Abstract
Background
The integration of smart home technology to support health and social care is acquiring an increasing global significance. Provision is framed within the context of a rapidly changing population profile, which is impacting on the number of people requiring health and social care, workforce availability and the funding of healthcare systems.
Objectives
To explore the effectiveness of smart home technologies as an intervention for people with physical disability, cognitive impairment or learning disability, who are living at home, and to consider the impact on the individual's health status and on the financial resources of health care.
Search methods
We searched the following databases for primary studies: (a) the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register, (b) the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library, issue 1, 2007), and (c) bibliographic databases, including MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007) and CINAHL (1982 to March 2007). We also searched the Database of Abstracts of Reviews of Effectiveness (DARE). We searched the electronic databases using a strategy developed by the EPOC Trials Search Co‐ordinator.
Selection criteria
We included randomised controlled trials (RCTs), quasi‐experimental studies, controlled before and after studies (CBAs) and interrupted time series analyses (ITS). Participants included adults over the age of 18, living in their home in a community setting. Participants with a physical disability, dementia or a learning disability were included. The included interventions were social alarms, electronic assistive devices, telecare social alert platforms, environmental control systems, automated home environments and 'ubiquitous homes'. Outcome measures included any objective measure that records an impact on a participant's quality of life, healthcare professional workload, economic outcomes, costs to healthcare provider or costs to participant. We included measures of service satisfaction, device satisfaction and healthcare professional attitudes or satisfaction.
Data collection and analysis
One review author completed the search strategy with the support of a life and health sciences librarian. Two review authors independently screened titles and abstracts of results.
Main results
No studies were identified which met the inclusion criteria.
Authors' conclusions
This review highlights the current lack of empirical evidence to support or refute the use of smart home technologies within health and social care, which is significant for practitioners and healthcare consumers.
Keywords: Humans; Disabled Persons; Electronics, Medical; Home Care Services; Monitoring, Ambulatory; Monitoring, Ambulatory/instrumentation; Monitoring, Ambulatory/methods
Plain language summary
The effect of smart home technologies to support people at home
People who are ill (physically or mentally), or who are frail, may find it difficult to meet their everyday personal and social needs at home. Healthcare providers are trying to find ways to support more people at home, but finding home care workers and the money to fund this help is challenging. Advances in technology have created new devices to help support people.
New devices are already starting to be used, such as mobile phones tailored to health care, or electronic sensors that sound alarms in emergency situations. Another new technology is sensors. Sensors can be placed in everyday appliances in the home, like the fridge, cooker or the door, and can send information to healthcare providers. Providers can find out how people are doing in their homes and then make decisions about their care, such as how often to visit the home. Homes with these technologies are called 'smart homes'.
As with many new technologies, smart home technologies are often used without first testing if they are effective. This review aimed to determine what effect any type of smart home technologies have on people. The review produced a significant volume of literature on the use of smart technologies within health care, but there were no studies testing their effectiveness. The effects of smart technologies to support people in their homes are not known. Better quality research is needed.
Background
The purpose of health and social care is to deliver targeted services which support individuals who are experiencing impaired functioning as a result of ill health (physical or mental), congenital abnormalities or frailty (often associated with ageing). The delivery of such care provides a means of sustaining people within local communities and preferably within their own home (DOH 2006). Within the Biopsychosocial Model of Disability (a synthesis of the Medical Model (Schwartz Barker 2001) and the Social Model of Disability (Clarke 2001)) an individual's experience of disability and their function is viewed as an outcome of the interactions between health conditions (diseases, disorders and injuries) and the contextual factors influencing performance. These contextual factors are the external environment, where the individual lives, and personal factors such as age, gender and social background (WHO 1998). This concept of health and disability is embedded within the International Classification of Functioning Disability and Health (ICF); a framework produced by the World Health Organization during 2001 (WHO 1998).
Globally, changes in the demographic profile of the world population suggest an increase in the number of people living into old age, and a corresponding decrease in the numbers within the economically active age range. The world population is predicted to rise to nine billion by the middle of this century. A complication within this is a shift in the structure of the population profile, including a quadrupling of the population aged 60 years and over by the year 2050 (Bloom 2004). This will be the first time in history that the number of older persons (those over 60 years) will exceed the young (under age 15) (WHO 1998). Potential associated repercussions are a higher demand for health and social care, due to the forecast increase in the prevalence of chronic illness and increase in the age of mortality, in tandem with a decrease in the workforce available to contribute towards funding and providing the care.
In 2006 the World Health Organization reported in the World Health Report that globally many healthcare systems are weak, unresponsive and inequitable ‐ even unsafe (WHO 2006). For communities and nations a healthcare system is a labour‐intensive sector and workforce issues are widely regarded as central to the successful organisation and management of health and social care. The changing population profile will invariably put pressure on an already challenged service. A major challenge to governments will be how to provide both the future financial funding of sustainable services; fit for purpose and meeting the demands of populations, and manage the challenges of decreased workforce availability to contribute to the healthcare system (WHO 2002).
Description of the methods being investigated
Electronic Assistive Technology (EAT) refers to a broad range of devices, for example, environmental control systems to enable a physically disabled person to have more control over the home environment, or a social alarm which a frail elderly person can use to summon help if, for example, they have fallen (Doughty 2003).
All electronic assistive technologies use information and communication technology (ICT) as a core component, generating dynamic, often intelligent devices capable of invoking a response following an action by a user. In addition, integration of a networked ICT infrastructure facilitates device communication, widening functional capability and capacity.
Currently the rapid developments within the domain of ICT have spawned the emergence of devices and communication networks that are commercially competitive and offer functionality and specifications which are applicable within health and social care scenarios. The emerging applications are diverse, as evidenced by the wide range of solutions available. However, ambiguity exists around how academics, service providers and service users categorise the integration and use of electronic assistive technology. Sometimes a descriptor of the created environment is used, for example, a 'smart home', though this is not a homogenous term and on comparison the technologies within studies may vary quite dramatically. Others report in terms of a service descriptor and define, for example, 'telecare' or 'telehealthcare' to support a particular population of disabled people.
Aldrich 2003 has proposed five hierarchical classes of 'smart homes', which have been adopted to guide the inclusion of studies in this review. The classification is outlined below.
Homes which contain intelligent objects: environments with generally stand‐alone appliances and objects, which function in an intelligent manner. For example, an environmental control system that is set up to facilitate access via the front door, or facilitate the opening and closing of windows.
Homes which contain intelligent objects, which are enabled via wire or wireless networking to exchange information with each other.
The 'connected home' or 'ubiquitous home', which has both internal and external networks allowing interactive and remote control of systems, as well as access to services and information from both within and beyond the home. In this environment the tenant is not always required to connect proactively with the technology, which is discreetly positioned in the home environment and may unobtrusively gather information in relation to the tenant. This generates data relating to the general activity of the tenant which can be used to inform the care process and alter the environmental context that the tenant experiences.
The 'learning home' builds on the preceding level and data on patterns of activity, such as water use or movement within particular rooms, are discreetly gathered and recorded. The accumulated data are used to anticipate users' needs and then control the technology accordingly.
The 'attentive home' has the technical capability to record activity patterns, and the location of people and objects is constantly registered. This information is used to control technology in anticipation of the occupant's needs.
Why it is important to do this review
Technology is increasingly being integrated into health and social care as an intervention and to date a systematic literature review on the effectiveness of smart home technologies had not been completed.
Objectives
To determine the effects of smart home technology interventions on an individual's health status.
To establish the effects of smart home technology interventions on healthcare resources (including clinician time and hospital admission).
To explore whether the sophistication of smart home technologies is related to their effects.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials (RCTs), quasi‐experimental studies, controlled before and after studies (CBAs) and interrupted time series analyses (ITS), where there is a clearly defined point in time when the intervention occurred and at least three data points before and three after the intervention. Studies published in all languages were to be included.
Types of participants
Adults over the age of 18, living in their home in a community setting. We included studies that included participants with a physical disability, dementia or a learning disability.
Types of interventions
We included studies of the following interventions: social alarms, electronic assistive devices, telecare social alert platforms, environmental control systems, automated home environments and 'ubiquitous' homes. We excluded studies if they solely evaluated telemedicine applications (Wooton 2008). Therefore, we excluded the development of an acute sector service traditionally carried out in the hospital but now offered to a citizen at home with a healthcare professional based at the hospital (e.g. development of a telecardiology service (Scalvini 2007) or remote facility to monitor patients (Terschuren 2007)).
We planned the following comparisons:
use of a smart home technology compared to no intervention;
use of a smart home technology compared to a single non‐technology intervention (e.g. provision of care staff);
use of a smart home technology compared to a multifaceted, non‐technology intervention (e.g. moving to a purpose‐built housing scheme with no technology).
Types of outcome measures
Any objective measure that records an impact on a participant's quality of life, and measures of health or social care requirements, for example:
quality of life measures;
health‐related quality of life measures;
prevention of admission to institutional care, i.e. residential/nursing home;
healthcare professional workload;
economic outcomes (a) costs to healthcare provider; b) costs to participant;
measures of service satisfaction;
measures of device satisfaction;
healthcare professionals' attitudes or satisfaction (we would have included these in this review but would have excluded studies reporting only these outcomes with no objective measure of patient outcomes or professional performance).
Search methods for identification of studies
We applied the methods recommended by the Cochrane Effective Practice and Organisation of Care (EPOC 2007) Group and the Trials Search Co‐ordinator assisted in the development of the search strategy.
We searched the following databases for primary studies:
(a) the Cochrane EPOC Group Register (and the database of studies awaiting assessment) (see Specialised Register under Group Details); (b) the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, issue 1, 2007); (c) bibliographic databases, including MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007) and CINAHL (1982 to March 2007).
We also searched the Database of Abstracts of Reviews of Effectiveness (DARE).
Other sources
We also:
a) handsearched those high‐yield journals and conference proceedings which have not already been handsearched on behalf of the Cochrane Collaboration; b) screened reference lists of all papers and relevant reviews identified; c) contacted authors of relevant papers regarding any further published or unpublished work; d) contacted authors of other reviews in the field of effective professional practice regarding relevant studies that they may be aware of; e) searched the ISI Web of Science for papers that cited studies included in the review.
We applied no language restriction to the search.
Data collection and analysis
Data collection
One review author executed the search strategy with the support of a life and health sciences librarian.
Selection of studies
Two review authors independently screened titles and abstracts for inclusion. SM reviewed all titles and abstracts. In addition, we randomly divided the full number of retrieved titles and abstracts among the co‐authors for screening. Any disagreement was to be resolved by discussion between the review authors and arbitrator(s) as required. We retrieved full text copies of all relevant papers, and also those where it was not possible to determine eligibility from the title or abstract.
Data extraction and management
Once the relevant studies were identified for possible inclusion, two review authors independently considered the data regarding inclusion criteria (design, participants, interventions and outcomes), quality criteria and results according to the Cochrane Handbook (Cochrane 2008). We proposed that data extraction should be undertaken independently by SM and checked by GK. In addition, the group had planned to explore the effects of increasing sophistication of the intervention according to Aldrich's five hierarchical classes (Aldrich 2003).
Results
Description of studies
The initial search generated 2380 citations. We retrieved a total of 62 full papers. From these, 14 papers were excluded as they were literature reviews of telemedicine (Barlow 2007; Bensink 2006; Brignall 2007; Demiris 2005; Garcia‐Lizana 2007; Hailey 2002; Hankansson 2000; Mair 2000; Martinez 2006; Whitten 2000; Whitten 2002; Whitten 2007; Williams 2001) or telehealth (Jennett 2003). From the remaining 48 studies, 44 were excluded as they were either discussion papers, editorials, reported on telemedicine applications or did not meet the pre‐defined inclusion criteria.
Two review authors then independently considered the remaining four papers for inclusion (Hopps 2006; Jutai 2000; Sixsmith 2000; Vincent 2006), and assessed them further for study design and methodological quality. This was required, as on first reading the studies appeared to meet the eligibility criteria. Guidance was also provided by a UK based EPOC editor. Following consideration, it was agreed that none of the studies met the inclusion criteria of the review.
Excluded studies
We inspected the following studies in detail prior to exclusion, as on the surface they appeared to meet the eligibility criteria. We excluded two studies on the basis that the methodological design was not in keeping with the eligibility criteria for inclusion within this review:
Sixsmith 2000 describes the evaluation of an intelligent home monitoring system applying a multi‐method research approach involving qualitative and quantitative techniques; Jutai 2000 reports on a study to investigate the impact of electronic aids to daily living for young adults with progressive neuromuscular conditions. This was a site‐control after study design.
We excluded Hopps 2006 as it reported on a telemedicine application, although this was described by the author as a telehealth intervention. We excluded Vincent 2006 as it could not be confirmed from the published paper as an ITS study, presenting as an uncontrolled study, and all efforts to contact the author failed.
The authors of Jutai 2000 and Hopps 2006 were contacted directly by Suzanne Martin and the studies were discussed prior to exclusion.
Reasons for exclusion are also set out in the table 'Characteristics of excluded studies'.
Risk of bias in included studies
No studies met the inclusion criteria for this review.
Effects of interventions
No studies met the inclusion criteria for this review.
Discussion
Summary of main results
Smart home technologies within health and social care include a wide range of information and communication technology (ICT) enabled electronic assistive devices. These devices may operate in a stand‐alone intelligent capacity to access, operate and control household appliances. In other scenarios, multiple device integration creates a home environment that is technology‐enriched, thereby facilitating and supporting the delivery of a range of health and social care services. The purpose of the technology is to enhance functional independence and the quality of life achieved by either directly enabling service users, informing service providers, or both.
An interesting finding from this review is the lack of national and international consensus on terminology, classification or taxonomy of devices, products or service models. Some of the literature reporting on telehealth or telecare is, in effect, describing a telemedicine application. To debate the difference between the two would be helpful for both researchers and clinicians and assist with the reporting and seeking of evidence.
The World Health Organization has stated that the adoption of ICT in the healthcare sector often occurs without comprehensive evaluation of the health impact or a true understanding of the added value of ICT to health services (WHO 2005). This would appear to be the situation globally as national governments promote the implementation of technology‐enriched health and social care services by a fusion of policy, investment and operational service change across the developed world.
Quality of the evidence
This review considered a substantial amount of published literature and did not find any studies that met the inclusion criteria. Current available published studies lack the application of robust empirical methodologies to validate smart home technologies as an effective intervention to support health and social care.
Agreements and disagreements with other studies or review
This review has similar findings to other reviews that have explored different aspects of technology within health care. Barlow 2007 found that less than 1% of literature retrieved could be included in a literature review on the use of telecare for frail elderly people with long term conditions. Similarly, Demiris 2005 classified only 4.7% of the telemedicine literature as a clinical trial. Another similarity with systematic literature reviews of telemedicine is that many authors find that good quality evidence is lacking; often methodological detail is under‐reported to such a degree that the deficiencies limit the generalisability of findings (Bensink 2006; Brignall 2007; Garcia‐Lizana 2007; Hailey 2002; Mair 2000; Whitten 2000; Whitten 2002; Whitten 2007; Williams 2001).
Authors' conclusions
Implications for practice.
This review does not provide sufficient evidence to support or refute the integration of smart home technologies into health and social care.
Implications for research.
1) There is a dearth of well‐designed studies despite the substantial amount of literature emerging from the literature search.
This intervention is complex, with substantial inherent heterogeneity, and impacts not only on service users but also on the service provider and the organisational processes. Opportunity exists to investigate all of these aspects of the intervention. The UK Medical Research Council has produced a framework for the development and evaluation of RCTs for complex interventions to improve health (MRC 2000), which may prove useful.
2) International consistency in describing and reporting on technology‐enabled interventions (telemedicine, telecare, telehealth as examples) could enhance the design, delivery, implementation and dissemination of research projects and enhance the quality and accessibility of the evidence base available for practitioners.
3) The adoption of any assistive technology into everyday activity is complex, yet integration of ICT into the pattern of daily routine must be assured if the full potential of the device is to be realised. Research to date, however, demonstrates that with all assistive technologies there is a high abandonment rate (Galvin 1996; Scherer 1996). Research into this aspect of the adoption and utilisation of ICT within the social context is essential to enhance understanding of integration into service and inform technology design and development.
What's new
| Date | Event | Description |
|---|---|---|
| 12 November 2008 | Amended | Minor changes |
History
Protocol first published: Issue 1, 2007 Review first published: Issue 4, 2008
| Date | Event | Description |
|---|---|---|
| 31 July 2008 | Amended | Converted to new review format. |
| 29 July 2008 | New citation required and conclusions have changed | Substantive amendment |
Acknowledgements
Laura Mills, Health Sciences Librarian, University of Ulster at Jordanstown, Northern Ireland.
Kay Ballantine, Health Sciences Librarian, University of Ulster at Coleraine, Northern Ireland.
Martin Eccles, Professor of Clinical Effectiveness and the William Leech Professor of Primary Care Research, Institute of Health and Society, Newcastle University, England.
Characteristics of studies
Characteristics of excluded studies [ordered by study ID]
| Study | Reason for exclusion |
|---|---|
| Hopps 2006 | Methodology and design. The intervention described is a telemedicine application aiming to provide nursing contacts beyond those available under traditional home care. |
| Jutai 2000 | Methodology and design. This study investigates the impact of electronic aids to daily living for young adults with progressive neuromuscular conditions. This was a site‐control after study design. |
| Sixsmith 2000 | Methodology and design. This study describes the evaluation of an intelligent home monitoring system, applying a multi‐method research approach involving qualitative and quantitative techniques. |
| Vincent 2006 | Methodology and design. This study was uncontrolled and was not an interrupted time series analysis (ITS). |
Differences between protocol and review
No changes were made to the protocol to enable the completion of this review. The following methods from the protocol could not be implemented in the current review because no studies met the inclusion criteria:
a) data abstraction; b) assessment of methodological quality; c) reporting; d) analysis of data; e) exploration of heterogeneity.
Contributions of authors
Suzanne Martin conceived and co‐ordinated the review. Funding was secured by Suzanne Martin in collaboration with Christopher Nugent. All authors contributed to the data collection for the review, i.e. Suzanne Martin, Greg Kelly, George Kernohan, Bernadette McCreight and Christopher Nugent. Suzanne Martin undertook data management. All authors contributed toward the writing of the review.
Sources of support
Internal sources
University of Ulster, UK.
External sources
Research and Development Office, Central Services Agency, UK.
Declarations of interest
There are no conflicts of interest with this review and no industrial funding was received.
Edited (no change to conclusions)
References
References to studies excluded from this review
Hopps 2006 {published data only}
- Hopps F, Woodbridge P, Subramanian U, Copeland L, Smith D, Lowery J. Outcomes associated with a Home Care Telehealth Intervention. Telemedicine and eHealth 2006;3:297‐307. [DOI] [PubMed] [Google Scholar]
Jutai 2000 {published data only}
- Jutai J, Rigby P, Ryan S, Stickel S. Psychosocial impact of electronic aids to daily living. Assistive Technology 2000;12:123‐31. [DOI] [PubMed] [Google Scholar]
Sixsmith 2000 {published data only}
- Sixsmith A. An evaluation of an intelligent home monitoring system. Journal of Telemedicine and Telecare 2000;6:63‐72. [DOI] [PubMed] [Google Scholar]
Vincent 2006 {published data only}
- Vincent C, Reinharz D, Deaudelin I, Garceay M, Talbot L. Public telesurveillance service for frail elderly living at home, outcomes and cost evolution: a quasi experimental design with two follow‐ups. Health and Quality of Life Outcomes 2006;4:41. [DOI] [PMC free article] [PubMed] [Google Scholar]
Additional references
Aldrich 2003
- Aldrich F. Smart homes past present and future. In: Harper R editor(s). Inside the smart home. 1st Edition. London: Springer, 2003:17‐39. [Google Scholar]
Barlow 2007
- Barlow J, Singh D, Steffen B, Curry R. A systematic review of the benefits of home telecare for frail elderly people and those with long term conditions. Journal of Telemedicine and Telecare 2007;13:172‐9. [DOI] [PubMed] [Google Scholar]
Bensink 2006
- Bensink M, Hailey D, Wooton R. A systematic review of success and failures in home telehealth: preliminary results. Journal of Telemedicine and Telecare 2006;12(suppl 3):8‐16. [Google Scholar]
Bloom 2004
- Bloom D, Canning D. Demographic Change: Dimensions and Economic Significance 2004. Available from http://www.kc.frb.org/PUBLICAT/SYMPOS/2004/pdf/BloomCanning2004.pdf (accessed 27th July 2007).
Brignall 2007
- Brignall M, Wooton R, Gray L. The application of telemedicine to geriatric medicine. Age and Ageing 2007;36:369‐74. [DOI] [PubMed] [Google Scholar]
Clarke 2001
- Clarke A. The sociology of healthcare. 1st Edition. Essex: Pearson Educational Limited, 2001. [Google Scholar]
Cochrane 2008
- Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0 [updated February 2008]. The Cochrane Collaboration, 2008. Available from www.cochrane‐handbook.org (accessed 16th June 2008).
Demiris 2005
- Demiris G, Toa D. An analysis of the specialized literature in the field of telemedicine. Journal of Telemedicine and Telecare 2005;11:316‐9. [DOI] [PubMed] [Google Scholar]
DOH 2006
- Department of Health UK. Health and Social Care. http://www.dh.gov.uk/AboutUs/DeliveringHealthAndSocialCare/TheHealthAndSocialCareSystem/fs/en (accessed 13th March 2006).
Doughty 2003
- Doughty K, Burton L. Assistive technologies to assess and support dementia suffers in the community. Occupational Therapy for Elderly People Workshop. 15‐16 July 2002. Available from http://64.233.179.104/scholar?hl=en&lr=&client=safari&q=cache:s6ii1iH6mD8J:www.northern‐consortium.org.uk/reports/Dementia.pdf+social+alarms+and+dementia (accessed 2nd November 2007).
EPOC 2007
- Effective Practice and Organisation of Care Group: a review group of the Cochrane Collaboration. Available from http://www.epoc.cochrane.org/en/index.html (accessed 13th August 2007).
Galvin 1996
- Galvin J, Scherer MJ. Evaluating, selecting and using appropriate assistive technology. Aspen Publishers, 1996. [Google Scholar]
Garcia‐Lizana 2007
- Garcia‐Lizana F, Sarria‐Santamera A. New technologies for chronic disease management and control: a systematic review. Journal of Telemedicine and Telecare 2007;13:62‐8. [DOI] [PubMed] [Google Scholar]
Hailey 2002
- Hailey D, Roine R, Ohinmaa A. Systematic review of evidence for the benefits of telemedicine. Journal of Telemedicine and Telecare 2002;8 (supp 1):1‐7. [DOI] [PubMed] [Google Scholar]
Hankansson 2000
- Hankansson S, Gavelin C. What do we really know about the cost effectiveness of telemedicine. Journal of Telemedicine and Telecare 2000;6 (Supp 1):133‐6. [DOI] [PubMed] [Google Scholar]
Jennett 2003
- Jennett P, Affleck Hall L, Hailey D, Ohinmaa A. The socio‐economic impact of telehealth: a systematic literature review. Journal of Telemedicine and Telecare 2003;9(6):311‐20. [DOI] [PubMed] [Google Scholar]
Mair 2000
- Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. BMJ 2000;320(7248):1517‐20. [DOI] [PMC free article] [PubMed] [Google Scholar]
Martinez 2006
- Martinez A, Everss E, Rojo‐Alvarez J, Figal D, Garcia‐Alberola A. A systematic review of the literature on home monitoring for patients with heart failure. Journal of Telemedicine and Telecare 2006;12:234‐41. [DOI] [PubMed] [Google Scholar]
MRC 2000
- Medical Research Council. A framework for development and evaluation of RCTs for complex interventions to improve health. Available from: http://www.mrc.ac.uk/Utilities/Documentrecord/index.htm?d=MRC003372 (accessed 16th June 2008).
Scalvini 2007
- Scalvini S, Capomolla S, Zanelli E, Benigno M, Domenighini D, Paletta L, et al. Effects of home based telecardiology on chronic heart failure: cost and outcomes. Journal of Telemedicine and Telecare 2007;11 (suppl 1):16‐8. [DOI] [PubMed] [Google Scholar]
Scherer 1996
- Scherer MJ. Living in a state of stuck: how technology impacts the lives of people with disabilities. Cambridge: Brookline Books, 1996. [Google Scholar]
Schwartz Barker 2001
- Schwartz Barker K. History and practice trends in the treatment of physical dysfunction. Occupational Therapy Practice Skills for Physical Dysfunction. 5th Edition. Missouri: Mosby, 2001:15‐7. [Google Scholar]
Terschuren 2007
- Terschuren C, Fendrich K, Berg N, Hoffmann W. Implementing telemonitoring in the daily routing of a GP practice in a rural setting in northern Germany. Journal of Telemedicine and Telecare 2007;13(4):197‐201. [DOI] [PubMed] [Google Scholar]
Whitten 2000
- Whitten P, Kingsley C, Grigsby J. Results of a meta‐analysis of cost benefit research: is this a question worth asking?. Journal of Telemedicine and Telecare 2000;6 (Suppl 1):4‐6. [DOI] [PubMed] [Google Scholar]
Whitten 2002
- Whitten P, Mair F, Haycox A, May C, Williams T, Hellmich S. Systematic review of cost effectiveness studies of telemedicine interventions. BMJ 2002;324:1434‐7. [DOI] [PMC free article] [PubMed] [Google Scholar]
Whitten 2007
- Whitten P, Johannessen L, Soerensen T, Gammon D, Mackert M. A systematic review of research methodology in telemedicine studies. Journal of Telemedicine and Telecare 2007;13:230‐5. [DOI] [PubMed] [Google Scholar]
WHO 1998
- World Health Organization. Towards a common language for functioning disability and health. http://www3.who.int/icf/intros/ICF‐Eng‐Intro.pdf (accessed 18th December 2005).
WHO 2002
- World Health Organization Europe. The European Health Report 2002. Available at http://www.euro.who.int/europeanhealthreport (accessed 18th December 2006).
WHO 2005
- World Health Organization. World Health Organization 2005. Connecting for Health: Global Vision, Local Insight. Available from: http://www.who.int/kms/resources/WSISReport_Connecting_for_Health.pdf (accessed 16th June 2008).
WHO 2006
- World Health Organization. The World Health Report 2006: working together for health. Available from http://www.who.int/whr/2006/chapter1/en/index.html (accessed 29th July 2007).
Williams 2001
- Williams T, May C, Esmail A. Limitations of patient satisfaction in telehealthcare: a systematic review of the literature. Telemedicine Journal and eHealth 2001;7(4):293‐303. [DOI] [PubMed] [Google Scholar]
Wooton 2008
- Wooton R. Telemedicine support for the developing world. Journal of Telemedicine and Telecare 2008;14:109‐14. [DOI] [PubMed] [Google Scholar]