Abstract
When the founding editor of a journal steps down after 20 years at the helm, this offers an opportunity for reflection and assessment of his contribution to the field. Twenty years ago modern telemedicine was planting its roots and a solid body of research had begun but there was no professional journal to call home. Research can provide the evidence to validate and justify new directions, but without peer-review and a means of publication these results cannot be disseminated or have an impact. This need was recognized and champions took on the challenge to create and foster dedicated telemedicine journals. One of those champions was Richard Wootton, BSc, MSc, PhD, DSc, FIMA, FInstP, FSS, who founded and nurtured the JTT for 20 years. I (EAK) have had the pleasure and honor of working with Richard for much of the life of the journal, first as a reviewer, then Editorial Board Member, then Co-Editor of JTT.
Like many of us in telemedicine, Richard probably never thought telemedicine would play such a large role in his career. He started out as a career scientist with the Medical Research Council at the Clinical Research Centre in London for 15 years and then became professor of Medical Physics at the Hammersmith Hospital and Royal Postgraduate Medical School for 7 years. In 1995 he established the Institute of Telemedicine and Telecare at Queen´s University in Belfast. From here he was recruited as Research Director for the newly-formed Centre for Online Health at the University of Queensland in Brisbane, Australia. His success there led to recruitment as Director of Research at the National Centre for Telemedicine and Integrated Care in Tromso, Norway where he took charge of advancing their research and innovation program. I had the opportunity to serve on an external panel reviewing the program a few years ago and our main conclusion was that Richard’s Directorship was the key factor in taking the program, research efforts and outputs to the next level and placing the program on the international landscape of excellence.
One would think starting or further developing telemedicine research and implementation programs in three countries on two continents would be enough for nearly everyone, but Richard extended his golden touch as the Director of the Scottish Centre for Telehealth. He is also Honorary chair at the University of Queensland, University of Aberdeen and Buckinghamshire New University. He has worked with the Swinfen Charitable Trust for over ten years and is stepping down as JTT Editor to further pursue international and charitable telemedicine endeavors. It seems safe to say that the programs he is and will be involved with in the future will benefit from his intelligence, caring, dedication and energy.
Throughout all of these challenges and accomplishments, Richard took JTT from a fledgling, niche journal to a key and respected international medical publication. I have been honored to work with Richard over the years and has greatly admired his vision and dedication to the journal and the field. It has often been a challenge deciding where to draw the line between publishing only the highest quality research and fostering those just getting into the field or trying to get published from countries with fewer resources and advantages than others, but we have generally reached decisions that have been fair and of benefit to the field. More often than not it has taken a lot of work with a bit of humor thrown in every now and then, but working with Richard always made even the challenges enjoyable and fruitful. I learned a lot from Richard not only about being a successful editor, but also about telemedicine, research and professionalism in general, and owes him many thanks for the opportunity to serve with him in the service of telemedicine. I will continue to uphold his high standards and will miss his guidance, leadership and humor, but wish him well in his new adventures.
For those of us who are continuing the JTT, we aim to meet the many challenges that lie ahead. Telemedicine is an area of healthcare which has had a long and difficult gestation and Richard has described some of this history in his final editorial. 1 It has been predicted that the term telemedicine will become obsolete when delivery at a distance becomes routine care, but this has only occurred in radiology (although “outreach imaging” still distinguishes teleradiology from in-house imaging). Small scale telemedicine services can exist in a niche alongside usual care for many years without being integrated into the broader system. 2 Many studies have been done on the barriers and enablers to uptake, and the reasons given for these difficulties have changed over time.
Initially, technical issues were thought to be a major barrier, such as limitations in bandwidth or the price of equipment. The advent of tablet computers, smartphones and high speed wireless connectivity have put the tools of telemedicine within the grasp of almost all health services and a large proportion of the general population. At this point then, attention has turned to the organisational and systemic changes needed for broad scale adoption. Where this has been successfully achieved, such as the US Veterans Health Administration, many years of effort were required and new models of care needed to be developed. 3 This illustrates that the task is much larger than simply installing some software or videoconferencing equipment. Telemedicine is a complex innovation; it is difficult enough to persuade clinicians to take up simple innovations such as prescribing one drug rather than another, whereas when an innovation produces changes to referral patterns, professional roles, diagnostic methods, information management and the patient population that can be served, it is hardly surprising that the process of change can be arduous.
In the early days, the main focus of telemedicine was in delivering services to rural, remote, and other hard to reach environments, particularly supplying specialist medical services to assist rural generalists. This is of continuing importance, being the model of care for tele-stroke, tele-oncology and acute tele-cardiology services, to give but a few examples. Added to this, there has been substantial growth in providing telemedicine directly to patients at home, as a means of providing chronic disease and risk factor management. Much of this is now delivered through mobile devices, which some have announced to be the new field of m-health, although it is actually a subset of telemedicine. Other current trends are the development of multi-purpose software systems which combine telemedicine and other health informatics functions. An area that has not yet been well developed, but may be poised to become of greater importance, is the use of telemedicine to enhance patient and carer participation in healthcare.
When telemedicine moves into the mainstream, it can no longer be being funded through trials and projects, and it must prove its value either to those who allocate health service budgets, or as a product in the open marketplace. The use of health economic analyses and business case development becomes an important component of proving this value. One of the problems of telemedicine is that whilst it is often cost-effective when the societal perspective is taken, that is, when all costs and benefits for the patients, the health services and the broader community are taken into account, the value is much harder to prove looking solely from the health services perspective. Much valuable data can be gained by including an economic analysis with a randomized controlled trial, but this can then lead to a lack of generalizability, as was shown with the Whole System Demonstrator trial of home telemedicine in the UK. The clinical benefits of reduced mortality and hospital presentations were not matched by economic value, 4 and one of the reasons for this was that the trial was conducted largely separately from existing services, 5 so the value of integration with the usual system of care could not be assessed. This illustrates the tension between conducting a controlled study versus an evaluation of existing services. The first approach may not be generalisable if it is specific to a particular health system and model of care, as telemedicine often is, and the second approach may have many threats to the validity of the data.
After this brief survey of the field, what changes can be expected at the JTT? The main focus of the journal will not alter; it will continue to have an international focus on original research, with a preference for publishing studies aiming to demonstrate the clinical or economic value of telemedicine for patients. In doing so we wish to make the JTT as useful as possible for those who are developing or operating telemedicine services. Studies reporting negative results are welcome, since we can learn as much from the “failures” as the “successes”. Editorials and opinion pieces will be published sparingly. A series of methodology articles are being planned, to take the general methodological issues faced in all research and explicate the particular points that are relevant to telemedicine researchers.
As well as encouraging well-designed quantitative studies with comparison groups which measure patient outcomes, we also encourage researchers to submit qualitative or mixed methods studies on issues such as uptake into normal practice or sustainability. However, these must be of high quality, and we recommend that potential authors attend to the extensive literature on the quality appraisal of qualitative research.6,7 The essence of qualitative research is to bring new conceptual understanding to the reader, and to achieve this we recommend that authors work within an explicit theoretical framework and describe how this relates to their chosen qualitative methodology. The JTT will also take some articles which are technically oriented but these must be aimed at the general reader, and of direct and immediate relevance to clinical services. Manuscripts concerning technical developments alone will be redirected to engineering or computer science journals.
Some smaller changes will be introduced, such as structured abstracts for research articles, and authors are urged to check the website for minor modifications of this nature. One of the perennial issues is the terminology problem; should the field be known as telemedicine or telehealth? Different terms are preferred in different countries and although some regard telehealth as more inclusive because it implies a broader range of service delivery, many employ the words interchangeably. We will continue to use the term that each author chooses.
With telemedicine being part of the the huge process of completely re-tooling healthcare and the systems that support it, a great deal of research remains to be done. Every clinical discipline, from speech pathology to cardiac surgery, is considering how much of their work can be done at a distance, what the place is of telemedicine in the overall care of patients, and how connected online health will influence practice. There is no shortage of areas to investigate, and we look forward to continuing the research journey with you.