedicine technology on the geriatric user population, (5) usability challenges associated with telemedicine platforms, and (6) the limitations observed.

Materials and Methods

Institutional Review and Human Subject Determination

This study was exempted from approval by the Clemson University's Institutional Review Board since it did not involve active human subject research. No individual patients participated in this study.

Inclusion and Exclusion Criteria

Only articles investigating usability factors in terms of telemedicine and geriatrics published in peer-reviewed publications between the years 2000 and July 2016 were considered for this review. However, one article identified from the reference section–Couturier et al.,¹⁶ which was published in 1998 was obtained from the reference section of an article—met the inclusion criteria and was included in the review. Other criteria included the use of a pilot study with the participants in the geriatric age group. In addition, the study had to include usability-related data from the perspective of the patient, not from the perspectives of the doctor or the caregiver. Another criterion important for inclusion was the requirement of a direct communication between the care provider and the patient.

Studies using such communication devices as Electronic Medical Records (EMR) and self-measurement of vitals and medication adherence were not included in this review nor were studies on peripheral medical devices used as part of telemedicine and general health monitoring using web-based applications, which did not consist of care-provider and patient communications. Virtual reality-based health training applications, literature reviews, posters, and extended abstracts were excluded, as were articles discussing problems of the geriatric population, but not including results from a user research study.

Search Strategy

As part of a systematic search, the online citation index services PubMed and Web of Knowledge were searched using the keywords telemedicine AND geriatrics, and telemedicine AND usability, and telemedicine AND usability AND older people. The terms geriatrics and older people were used to find articles on the use of telemedicine by older adults, and the term usability was used to include usability studies with the geriatric population. The initial search for this review found 197 articles on the Web of Knowledge and 100 articles from PubMed.

The first and third authors independently screened the titles and the abstracts of these 297 articles identified from the search to determine which met the inclusion criteria. The remaining four authors further reviewed each abstract to determine its appropriateness, with any discrepancies between the screening and review processes being resolved by discussion between the reviewers involved. This two-step process resulted in 62 articles that met the inclusion criteria, with another 12 being selected from the references listed in these articles.

Content screening was then conducted on these 74 articles. It was found that although the mean age of the participants in several was in the geriatric range, the individual participants did not meet this age criterion. Other factors leading to exclusion were insufficient data regarding the usability of the telemedicine systems, no direct communication between the care provider and the patient, and telemedicine systems consisting of medical records and health monitoring, but no consultations. Finally, a total of 16 articles were selected for this systematic literature review (Fig. 1).

Fig. 1.

Study selection process.

Data Extraction and Presentation

A table consisting of author name, year of publication, study objective(s), methods, and a summary of findings was constructed to systematically document relevant information from these 16 publications. Table 1 below displays these data. Tables showing more specific details regarding patient selection criteria and size, the data analysis methods, the technology used, and the impact of telemedicine are presented in the appropriate sections of this article.

Table 1.

Summary of Research Articles

AUTHORS	OBJECTIVE	METHOD	FINDINGS
Couturier et al.¹⁶	To investigate the feasibility of orthopedic consultation for geriatric population recuperating from fractures.	15 participants were involved in the study.	Favorable reaction from patients (9 patients = excellent, 3 patients = good, and 3 could not complete the survey because of cognitive impairment).
		A 5-step teleconsultation was used to determine the patient's physical situation—an interview, static clinical examination, test of walking, reading of radiograph, and the conclusion.	The clinical examination was not a problem, but one patient was uncomfortable in front of the camera.
		The first consultation was a teleconsultation followed by a face-to-face consultation.	7 participants rated “acceptable”, and 5 good, with a mean value of 8 and standard deviation of 1.3. Patient satisfaction was seen to be high.
		Clinical information from teleconsulting was noted on an evaluation form.
		For the feasibility study, notes made by the doctor during examination, ratings by the doctor, and ratings by the patient were used.
Pallawala and Lun¹⁷	To introduce a new mode of delivering healthcare, a low-cost alternative to traditional medical care and an examination of how people understand new technology. Focused on providing tangible and intangible benefits to patients.	The system was set up in two remote nursing homes and a geriatric hospital.	Elderly patients preferred telegeriatric system as it eliminated physical problems of personal visits.
		Doctors conducted a detailed inspection of the patient's health before beginning the study and recorded results on an EMR.	Patients were confident about the teleconsultations and thought it was a valuable resource.
		When a telemedicine system was required, nursing staff at elderly home created a consultation request.
		Using the EMR and videoconferencing, doctor communicated with patient.
Hui et al.¹⁸	To study the feasibility of providing telemedicine to patients in a nursing home and its impact on productivity and savings.	200 participants were involved in the study.	Depending on the specialty, 82–95% of the clients were satisfied with telemedicine and favored it.
		Dermatological and podiatric services were provided through real-time video calls.	Telemedicine was cheaper than conventional method.
		Follow-up consultations were also provided this way.	Patients asked for face-to-face consultation only in cases where physical examination was necessary or there were serious communication issues.
		If patient felt the need for face-to-face consultation, it would take place the same day or the next morning.	Inability to hear or see the specialist in some situations and lack of confidence in teleconsultation.
Kobb et al.³⁰	Use technology to provide care to chronically ill Veterans (Rural Home Care Project) with the aim of reducing hospitalization, emergency room visits, and prescription medicine cost.	281 participants were included in the intervention group and the control group consisted of 1120 participants.	Patients satisfaction survey conducted over 6 months indicated high rates of satisfaction.
		Veteran in normal care and in RHCP were compared.
		Veterans within the RHCP were compared before and after being a part of the program.
		At the beginning of the program, veterans completed a tool for validating function and perceived health.
		All other interviews were done by telephone.
		Customer satisfaction reports were collected every 6 months.
Corcoran et al.²⁴	To investigate the applicability and acceptance of telemedicine in podiatry.	49 participants took part in the study.	87% chose telemedicine over being transported to a hospital for podiatric care.
		A podiatrist carried out a foot examination through videoconference and then a treatment plan was determined.	Some said teleconsultation was more convenient and less expensive.
Wiborg et al.²⁵	Understand the feasibility, acceptance, and economic effects of using telemedicine.	153 participants took part in the study.	Patients were satisfied with the tele-examination and commented that it was easy to speak to and cooperate with the neurologist.
		Local physician at participating hospital investigated the use of teleconferencing in a stroke care center.	Analysis of patient and CT scans in case of acute stroke care is possible through telemedicine.
		The video call is placed and patient history is provided along with results. CT scan is examined and a decision is made about further steps.	Transport time due to telemedicine followed by a physical examination (where necessary) led to the need of extra time.
Poon et al.²⁰	Compare the feasibility, acceptability, and the clinical outcome of a cognitive intervention (CI) program started for the elderly with mild cognitive impairment and mild dementia using telemedicine and face-to-face methods.	The intervention group and the control group each consisted of 11 participants.	Majority of the videoconferencing group preferred the method.
		Candidates were screened using Cantonese version of Mini–Mental State Examination.	Both groups showed improvements in areas of attention and memory, calculation, and language on dementia scale.
		Qualified patients were categorized randomly into videoconferencing group and face-to-face interaction group.	The two groups did not differ significantly in neuropsychological outcomes.
		Using cameras set-up, the telemedicine session was carried out.
Schofield et al.²⁹	A report describing the outcomes of a study on the effects of enrolling in a home telecare program for heart failure, but without randomization or controls.	73 participants were included in the study.	Patient satisfaction with care coordination and the use of technology for overall program was 94%
		At baseline, patient history of illness and basic reading of weight and blood pressure were collected.	Before the study, 75% of the patients had recent hospitalizations, but during the study only 11% were hospitalized.
		Telephonic interviews were carried out by Veteran Health Administration (VHA) staff for 6 months.	The mean Bed Days of Care (BDOC) was reduced.
		Patients were also asked health-related question using the in-home messaging device provided.
Parker Oliver et al.²⁷	To investigate the acceptance and usability of videophone technology for telemedicine.	12 participants were involved in the study.	71% of participants affirmed that the technology was easy to use.
		Demonstration booth was set up requiring the participants to call a number connected to the researcher.	Participants found it comfortable to use the videophone and would adopt it if it was provided in their residence.
		They were then given an overview of the study and told to call another number to connect to a doctor through a video call.	People with hearing impairment found it difficult to use the videophone.
		They were then questioned about their impression of and experience using the system.	Others who read lips could not do so due to lag in the video.
		An issue was raised regarding the inability to read numbers on the phone button due to the color.
Lamothe et al.²²	To study the effects of Home telehealth on the elderly with chronic heart conditions.	82 participants were studied.	Patients had difficulty using the monitor.
		Patients had a local monitor with apparatus.	Patients and caregivers thought it was a better means for accessing the services.
		On a regular basis, patients had to take and send medical readings.	Results supported previous research outcomes on its positive effect on patients and providers.
		A nurse at the central monitor responded to alerts either through telephone calls or a nurse was sent to the patient's home.	Reduced visits to the ED.
		Patients were satisfied with use of THC.
		Other advantages mentioned were, not necessary to visit the doctor for BP, and no waiting time for nurse to take BP reading before meeting the doctor.
Jasemian²⁶	To understand and evaluate the compliance, trust, and comfort in using real-time telemedicine systems at their home.	Study consisted of 24 nonrisky heart patients.	80% of the participants thought the systems were user friendly and system had good usability.
		Participants had to wear a vest, which measured their ECG during their daily activities.	76% rated reliability aspect as ‘good’.
		Vitals were transmitted from the vest to a mobile phone and in turn to the researcher.	84% felt their privacy expectations were met.
		In case of uncommon ECG reading, the participants were contacted through telephone.	72% trusted the system and 80% also indicated that they were comfortable using the system.
Makai et al.³¹	To study the success of an Online Health Community (OHC) program for older people to help in obtaining multidisciplinary communication.	The intervention group consisted of 291 participants with 392 were included in the control group.	76/290 (26.2%) of the intervention group participants used ZWIP actively.
		The patients in the intervention group were observed using Zorg en Welzijns Informatie Portaal (ZWIP).	The small number may be an indication that introducing new technology to the elderly is difficult.
		Nurses performed measures and patient feedback was initially obtained and then subsequently at regular intervals in face-to-face meetings.	Despite theory-driven intervention design and implementation techniques, usage and effectiveness were low.
Czaja et al.²³	To investigate the feasibility and to determine the problems associated with telemedicine.	The study included 34 participants.	92% of participants found it easy-to-use.
		Participants had to upload BP and weight every day.	92% also felt they could follow their medical schedule better.
		Doctors sent reminders to patients daily.	67% confirmed that it made them feel better.
		In case of abnormal BP reading, the nurse at the Home Care Service Center was informed through email and a message was sent to the patient's message system to relax and retake the readings.	It was observed that experience with technology helped people use the system.
		If the reading did not return to normal, the nurse contacted the patient.	Some patients had trouble using the equipment.
Vermeersch et al.¹⁹	To explore the acceptability and usability of a Remote Presence Robot (RPR) using providers and older adults.	13 participants were involved in the study.	Participants reported higher positive responses.
		Participant signed into study and was provided a survey.	Residents rated more than 4/5 for both effectiveness and usability.
		An Advanced Practice Registered Nurse (APRN) greeted the participant through the RPR.	Positive comments about effectiveness concerning the APRN operating the RPR while making suitable comments.
		Patient measured weight, height, and read Snellen chart for eyesight test.	However, a few comments were made about the technology, such as having better temperature-measuring devices and reduced glare of lights during examination.
		For the physical examination, the APRN observed the participant's exposed skin, while walking, sitting, or standing and directed patient to place attached stethoscope on the heart.
Grosch et al.²¹	To study the hypothesis that video teleconference (VTC)-based screening for neurocognitive problems is feasible and gives the same results as face-to-face consultation.	8 participants were involved in the study.	Interviews with participants showed that they were satisfied with VTC testing procedure.
		Global cognition, attention, and visuospatial function were tested using three neurocognitive tests. Once completed, the patients held their test papers in front of the webcam for the physician to assess.	Mean measures from the tests indicated similar values for both methods.
Shah et al.²⁸	To study the effect of Health-e-access, a high-intensity telemedicine program for older people, on the use of emergency departments.	The intervention group contained 495 participants with 1058 included in the control group.	86.7% of patients indicated they would choose telemedicine in the future,
		On falling ill, the patient or a caregiver called the medical service.	Indicating a high rate of acceptability.
		The care provider provided a solution through immediate visit or telemedicine.	Individuals in the program saw a decrease in the ED visits with Health-e-access.
		In case of a telemedicine visit, an assistant collected health details from patient's home, which were uploaded onto EMR.
		The doctor, contacted by the assistant, then provided necessary feedback.

Results

Of the 16 studies identified for this review, 7 were conducted in the United States, 3 in China, and 1 each in Canada, The Netherlands, Germany, France, Denmark, and Singapore. A representation of this classification can be seen in Figure 2.

Fig. 2.

Number of telemedicine studies per country.

The articles included in this review focused on a wide array of issues, with 75%^{16

–27} addressing such issues as acceptability, usability, reliability, feasibility, satisfaction, implementation of telemedicine and costs. The remaining 25%^28

–31 of the articles focused on specific objectives with patient satisfaction being one of several. However, this difference in primary objectives resulted in the studies giving limited attention to patient usability criteria. Four articles, or 25%,^20,28,30,31 involved studies using one control group and one intervention group, with the former seeing the care provider in person and the intervention group using telemedicine. Seven studies, or 43.75%,^{17

–20,24,27,28} were based in elderly living centers; six articles, or 37.5%,^{22,23,26,29
–31} were based in the homes of the elderly, and 18.75%, or three studies,^16,21,25 took place in a hospital/clinical setting. Details of each of these studies can be found in Table 1.

Patient Selection and Sample Size

Patient selection in 25% (four studies) was based on age only, that is, participants had to be aged 65 years or older, whereas the remaining 75% had specific criteria for patient inclusion. The four studies^17
–19,28 with the general age criterion required the patients to be within the appropriate age limit and have the capacity to independently read and sign the consent form. Some of the criteria for participant selection in the remaining 12 articles included mild cognitive impairment and mild dementia²⁰ as well as geropsychiatric patients.²¹ Specific health conditions such as chronic systolic heart failure,²⁹ severe cardiac insufficiency, hypertension or unstable diabetes,²² at least a one-year history of blood pressure problems,²³ patients with potential or active foot problems,²⁴ stroke patients,²⁵ geriatric orthopedic patients,¹⁶ and patients requiring multidisciplinary care were criteria for participant selection in various studies. Other criteria included similarity in health issues, healthcare resource utilization and healthcare expenses,³⁰ heart arrhythmia,²⁶ and elderly living in a particular senior assisted living facility.²⁷

In addition to these criteria, several studies conducted tests to determine the physical frailty and mental condition of the patients. The Cantonese Mini–Mental State Examination (Cantonese-MMSE),²⁰ the EASY-care Two-Step Older Person Screening,³¹ the Mini–Mental State Examination (MMSE), and the Epidemiology Studies Depression Scale (CESD)^23,31 were specific tests used for further screening of prospective participants.

The studies varied in their sample sizes, the number of participants ranging from 8 to 495. The average age for all the participants in all the studies was over 65, hence qualifying them to be included in this review. Table 2 lists the criteria used by each study for selecting its participants.

Table 2.

Criteria for Patient Selection

AUTHOR	AGE CRITERION ONLY	COGNITIVE IMPAIRMENT AND DEMENTIA	GERO PSYCHIATRY	CHRONIC SYSTOLIC HEART FAILURE	COMMON HEALTHCARE ISSUES/HEALTH COST	MULTIDISCIPLINARY CARE	CARDIAC INSUFFICIENCY, HYPERTENSION, DIABETES	BLOOD PRESSURE	FOOT PROBLEMS	STROKE CARE	GERIATRIC ORTHOPEDICS	AFFILIATION TO A NURSING HOME	CARDIAC ARRHYTHMIA
Couturier et al.¹⁶											●
Pallawala and Lun¹⁷	●
Hui et al.¹⁸	●
Kobb et al.³⁰					●
Corcoran et al.²⁴									●
Wiborg et al.²⁵										●
Poon et al.²⁰		●
Schofield et al.²⁹				●
Parker Oliver²⁷												●
Lamothe et al.²²							●
Jasemian²⁶													●
Makai et al.³¹						●
Czaja et al.²³								●
Vermeersch et al.¹⁹	●
Grosch et al.²¹			●
Shah et al.²⁸	●

● indicates the patient selection criterion for each article.

Telemedicine Technology

The devices and equipment used in the practice of telemedicine varied among the studies reviewed here. The most widely used communication device for video conferencing was a computer,^{16,17,20,24,31} sometimes paired with a telephone to conduct the sessions.^22,28,30 In addition, telephone calls were used by the nurse to contact patients when the vitals they uploaded were significantly different from their normal values.^22,26 Telephones were also used to interview patients upon completion of a baseline vital check and to review their electronic records,^28,30 and one study used videophones for research purposes.²⁷

The study conducted by Vermeersch et al.¹⁹ incorporated a robot, specifically built for telemedicine, consisting of a laptop, cameras, a joystick for movement, and a stethoscope attached. This telepresence robot was actively involved in the sessions as the patients used it to take various simple measurements ordered by the consulting care provider.

In two studies,^23,29 devices other than conventional communication modes were provided by the healthcare providers to help patients upload their vitals onto a website. The devices used for this purpose included Health Buddy by Health Hero Network, Inc. and LifeLink Monitoring based in Lake Katrine, New York.²⁹ These in-home messaging devices transferred data concerning the patient's vitals to a nurse who followed up with a telephone call if a problem was detected. In addition to Health Buddy, the study conducted by Czaja et al.²³ also used American Telecare's audio–video devices and IDEAL Life Telehealth System. A color television was also used for video output in two studies^18,25 and a Tanberg 1000 Video Conferencing System was used for patient and care provider communication in one study.²¹ Figure 3 represents the communication devices used categorized as per 5-year period.

Fig. 3.

Communication devices used per 5-year period.

Peripheral devices were also incorporated with these devices. High-resolution cameras were used in 31.25% to obtain a better view of the patient,^{16,18
–20,25} with one study using a 3Com webcam inbuilt in a laptop for patient monitoring,¹⁷ and a document camera was used in another.²⁴ In addition to video cameras, some studies incorporated medical devices to measure blood pressure^23,26,29 and scales to measure body weight,^23,29 whereas others had a more elaborate setup, including other medical testing devices such as a stethoscope¹⁹ and a sphygmomanometer and oximeter.²²

To transfer the medical data from the patient to the medical professional, two studies^20,21 used standard broadband connections; three studies^18,24,25 used ISDN connections; two used wireless data transfer;^19,22 three studies^23,27,30 specified telephone line connections; 1 study used a standard GSM/GPRS connection,²⁶ and 1 study an ADSL connection.¹⁷ One within-hospital teleconsultation study¹⁶ used a coaxial cable for video conferencing across rooms. Of the 16 studies included in this review, 3 did not mention the data transfer connections used,^28,29,31 referring only to the website used for the data uploaded.

Websites were also used by care providers for obtaining patient information on a regular basis. One study³¹ referred to the use of a self-developed portal, ZWIP, an Online Health Community (OHC), which contained a secure messaging system and a shared Electronic Health Record. Messages shared through this portal were visible to others, and discussions could be initiated by a user. A professional could enter the discussion only with the consent of the user. Another study²⁸ investigated the impact of the team's Health-e-access Program for acute illness care. In this study, when a telemedicine consultation was requested, a clinical technician first collected and transferred the clinical history of the patient through an EMR Service, TeleAtrics, then initiated the consultation. Tables 3 and 4 represent the communication devices and data transmission methods used, respectively, in each study.

Table 3.

Communication Device Used

AUTHOR	COMPUTER	TELEPHONE	VIDEOPHONE	MESSAGING DEVICES	TELEVISION	VIDEOCONFERENCING EQUIPMENT	ROBOT
Couturier et al.¹⁶	●
Pallawala and Lun¹⁷	●
Hui et al.¹⁸					●
Kobb et al.³⁰	●	●
Corcoran et al.²⁴	●
Wiborg et al.²⁵					●
Poon et al.²⁰	●
Schofield et al.²⁹		●		●
Parker Oliver²⁷			●
Lamothe et al.²²	●	●
Jasemian²⁶		●
Makai et al.³¹	●
Czaja et al.²³		●		●
Vermeersch et al.¹⁹							●
Grosch et al.²¹						●
Shah et al.²⁸	●	●

● indicates the communication devices used in each study.

Table 4.

Data Transmission Method

AUTHOR	BROADBAND	WIRELESS	TELEPHONE LINE	ISDN	ADSL	COAXIAL CABLE	GSM/GPRS	UNKNOWN
Couturier et al.¹⁶						●
Pallawala and Lun¹⁷					●
Hui et al.¹⁸				●
Kobb et al.³⁰			●
Corcoran et al.²⁴				●
Wiborg et al.²⁵				●
Poon et al.²⁰	●
Schofield et al.²⁹								●
Parker Oliver²⁷			●
Lamothe et al.²²		●
Jasemian²⁶							●
Makai et al.³¹								●
Czaja et al.²³			●
Vermeersch et al.¹⁹		●
Grosch et al.²¹	●
Shah et al.²⁸								●

● indicates the data transmission method used in each study.

Data Analysis Methods

The articles reviewed in this study used a combination of both qualitative and quantitative data analysis methods, with the former primarily being for interview data, whereas the latter involved data obtained from Likert scale values and ratings for qualitative values, such as satisfaction, reliability, confidence in the system and acceptance, and for dependent variables such as the before and after effects of telemedicine. Three studies used qualitative data analysis, with the remaining using quantitative data analysis methods.

Qualitative Analysis

In the study focusing on understanding the impact of home telehealth in terms of patients, providers, and organizations,²² data collected through interviews were recorded and compression techniques were applied. Notes made during the periodic meetings with patients were also analyzed to gain an understanding of the patient perspective of home telehealth. One study analyzed patient satisfaction surveys provided at 6-month intervals through custom-made interview questions,³⁰ and exit interviews at the end of the teleconsultation were used to obtain feedback on patient satisfaction in another.²¹

Quantitative Analysis

In addition to a Likert scale for analyzing telemedicine characteristics, several other statistical methods were used, sometimes in combination with a Likert scale. The study conducted by Jasemian²⁶ used questionnaires to test the usability, reliability, freedom, and mobility, and degree of confidence and trust in the system under study. To understand improvement before and after the telemedicine consultation, a within-group paired sample t-test was used by Schofield et al.²⁹ In conjunction with this, a signal ranked test to compute the mean number of hospital bed days of care before and after teleconsultation was also performed. In the test conducted by Shah et al.,²⁸ baseline values for patients were measured using descriptive statistics along with a two-sample t-test, chi-square, or Fisher's exact test. To study the impact of the use of telemedicine on emergency departments, Generalized Estimating Equations were used. A mixed design repeated measure analysis of variance was used to test for differences between baseline time and the effects of telemedicine after 6 months along with a Mann–Whitney U test to measure patient satisfaction obtained through a questionnaire.²³ Another study analyzed categorical data using a chi-square test along with the Mann–Whitney U test for analyzing ordinal data and the Student's t-test for normal data. This was combined with a 5-point Likert scale test to analyze patient satisfaction.²⁵

A few studies used both qualitative and quantitative data analysis.^{16,17,19,21

–25,27} Likert scale values were used to find the mean and standard deviation values for characteristics such as reaction, satisfaction, effectiveness, and usefulness and written comments for each of the Likert scale questions were characterized as positive or negative. One study did not specify the data analysis method used.¹⁷

Impact of Telemedicine

Five studies, or 31.25%, investigating patient satisfaction reported that the participants indicated high levels of satisfaction,^{16,18,21,29,30} whereas a high level of acceptance for telemedicine was also found in 5 (31.25%) studies.^{16,22,24,27,28} In addition, 3 (18.75%) articles^17,20,24 determined that the participants found telemedicine to be more convenient than a regular visit to the doctor. Usability and effectiveness ratings¹⁹ in one study (6.25%) and convenience of telemedicine²⁵ in another were reported to have high ratings. Another study²⁶ reported that more than 50% of the participants reported high values for usability, reliability, privacy, and trust and confidence in the system.

Confidence in teleconsultation¹⁷ and care coordination²⁹ was found to receive high ratings by the participants involved in the studies. The technology was perceived to be easy to use by the participants,^27,29 and patients indicated that they could monitor their health better^22,23 and received better health-related information using telemedicine²² than through traditional face-to-face consultations.

Results from two studies found that the number of emergency department visits declined due to the use of telemedicine,^22,28 and two studies^18,25 indicated that the cost of telemedicine was cheaper than its conventional alternative. However, one study found low rates of usage of a telemedicine portal, concluding that introducing new technology to the older population is not easy.³¹ In addition, participants reported trouble seeing and hearing the care provider as well as a general lack of confidence in the system.¹⁸

The patients using telemedicine indicated an improved awareness of their health in addition to feeling that the technology helped them monitor their health. More specifically, results reported that patients saw telemedicine as a convenient way to manage their healthcare.¹⁷ Users also reported reduced privacy concerns and high confidence in these systems.²⁶ The presence of a nurse was attributed to higher confidence in navigating through the procedure.²² While an increase in the technological experience directly impacted the patients' attitudes toward technology, studies also showed that issues such as interference between videophones and hearing aids were reported.²⁷ Patients were also found to be ill at ease due to the presence and use of a camera in one study.¹⁶ A participant in another study complained about the inability to read the numbers on a videophone used for telemedicine purpose because of the color used.²⁷ However, this review found that limited research has been conducted focusing exclusively on the design of the telemedicine technology and how these factors impact a geriatric user's reaction to telemedicine systems.

Discussion and Future Direction

Contrary to the common belief that older adults are reluctant to use technology, research has found that 65% of the geriatric population wants to keep abreast of current advancements.³² However, for telemedicine systems to be usable and friendly for these older adults, there is a need to adopt a human-centered design approach in their development.²³ The majority of studies included in this systematic review were conducted late in the telemedicine system design cycle, either at the end of the system design or after implementing the system. Future research should be conducted throughout the design process, specifically considering how age-related factors may affect the interaction of the elderly with telemedicine technology and, in turn, making the appropriate design changes. These problems may be in the areas of vision, hearing, cognition, and motor skills, to name a few.¹⁰

Vision-related issues found in the aging population include problems in visual acuity, contrast sensitivity, and visual search. Visual acuity refers to the resolution at which a person sees an object while contrast sensitivity is the ability to differentiate between light and dark areas of an object, and visual search involves the movement of the eyes in conjunction with the focus on the surrounding area when in search of a specific object. In telemedicine systems, these visual problems may manifest in older patients experiencing difficulty reading the buttons on a phone or laptop.²⁷

Older adults also experience hearing issues involving problems with sound localization making it difficult to pinpoint the direction of a sound or difficulties in the perception of its loudness or in hearing the background noise indicating such issues as mechanical failure of devices.³² These sound-related difficulties should be considered in selecting devices for telemedicine as they should either include appropriate adjustments to accommodate the older population or alternative means should be provided to compensate for the hearing problems. It was found in the studies reviewed here that patients with hearing disabilities found it difficult to communicate using telemedicine equipment, and participants also reported interference between a videophone and the hearing aid in the study.²⁷ Such problems as these, need to be addressed, as these systems are being designed and prototyped.

An effective device or display screen is one that helps users easily navigate through a series of activities to achieve a final goal. The success of this process depends on cognitive ability, which, in older adults may be affected as a result of age, resulting in reduced working memory capacity, perceptual speed, reasoning ability, and attention. Increased reliance on environmental support or on additional information concerning a specific task is also found in older adults. In addition, spatial ability, the skill to manipulate objects based on location required, for example when reading a map or a computer screen, also degrades with age, meaning the elderly may have issues with telemedicine. Bearing in mind the visual and cognitive constraints resulting from the onset of old age, a study to understand the needs of the elderly in telemedicine computer applications must be carried out. This would lead to a comprehensive list of problems faced by the geriatric population in using these applications. In turn, their requirements in such a system and design ideas to mitigate these issues could be formed.

Finally, a loss in motor skills and motor coordination in older adults also affects their ability to carry out tasks.¹⁰ Their response time and the time taken to complete a task as well as their accuracy in doing so are reduced with age,³² issues that should be considered in designing telemedicine systems. In addition to these factors, other suggestions for future research in this area are provided below.

Sample Size

Of the 16 research articles considered for this review, 8 cited sample size as a limitation of the study. Most of these involved sample sizes of fewer than 50 participants, with some being as low as 8. The remaining 8 studies used sample sizes ranging from 82 to 495 participants. One article made no mention of the number of participants included in its study.¹⁷ As these results suggest, there is a need for studies with larger sample sizes to explore telemedicine usability among the geriatric population.

Cost Analysis

Although two studies^18,25 indicated that telemedicine was a cost-effective alternative to traditional in-person visits to the doctor, more studies are needed to validate this conclusion. In addition, it is important that future work investigate the impact of the equipment (high-end audio–video devices, basic smartphones) and the setting (hospitals, nursing homes) where telemedicine is used on its cost.

Absence of External Help

Patients explicitly reported feeling more comfortable using the telemedicine system in the presence of a nurse.²² While this presence may have been reassuring leading to higher patient satisfaction in the study, circumstances may occur when a nurse is unavailable to provide this assistance. It is important to examine how people perform without this external help. Doing so may lead to new perspectives as well as problems concerning the usability of telemedicine by the older population.

Accessibility

All studies included in this literature review were set in hospitals, elder living communities, nursing care, or private homes. In all these settings, the patients had access to private audio–video devices or community equipment specified for general use, all of which were in place before the study was conducted. However, there is a need to study the availability of Internet access and videoconferencing devices among the geriatric population in general and in rural areas specifically.³³

Others

Other areas for future work include the issues related to privacy in the exchange of medical records online, the level of participant trust associated with telemedicine systems, and the availability of insurance coverage for these sessions. The security of data uploaded online is also an issue which may need further investigation.

Limitations

This systematic review is not without limitations. The search string was very specific and may not have captured all relevant articles. The lack of uniformity in the description of the articles' descriptions of usability reporting and the methodology employed in the studies means it is possible that articles meeting our inclusion criteria were overlooked and not included in this review. The exclusion of studies not published in English may limit the generalizability of our findings to the global effort to improve telemedicine usability evaluation.

Conclusion

This article reviews the research conducted on telemedicine systems as applicable to the geriatric population, focusing on its usability. While telemedicine has repeatedly been shown to be useful in obtaining medical information and advice, this review suggests a limited number of published studies describing scientifically valid and reproducible usability evaluations at various stages of telemedicine system development. To foster user acceptance of telemedicine technologies, it is important for healthcare consumers to have a positive attitude toward using such system.^33
–35 A key factor influencing user acceptance is the usability of the telemedicine system.^33

–37 It is critical for real-world applicability to situate telemedicine applications within the context-specific needs of the people benefiting from or otherwise affected by them.^33

–37 Limited research has been conducted evaluating the usability of such tools with geriatric patients. Studies with larger sample sizes and with a special focus on use of this technology by this population are needed. The geriatric population can profit from this method of medical consultation and, hence, efforts must be directed toward understanding usability issues and addressing them to ensure effective use by the elderly, an increasing important area of research as this population group continues to grow and medical costs increase.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Bashshur

, Reardon

, Shannon

. Telemedicine: A new health care delivery system. Annu Rev Public Health, 2000; 21:613–637.

Sene

, Kamsu-Foguem

, Rumeau

. Telemedicine framework using case-based reasoning with evidences. Comput Methods Programs Biomed, 2015; 121:21–35.

Lustig

, Services

BHC

, Medicine

. The role of telehealth in an evolving health care environment: workshop summary. Washington, DC: National Academies Press, 2012.

Matusitz

, Breen

G-M

. Telemedicine: Its effects on health communication. Health Commun, 2007; 21:73–83.

Izquierdo

, et al. A comparison of diabetes education administered through telemedicine versus in person. Diabetes Care, 2003; 26:1002–1007.

Koch

. Home telehealth-current state and future trends. Int J Med Inform, 2006; 75:565–576.

Agnisarman

, et al. Lessons learned from the usability assessment of home-based telemedicine systems. Appl Ergon, 2017; 58:424–434.

Merrell

. Geriatric telemedicine: Background and evidence for telemedicine as a way to address the challenges of geriatrics. Healthc Inform Res, 2015; 21:223–229.

Kang

, et al. In situ monitoring of health in older adults: Technologies and issues. J Am Geriatr Soc, 2010; 58:1579–1586.

10.

Stronge

, Rogers

, Fisk

. Human factors considerations in implementing telemedicine systems to accommodate older adults. J Telemed Telecare, 2007; 13:1–3.

11.

Merrell

, Doarn

. Geriatric Telemedicine. Telemed J E Health, 2015; 21:767–768.

12.

Brignell

, Wootton

, Gray

. The application of telemedicine to geriatric medicine. Age Ageing, 2007; 36:369–374.

13.

Jennett

et al. The socio-economic impact of telehealth: A systematic review. J Telemed Telecare, 2003; 9:311–320.

14.

Demiris

, Finkelstein

, Speedie

. Considerations for the design of a Web-based clinical monitoring and educational system for elderly patients. J Am Med Inform Assoc, 2001; 8:468–472.

15.

, Chau

PYK

, Liu Sheng

, Tam

. Examining the technology acceptance model using physician acceptance of telemedicine technology. J Manage Inform Sys, 1999; 16:91–112.

16.

Couturier

, et al. Feasibility of orthopaedic teleconsulting in a geriatric rehabilitation service. J Telemed Telecare, 1998; 4:85–87.

17.

Pallawala

, Lun

. EMR based telegeriatric system. Int J Med Inform, 2001; 61:229–234.

18.

Hui

, Woo

, Hjelm

, Zhang

, Tsui

. Telemedicine: A pilot study in nursing home residents. Gerontology, 2001; 47:82–87.

19.

Vermeersch

, Sampsel

, Kleman

. Acceptability and usability of a telepresence robot for geriatric primary care: A pilot. Geriatr Nurs, 2015; 36:234–238.

20.

Poon

, et al. Cognitive intervention for community-dwelling older persons with memory problems: Telemedicine versus face-to-face treatment. Int J Geriatr Psychiatry. 2005; 20:285–286.

21.

Grosch

, Weiner

, Hynan

, Shore

, Cullum

. Video teleconference-based neurocognitive screening in geropsychiatry. Psychiatry Res, 2015; 225:734–735.

22.

Lamothe

, Fortin

J-P

, Labbé

, Gagnon

M-P

, Messikh

. Impacts of telehomecare on patients providers and organizations. Telemed J E Health, 2006; 12:363–369.

23.

Czaja

, Lee

, Arana

, Nair

, Sharit

. Use of a telehealth system by older adults with hypertension. J Telemed Telecare, 2014; 20:184–191.

24.

Corcoran

, Hui

, Woo

. The acceptability of telemedicine for podiatric intervention in a residential home for the elderly. J Telemed Telecare, 2003; 9:146–149.

25.

Wiborg

, Widder

, Telemedicine in Stroke in Swabia Project. Teleneurology to improve stroke care in rural areas: The Telemedicine in Stroke in Swabia (TESS) Project. Stroke, 2003; 34:2951–2956.

26.

Jasemian

. Elderly comfort and compliance to modern telemedicine system at home in 2008 . Second International Conference on Pervasive Computing Technologies for Healthcare, 2008; 60–63.

27.

Parker Oliver

, Demiris

, Porock

. The usability of videophones for seniors and hospice providers: A brief report of two studies. Comput Biol Med, 2005; 35:782–790.

28.

Shah

, et al. High-Intensity Telemedicine Decreases Emergency Department Use by Senior Living Community Residents. Telemed J E Health, 2016; 22:251–258.

29.

Schofield

, et al. Early outcomes of a care coordination-enhanced telehome care program for elderly veterans with chronic heart failure. Telemed J E Health, 2005; 11:20–27.

30.

Kobb

, Nannette

, Robert

, Sheri

. Enhancing Elder Chronic Care through Technology and Care Coordination: Report from a Pilot. Telemed J E Health, 2003; 9:189–195.

31.

Makai

, et al. Evaluation of an eHealth intervention in chronic care for frail older people: Why adherence is the first target. J Med Internet Res, 2014; 16:e156.

32.

Pak

, McLaughlin

. Designing displays for older adults. Boca Raton, FL: CRC Press, 2010.

33.

Narasimha

, et al. An Investigation of the Usability Issues of Home-based Video Telemedicine Systems with Geriatric Patients. Proc Hum Fact Ergon Soc Annu Meet, 2016; 60:1804–1808.

34.

Chalil Madathil

, Greenstein

. Synchronous Remote Usability Testing: A New Approach Facilitated by Virtual Worlds in Proceedings of the SIGCHI Conference on Human Factors in Computing Systems 2225–2234 (ACM 2011).

35.

Byham

, Madathil

. Developing consumer-centered healthcare public reports understanding the healthcare consumers' decision making process. Proc Hum Fact Ergon Soc Annu Meet, 2015; 59.

36.

Chalil Madathil

, et al. An investigation of the efficacy of electronic consenting interfaces of research permissions management system in a hospital setting. Int J Med Inform, 2013; 82:854–863.

37.

Madathil

, Rivera-Rodriguez

, Greenstein

, Gramopadhye

. Healthcare information on YouTube: A systematic review. Health Informatics J, 2015; 21:173–194.