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Electronic communications with patients


Providing medical care from a distance

Medical care from a distance is one of the most promising applications of advanced communications technology. There is a popular assumption that tele-medicine can help provide health services to patients whose access to care is limited for geographic or other reasons. The use of a wide range of technologies is being considered, but questions are being asked about whether all the promises to improve access to quality medical care are realistic. What is practical in terms of the delivery of tele-medicine? These concerns prompted a systematic review [1] to establish what was known about the ability of distance medicine to improve health care.


EA Balas et al. Electronic Communications with Patients: Evaluation of Distance Medicine Technology. JAMA. 1997 278: 152-159.

How was the question tackled?

Criteria to guide a search of databases focused on work that involved randomised-controlled trials, on the use of electronic communications; and on the measurement of the effectiveness of the intervention in terms of process; or outcomes of patient care. Search strategies, relevant to the individual databases, used a combination of MeSH headings and key words. The located papers were then subject to a methodological assessment to check their quality.

Eighty-three papers met the criteria but three were excluded because they failed the quality assessment. A standardised abstraction form was used to collect data from each paper. The distance medicine interventions were grouped into six categories:

Within these categories papers were clustered based on their clinical application areas.

What did the review find?

Computerised communications

Studies in this category were aimed at improving health care by offering better record keeping, increasing access to education resources and providing an opportunity for patients to be more active participants in their health care. A range of technologies was being use by patients - from telephones and modems to fax machines and video conferencing.

Four studies of computerised communications found beneficial effects in the management of patients with diabetes. Here are some examples. In two trials the monitoring of glucose levels led to significant reductions for patients in a group using modems compared to patient in a control group. Similarly, a trial to evaluate remote access to diet education found that patients with access to this system significantly improved their dietetic knowledge compared to patients with no access to this system.

Telephone follow-up and counselling

Studies here show that telephone follow-up consisted of live and interactive clinician-initiated telephone contact with questions, answers and recommendation about lifestyle, prevention of complications, medications, and other aspects of self-management. It was considered an extension of traditional care and viewed by some as a way to develop patient support in the community.

Many of the trials reported benefits. Telephone follow-up after A&E visits was useful. Telephone counselling after cardiac surgery and acute MI also showed positive outcomes. Telephone follow-up among women significantly increased mammography and colposcopic examination rates and motivated adherence with breast screening programmes. Some studies showed greater compliance with follow-up instructions, higher patients satisfaction and fewer missed appointments.

But all was not positive; some studies failed to show significant benefits. These included trials involving smoking cessation, social support for carers of elderly patients and patients undergoing radiation therapy.

Telephone reminders

The studies show that telephone reminder conversations did not normally extend beyond the specification and timing of particular visits or of clinical procedure. They were generally short messages encouraging compliance.

Many of the studies reported significant benefits such as: improved immunisation compliance among young children; increased compliance with foot care instructions for patients with non-insulin dependent diabetes; and medication compliance. One study analysing the effects of different types of reminder showed that a telephone reminder from a nurse was the most likely to persuade elderly patients to receive an influenza vaccination. Telephone reminders were also successful in improving appointment-keeping rates. However, in some studies (such as blood pressure screening) mailed reminders resulted in higher compliance rates that telephone reminders.

Interactive telephone systems

New computer-based telephone systems can deliver pre-recorded messages or instructions, reminders and be interactive, for example to allow patients to select additional information using their touch-tone telephone. Several studies covered application of this technology. Three of these showed beneficial effects for elderly patients, for example in adherence to medications and increased influenza vaccination rates. Another study showed that a system, which offered information (as mini lectures) about Alzheimer's disease, improved the knowledge of patients who listened to the series of lectures.

Telephone access

Four studies suggest that providing after-hours telephone access for patients can reduce hospital use and is a cost effective approach to offering primary care consultative services. Telephone contact is initiated by the patients and answered by a member of the health care team. The service is available 24 hours a day and seven days a week and offers emergency consultation, clarification of instructions and emotional support. Three studies reported positive outcomes for telephone access designed to assist patients who are chronically or terminally ill.

Telephone screening

Telephone screening could be an alternative to written or personal interview as a means on assembling clinical and administrative data. One study found that this approach was as reliable as traditional methods. However two studies failed to substantiate the value of telephone interviews for health-related quality of life assessments.

What has the review told us?

This is a helpful review which takes stock of progress in ways that new IT technologies can advance health care. There is evidence that it works in many areas, such as preventative care and the management of diabetes. Similarly, telephone reminders can improve influenza vaccination and childhood immunisation rates and telephone follow up can improve mammography rates. Telephone reminders and follow-up are the two most researched applications. The references in the paper give access to a wide range of original work.

The main downside is that the review shows the dearth of information about the costs and cost-effectiveness of these developments. The trials provide very little cost effectiveness data: indeed most studies offered no comment on the cost of the intervention. Bluntly, the review suggests that there is no evidence to show whether tele-medicine applications are cost-effective. The application of new distance technology may strengthen the continuity of care between patient and clinician by improving the c-ordination of health care activities from a single source. But care will be need do ensure that new developments are thoroughly evaluated - including their cost-effectiveness aspects.