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International Journal of Telemedicine and Applications
Volume 2013 (2013), Article ID 461829, 31 pages
Using Information and Communication Technology in Home Care for Communication between Patients, Family Members, and Healthcare Professionals: A Systematic Review
Division of Nursing, Department of Health Science, Lule####^~^~^~^~^~^####xe5; University of Technology, 971 87 Lule####^~^~^~^~^~^####xe5;, Sweden
Received 18 November 2012; Revised 17 January 2013; Accepted 3 February 2013
Academic Editor: Carlos De Las Cuevas
Copyright © 2013 Birgitta Lindberg et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction. Information and communication technology (ICT) are becoming a natural part in healthcare both for delivering and giving accessibility to healthcare for people with chronic illness living at home. Aim. The aim was to review existing studies describing the use of ICT in home care for communication between patients, family members, and healthcare professionals. Methods. A review of studies was conducted that identified 1,276 studies. A selection process and quality appraisal were conducted, which finally resulted in 107 studies. Results. The general results offer an overview of characteristics of studies describing the use of ICT applications in home care and are summarized in areas including study approach, quality appraisal, publications data, terminology used for defining the technology, and disease diagnosis. The specific results describe how communication with ICT was performed in home care and the benefits and drawbacks with the use of ICT. Results were predominated by positive responses in the use of ICT. Conclusion. The use of ICT applications in home care is an expanding research area, with a variety of ICT tools used that could increase accessibility to home care. Using ICT can lead to people living with chronic illnesses gaining control of their illness that promotes self-care.
Due to an ageing population and a shortage of hospital beds, it has become a challenge to find new ways to support and care for people with chronic illness living at home. Living with chronic illness changes the lives of those affected, who are often in need of support and nursing care in their homes [1####^~^~^~^~^~^####x2013;3]. eHealth has the potential to become a means of providing good care at home , which is especially challenging with regard to this emerging field . eHealth refers to information and communication technology (ICT) tools and services for health, whether the tools are used behind the scenes by healthcare professionals or directly by patients and their relatives . ICT tools can be used to access a wide variety of technological solutions for communication, including text messaging, gathering and monitoring data, diagnosis and treatment at distances, and retrieving electronic health records [5, 7]. According to the World Health Organization (WHO) , eHealth is used in the healthcare for transmission of digital data, including data stored and retrieved electronically to support healthcare, both at the local site and at a distance.
E-Health includes the interaction between patients and health service providers or peer-to-peer communication between patients and/or health professionals. Interest has primarily focused on the use of ICT tools in the care of older  and severely chronically ill people . Although ICT has been increasingly used in healthcare in recent years, efforts across countries have been fragmented and could benefit from improved cross-border coordination. eHealth tools and services have been widely introduced and implemented, and the potential benefits ICT can bring people with chronic illness will increase significantly .
The aim was to review existing studies describing the use of ICT in home care for communication between patients, family members, and healthcare professionals.
The particular objectives of the review were the following:(i)to provide an overview of characteristics of studies describing the use of ICT in home care,(ii)to describe how ICT was used for communication in home care, (iii)to describe the benefits and drawbacks of the use of ICT in home care.
The design for conducting this systematic review was guided by DiCenso et al. , with the following steps taken: for formulating a research question, conducting a literature search, applying inclusion and exclusion criteria, abstracting data, and undertaking an analysis.
3.1. Selection Criteria
The inclusion criteria for this literature review were set as follows: ICT interventions; communication between any healthcare professionals, patients, and/or family members; studies published in scientific journals; studies published between 2000 and 2010; and in the English language. Criteria for exclusion were ICT interventions that included technological systems not involving people (no active patient acceptance) such as monitoring by camera, alarm systems, and use of ordinary telephones, noting that telephones can be used complementarily to other techniques. Letters, editorials, and news items were also excluded.
3.2. Search Strategy
In the literature search the following electronic bibliographic databases were used: PubMed, Scopus, and CINAHL. Search limits were set to English language studies published in scientific journals from 2000 to June 2010. The search terms and search strategy were customized for each database to search completely and exactly. The search strategy included thesaurus terms (MeSH terms and subject headings) combined with free-text words. Examples of main search terms used were telemedicine, information and communication, ICT, technology, e-health, home care, home, and nursing. To maximize the search results, multiple sets of search terms were used. The search was done until an overlap in the studies was observed. All studies retrieved from the search in databases were imported into a reference manager (EndNote). The literature searches resulted in 1,276 studies; after duplicates were discarded by EndNote, 923 studies remained. A search alert was created to get the latest published studies, which resulted in 11 additional studies. The final total to be reviewed was 934. The literature search was performed with support from librarians.
3.3. Selection Process
A first selection was based on titles and abstracts of the 934 studies to identify whether or not they were within the scope of the research question. Next, a selection based on inclusion criteria was conducted, with focus on studies of ICT applications used in home care. After this selection, a total of 320 studies remained for closer review. The full-text version of the studies was then read and initially categorized based on type of communication applied in the studies. Two authors read all the studies independently. To increase reliability they discussed ambiguities of inclusion criteria until consensus was reached. This reduced the number to 139 studies relevant to the research question. However, nine relevant studies were unavailable both electronically and in paper form, which thereby were excluded from this study, leaving 130 studies. The selection process for the studies reviewed is presented in Figure 1.
3.4. Quality Appraisal
All eligible studies were evaluated for scientific quality on a three-grade scale: high scientific quality, good scientific quality, and fair scientific quality. The grading system is used by The Swedish Council on Technology Assessment in Health Care (SBU) for systematic reviews [12####^~^~^~^~^~^####x2013;14]. The quality appraisal was performed in accordance with a previously presented method for quality appraisal [15####^~^~^~^~^~^####x2013;18], which was chosen to be appropriate. In appraising the scientific quality of each study, protocols were used to extract data. Different protocols were used for studies with a quantitative approach and for studies with a qualitative approach. In the protocol for quantitative studies the items focused mainly on exclusion, sample procedures, intervention, dropouts, randomization, similarity of groups, blinding, outcomes, statistical procedures, ethical considerations, validity and reliability of instruments used, and possibility of generalization of results. In the protocol for qualitative studies the items focused mainly on context, ethical reasoning, procedure of sample, data collection, analysis procedures, saturation, clarity and logic of results, theoretical framework, theory generation, and description of main results. The protocols contained questions to be answered with yes/no/unclear and additional space to comment on the relevance of each item and for the extracted data. The number of questions answered yes was divided by the total number of questions and thereafter converted to percentage. Willman et al.  state that the use of percentage makes it possible to weight and compare different study####^~^~^~^~^~^####x2019;s methodologies. As recommended  the percentage was transformed to high scientific quality (80####^~^~^~^~^~^####x2013;100####^~^~^~^~^~^####x25;), good scientific quality (70####^~^~^~^~^~^####x2013;79####^~^~^~^~^~^####x25;), and fair scientific quality (60####^~^~^~^~^~^####x2013;69####^~^~^~^~^~^####x25;). The studies that scored less than fair were excluded , as they were considered not to be of sufficient scientific quality to be included. The quality appraisal was performed by two of the authors, initially together to obtain an equal assessment, but thereafter independently. When uncertainties arose, the authors discussed the result of the quality appraisal until consensus emerged. After the quality appraisal was undertaken, 107 studies remained.
3.5. Data Abstraction
The remaining 107 studies were classified as relevant to the research question and met the inclusion and quality criteria for being included in the data abstraction. A list of all included studies can be found in Table 6. Each of the included studies was given an indexation and then categorized according to a number of different areas based on the following characteristics: country of origin, year of publication, study approach, journal, communication strategies, type of technology, type of communication, disease diagnosis, and quality appraisal. Thereafter, data from each of the included studies were extracted and entered into a matrix.
The result presentation is divided in two parts; general and specific results.
4.1. General Results
The general results give an overview of characteristics of studies describing the use of ICT applications in home care. The results are summarized in areas including study approach, quality appraisal, publications data, terminology used for defining the technology, and disease diagnosis.
4.1.1. Studies####^~^~^~^~^~^####x2019; Approach
Most of the included studies had a quantitative approach. Only about one-fifth had a qualitative approach. Further, some of the studies used mixed methods, with both qualitative and quantitative approaches (Table 1). Twenty-one studies were part of larger projects.
4.1.2. Quality Appraisal
In the critical quality appraisal of all 107 studies, just under half were rated as high scientific quality . That number was compared to studies rated as good scientific quality and fair to good scientific quality (Table 1). When comparing the quality appraisal between qualitative and quantitative approaches, differences could be noted. A greater proportion of the qualitative studies were rated as high scientific quality. In comparison, less than half of the quantitative studies were rated as high scientific quality. The opposite was the case with qualitative and quantitative studies rated as fair scientific quality. Good scientific quality ratings were found in both qualitative and quantitative studies.
4.1.3. Publication Data
All of the 107 included studies were published between January 2000 and June 2010, so only part of year 2010 was included. During this period the number of publications increased by time, with about half of the included studies published between 2007 and 2009. Note that 2009 alone represents 23 studies of the total publications (Figure 2).
The studies included were published in 69 different scientific journals. The two most common journals were Journal of Telemedicine and Telecare and Telemedicine Journal and e-Health , together representing almost one-quarter of the total number of studies. The rest of the studies were spread over a variety of other journals . The impact factor in the journals ranged between 0.348 and 14,293.
The majority of the studies were performed in North America . About one-third of the studies were done in Europe , with United Kingdom, Sweden, and Italy being the most prominent. Only a few studies were conducted outside North America and Europe; those were done in Asia and Australia . Three studies were carried out in cooperation between different countries, but only one study was a combined study involving the continents of North America and Europe (Table 2).
4.1.4. Terminology Used for Defining the Technology
The results show that 13 different terms were used to define the technology utilized to increase accessibility to home care services and home nursing. The most frequently used terms were telehealth, telemedicine, technology, and telecare. Telehealth and telemedicine together account for more than half of the terms used in the included studies. Other terms used three times or more were e-Health, ICT/IT, telehealthcare, telemonitoring, and telenursing. Further, in some studies other terms were used as follows: e-rehabilitation, teleassistance, and telerehabilitation (Table 3).
4.1.5. Disease Diagnosis
The ICT applications were used in healthcare for a wide range of different conditions through the life span. In the majority of the studies , the technology was developed specifically for supporting people with chronicle illness living at home. The most frequent diseases studied were heart and lung diseases, chronic wounds, diabetes, cancer, and stroke. Chronic illness was used in 12 studies without any definition of the specific disease. Other conditions were, for example, infectious diseases, spinal cord injuries, and end-of-life care. A number of studies included did not specify the diagnoses (Figure 3).
4.2. Specific Results
The specific results describe how ICT was used for communication in home care and benefits and drawbacks within the use of ICT in home care. The results are summarized in the following main areas: type of technology, communications between participants, and benefits and drawbacks of the use of ICT.
4.2.1. Types of Technology
Three fields of applications were found to be prominent in the use of ICT in homecare: video technology, text messages and health monitoring. An important result was that a mix of more than one ICT applications was used in several studies . A small number of studies included all types of ICT applications above. In some of the studies, a mix of text and pictures and/or audio was used. In a few studies digital images were used. Some studies did not specify the used ICT application (Table 4).
Video Technology. The most frequently used type of technology was video technology ; the number includes studies using more than one ICT application. In several of those studies , the main focus of the intervention was the use of videophones or videoconferencing. Another use of video technology was to complement patient health monitoring . It is notable that web-based video conferencing was used only in a small number of studies . In all studies involving parents of children with chronicle illness, video technology was used to communicate.
Video technology was used with different types of applications. Examples of use were guiding patients in their use of medical equipment and to improve self-management, via video-based home telecare services. Another use was teleadvice given by clinical nurse specialists in different areas to community nurses. Videoconferencing was used between patients/family members and healthcare personnel for education and psychosocial or emotional support. Another way to use videoconferencing was to enable interactions between patients and nurses. Consultation via videoconferencing in the patient####^~^~^~^~^~^####x2019;s home was used instead of visits to the hospital, which enabled access to experts to a greater extent. Virtual nurse visits after, for example, discharge from the hospital, were offered to both patients and family members.
Text Messages. As shown in many studies , a common way of communicating was via text messages. For sending text messages, websites or web-based programs were used in some studies . Handheld platforms, such as mobile phones, laptop computers, or text telephones, were used by patients to both send and receive information as well as to communicate . In other studies , mobile phones or hand held equipment was used to send text messages.
For example, text messages were used for sending messages to patients with self-care advice as a response to symptoms and test results they had reported. Another way to use text messages was by electronic diary for home monitoring to improve communication between patients and healthcare professionals. An electronic messaging programme via computers and mobile phones or e-mail and video mail messages was used, enabling nurses and patients to exchange messages to and from anywhere. Via a symptom management system, patients can receive messages in their daily management of symptoms.
Health Monitoring. About half of the total studies included health monitoring, focusing on patients who sent health data to be analyzed by healthcare professionals. In most of the studies that looked at monitoring patient health, text messaging or video technology was used to communicate the data . Other forms of communication were also used, including the telephone . Health Buddy, was the most commonly used device for monitoring patient health . Health Buddy, a system that connects patients in their homes with care providers, is a telehealth device that collects and transmits disease management information about a patient####^~^~^~^~^~^####x2019;s condition including vital signs, symptoms, and behaviors. Types of patient health data collected from health monitoring systems in real time were, for example, weight, blood pressure, heart rate, and pulse.
4.2.2. Communication between Participants
Different types of communication via ICT were described as being used between participants, who were typically nurses, healthcare professionals, patients, or family members. The most frequent line of communication in the studies was between patients and nurses or other healthcare professionals. ICT was used most for communication between nurses and patients. In 24 studies, the patient was not the focus for communication. Instead, it was common for the technology to be used for communication with family members. In five of the studies with a focus on family members, the ICT was developed for healthcare personnel giving support to parents. In some studies, the communication was merely between healthcare professionals and neither patients nor family members were part of the communication. The review shows that people living with illnesses at home and healthcare professionals gave positive responses from using different ICT applications for healthcare in communication with each other (Table 5).
4.3. Benefits and Drawbacks with the Use of ICT in Home Care
Results of the included studies were predominated by positive responses from the use of different ICT applications in home care from both people living with chronic illnesses and healthcare professionals. For example, healthcare professionals####^~^~^~^~^~^####x2019; opinions were that their work was facilitated. Most studies show that communication between healthcare professionals and patients living at home was improved by using various ICT applications, as improvement in management of symptoms in daily life. It was revealed that various ICT applications can be advantageous to use in follow-up care of patients at home. Another benefit of using ICT applications in home care was found to be an improved accessibility. Results from studies show that using ICT in communication in home care can be cost saving but also the opposite. However, the use of ICT cannot replace a face-to-face encounter but can be used as a complement.
The aim of this study was to review existing studies describing the use of ICT in home care for communication between patients, family members, and healthcare professionals. This review provides an overview of characteristics of studies describing the use of ICT applications in home care. The results show that ICT in home care is an expanding field of interest, with a variety of ICT tools beginning to be evaluated significantly. Half of the included studies reviewed represent the year between 2007 and 2009. This may reflect the increased use of the Internet and ICT tools for care management with involvement of patients and family members####^~^~^~^~^~^####x2019; participation in care processes. Previous research  stated that focus has emerged from being technology focused to taking the users####^~^~^~^~^~^####x2019;, that is, the patient, family members, and healthcare professionals, perspective into account.
The review shows a trend that most studies were accomplished in North America and Europe, where the United Kingdom, Sweden, and Italy were most prominent. This is noticeable since Italy is one of the European countries in which less than 30 percent of the population uses the Internet on a daily basis. The maturity of the Internet use in daily life is an indicator of how far the digitalization of the healthcare sector should have come . For instance, despite Sweden being a small country, seven of the studies included in this review were performed there, which might be explained by the fact that 75 percent of the population uses the Internet on a daily basis.
This review shows that a wide variety of terms were used in the reviewed studies to define ICT. Most frequently used definitions were telehealth and telemedicine. This is in line with Koch####^~^~^~^~^~^####x2019;s  review of the current state and future trends in home telehealth. The term telehealth has been broadly defined as the use of telecommunication and information technologies for provision of healthcare to individuals at a geographical distance . Telehealth involves a wide variety of specific modalities including telephone-based interactions, Internet-based information, still and live imaging, personal digital assistants, and interactive audio-video communication or television . Furthermore, eHealth is described as the overall umbrella field that includes both ICT and telehealth, combining use of electronic communication and information technology in healthcare . This may explain the results of this review with many different terms used to define the technology.
This review describes how ICT was used for communication in home care, and an interesting result found was that the most frequent type of communication was between patients and healthcare professionals. This indicates that user focus needs to be shifting from tools for professionals to tools for patients and family members. This is in accordance with Koch , describing trends toward tools and services not only for professionals, but also for patients and citizens. However from a nursing perspective, there is a lack of knowledge about how to use ICT solutions to meet the needs of people with chronic illness. In specific, by performing qualitative studies people####^~^~^~^~^~^####x2019;s needs related to living with chronic illness can be elucidated. A challenge in home care will therefore be to use existing ICT tools to meet caring needs of people with chronic illness based on their experiences . From a caring perspective, it is important to understand ICTs impact on quality of life, quality of care, and medical impact of measureable parameters .
This review describes benefits and drawbacks when ICT was used for communication in home care. A variety of ICT applications are described in the review. Bardram et al.  stated that ICT applications used in home care must take into consideration the role technology should play in the use of patient and healthcare professionals. Neglecting this aspect may lead to technology that not provide the needed support for communication. According to Koch et al. , research and practice of health-enabling and ambient-assistive technologies may significantly contribute to that technical solutions are explored in a social context and in relation to individual needs. Telehealth systems in the form of online and mobile tools are already opening up the possibilities for reduced hospitalization and an increased home care . Various ICT applications will thereby offer healthcare professionals to become more flexible and able to address the differing needs of individual patients , that is, a more person-centred care.
The results of this review show that people living with chronic illnesses and healthcare professionals were positive to the use of ICT applications, despite that ICT cannot replace a face-to-face encounter but can be used as a complement. Across the literature, outcomes for telehealth-based services are generally comparable to outcomes for services delivered face to face . According to Charlton et al. , the style and type of communication the healthcare professional uses influence care outcomes. A literature review  shows that patients with possibilities of being cared for and using telecare at home preferred a combination of telecare and traditional healthcare delivery. Therefore, ICT applications must be used as an adjunct and not as replacements for standard care; otherwise, the positive results might not be replicated . Many patients prefer being involved and participating in decision making regarding the care they will receive. Despite this, caring programs will be developed without caregiver####^~^~^~^~^~^####x2019;s participation .
5.1. Methodological Considerations
The strength of this review is the broad literature search that finally resulted in 107 studies. The literature search was systematically conducted using selected databases based on relevant search terms. Even though the database search was done with assistance from a librarian expert in that field, it is possible that some study might have been missed. To get the latest published studies, a search alert was created. A limitation of this review may be that relevant studies might have been missed because of the selection of the English language. During the selection process, a quality appraisal was conducted; thereby, the scientific quality of the included studies could be ensured. The studies included have a great variation in study designs. Therefore, it is not possible to integrate the results and give a more specific summary in this review. However, this was not the intention as the aim was broad; we wanted to find numerous studies for being able to present the state of the art in this field of research.
The use of ICT applications in home care is an expanding research area, with a variety of ICT applications used to increase access to home care. The result shows that ICT in home care is mostly used as a tool for communication between healthcare professionals and patients or family members. Healthcare professionals can, based on this result, advantageously use ICT applications in home care as a tool to support people living with chronic illnesses gaining control of their illness that promotes self-care. However, a great number of the included studies were performed as pilot studies. For being able to evaluate the effects of ICT applications in home care, more extensive longitudinal studies are needed. To understand more about how ICT can be adjusted to home care, multidisciplinary and qualitative studies are needed from the perspective of the patient and their close relatives.
Conflict of Interests
The authors claim that there are no competing financial interests.
The authors are grateful to Lotta Frank, librarian at Lule####^~^~^~^~^~^####xe5; University Library LRC, Lule####^~^~^~^~^~^####xe5; University of Technology, for valuable help with the systematic literature search.
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