Be smart and use smartphones for telemedicine: narrative review

Abstract

Background and Objective

With the evolution of technology, the delivery modes of healthcare have been completely transformed. Since the first use of telemedicine in the late 20th century, it has continued to evolve with advancement of technology. Today, telemedicine does not need sophisticated equipment and expensive platforms. Using a singular device to offer a wide range of services is both desired and necessary to provide higher-quality care at greater quantities. The inclusion of smartphone-telemedicine in many high-income countries proves a plausible framework to build upon for inclusion in low- and middle-income countries (LMIC). The primary goal of this review is to analyze existing literature on smartphone-based telemedicine and assess the scalability of this form of care to provide both accessible and equal care for all.

Methods

This is a narrative review that analyzed English published literature in PubMed, Medline, Cochrane Reviews, and Google Scholar over the last 50 years.

Key Content and Findings

Smartphone-based telemedicine can be divided mainly to mHealth and teleconsultation. Both applications are proven cost-effective at different extents and can augment health in different capacities. While mHealth is more suitable for health behavior change, smartphone teleconsultations can be employed in direct patient care. Smartphones’ applicability to different settings and flexibility make them ideal for telemedicine. This form of telemedicine might be more suitable for low-resource settings and LMIC due to compatibility with current infrastructure, ease of use, lower cost and high availability. However, ease of use comes with risk of overutilization and providers’ burnout. Privacy, digital divide and health literacy are other barriers of accessing smartphone-based telemedicine. Growing smartphone penetration and technology advancement carry future potentials for scaling up smartphone telemedicine in LMIC to advance equity and equality. Still, policies and regulations need to be implemented to protect privacy while using smartphones for telemedicine.

Conclusions

Smartphone-based telemedicine is an applicable form of telemedicine for low-resource settings and LMIC. Not all mHealth applications are suitable for LMIC, but investing in smartphone-based telemedicine for teleconsultation can save lives and lower the cost of care to reach everyone efficiently without a huge burden in a cost-effective manner for many LMIC.

Introduction

Emerging into the 21st century, technological advances paved the way for the modernization of healthcare platforms. Healthcare systems constantly aim to improve and optimize patient care but have been historically restricted by geographical barriers. As technology continues to evolve so has the potential to expand healthcare remotely. The initial use of telephones served to only provide a source of contact between patient and provider. The first mention of the potential to expand telephones was not until the late 1870s, when the editor of the Lancet journal suggested the capacity of a telephone to perform better than a stethoscope (1). At first glance, telemedicine was produced by the National Aeronautics and Space Association (NASA) in the late 20th century, with virtual methods being used to track the health status of astronauts while in space (2). Again, technology has evolved so has the potential of telemedicine, with the ability to provide healthcare over a hand-held device, a smartphone. These devices now can store medical apps, connect to medical monitoring devices, conduct video calls, and easily send and store information across platforms. This rapid transmissibility of data has proven to be an effective tool to elevate the level of healthcare across many barriers (3).

Telemedicine is defined as the remote delivery of healthcare across technology platforms (2). Three main types of telemedicine exist: synchronous, asynchronous, and remote monitoring (4). Synchronous telemedicine is the ability to provide real-time patient care through a virtual platform. Asynchronous is virtual-based care, also known as “store and forward”, that allows medical information to be transmitted electronically between patient and provider without the constraints of time (5). The third type of telemedicine is remote monitoring, or tele-monitoring, which allows providers to access and interpret clinical parameters without the patient in the office. This type of monitoring allows for the electronic transfer of clinical data between patient and provider or from monitoring devices (1). For example, providers can obtain vital signs, blood-glucose readings, and cardiac monitoring remotely (6). Additionally, telemedicine can be classified based on consumers and beneficiaries. It can be provider-to-provider for the purpose of getting teleconsultations or patient-to-provider to obtain medical care (7). With richness of telemedicine and its protentional, it should not be limited to high-income countries only. It should be simplified to meet current infrastructures in many low- and middle-income countries (LMIC) and adapt to feed unmet needs.

The scope of telemedicine expands further than just virtual visits with providers and remote monitoring, it also encompasses the ability to monitor prescription compliance, close gaps in continuity of care following hospitalizations, and manage chronic health conditions with easy access to subspecialty providers (3). In the United States, it is estimated that 60% of medical facilities use telemedicine, highlighting its already prominent role in high-income countries (5). Furthermore, the coronavirus disease 2019 (COVID-19) pandemic eased many restrictions and surged the appetite while expanding the telemedicine market (8). This review of existing literature sets out to display the advantages of using smartphone-based telemedicine and its potential to be expanded and implemented in LMIC. Despite its obvious appeal, consideration of infrastructure, cost, effectiveness, security and privacy must be discussed to guide future directions of smartphone-based telemedicine (4,9). We present this article in accordance with the Narrative Review reporting checklist (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-71/rc).

Methods

Search engines and data selection

The literature review was done using multiple databases including PubMed, Medline, Cochrane Reviews, and Google Scholar over the last 50 years. The review included English literature published in peer-reviewed journals. Inclusion criteria allowed original articles and systematic reviews published in English in the last 50 years up to September 2024 addressing telemedicine using smartphones in LMIC to be considered. Non-peer-reviewed and other languages were excluded from this review to ensure quality and ability to appraise included studies. Over 20 keywords were used and combined to capture all possible manuscripts (Table 1).

Table 1. Study protocol is illustrated to explain specifications of the literature review.

Items	Specification
Date of search	Jul 2023 to Sep 2024
Databases and other sources searched	PubMed, Medline, Cochrane Reviews and Google Scholars
Search terms used	Smartphone, Telemedicine, cost, efficacy, cost-effectiveness, mHealth, LMIC, QALYs, Non-communicable diseases, health promotion, Lifestyle, Diabetes, Hypertension, Pediatrics, computer-based telemedicine, Telehealth, Tele-visits, Tele-consult, Equity, low bandwidth internet
Timeframe	Over the last 50 years until Sep 2024
Inclusion and exclusion criteria	Inclusion: peer reviewed, english, original articles and systematic review articles
	Exclusion: non-peer reviewed, editorial, non-English
Selection process	Selection done by Y.A., N.G., F.M., and C.P. If conflict rose, Y.A. was able to resolve it by making a final decision

Data extraction and appraisal

Each study was selected and approved by two authors. Study quality and findings were appraised individually and approved by the principal investigator (PI). In case of conflict, PI was able to resolve it by making a decision to include or exclude a particular study. A final 42 articles met the inclusion criteria and were included in the final review.

Main findings and discussion

Why smartphones can be an appealing option for telemedicine?

Today, people across the world are utilizing smartphones to communicate and receive information across apps, web browsing, texting, and videoconferencing without leaving their homes. In resource-limited areas, healthcare can be scarce leaving patients with inadequate diagnoses, treatment, and poor healthcare outcomes. To put this into perspective, amongst the poorest countries the allocation of gross domestic product (GDP) to healthcare systems ranges from 0.6–1.7%. This is a stark contrast to high-income countries, whose GDP ranges from 5.5–7% (4). This emphasizes the issue of accessible and equitable healthcare in many LMIC due to the inability to provide adequate resources to this sector (10). No matter how low GDP is, mobile phone penetration remains high even in the lowest-income nations (11). This makes smartphone-based telemedicine an appealing model of care to supplement or replace the current healthcare system based on current needs and resources.

Applicability of smartphones for telemedicine

Based on the US Federal Drug Administration (FDA), digital health incorporates mobile health (mHealth), health information technology, wearable devices, telehealth and telemedicine, and personalized medicine (12). Thanks to the COVID-19 pandemic, mHealth and wearable devices proved more convenient and became more acceptable by both patients and providers (13). Patients can track their health progress and providers can capture patient health markers in the patient’s home environment. In the US, the FDA established guidelines for digital health tracking to incorporate stakeholders (providers, patients, ancillary services, and administrative staff) in reducing inefficiencies, improving access to care, reducing costs, increasing quality, and making medicine more personalized for patients (12).

Quality assessment and improvement in mHealth apps are important in determining the effectiveness of use. It is important to have patient-centered care (or personalized medicine), catering to the lifestyle and patient behavior while at the same time providing disease prevention and management. There are hundreds of active and prototype apps in mHealth but determining the right app to use is a challenge. To assist providers and patients, based on the needs to meet certain goals, an app must be carefully chosen for relevancy, infrastructure, and compatibility with each patient’s daily life. Despite the high potential, the effectiveness of mHealth-based apps has been questionable. The use of mHealth to manage diabetes or hypertension failed to prove usability and acceptability among both providers and patients in addition to incompatibility with current electronic health records (14). Adding the cost and time of recruiting patients for mHealth, the benefits of mHealth in diabetes and high blood pressure management are not appreciable. Additional monitoring and knowledge about health conditions do not always indicate a lifestyle change. Instead, mHealth apps aiming to improve health behavior to prevent serious complications of non-communicable diseases (NCD) were found to be very successful (15). The use of mHealth can promote better health through change in health behavior but might not be suitable for direct management of NCD. This provides insights into the acceptability of the role of mHealth among patients to improve its applicability in the management of NCD.

Using smartphone-based telemedicine is very applicable to reach rural and hard-to-reach communities where accessibility to a hospital or clinic is limited. Globally, smartphones are used for screening, diagnostics, and treatment of many diseases (16). With the advancement of technology, smartphones are capable of conducting similar functions to computers or even more. Therefore, it can be used for sending teleconsultations, multidimensional data views, creating online platforms for medical education, capturing images, and conducting some vital signs (17). As technology continues to thrive and the telemedicine market continues to expand, the capacity of smartphones for telemedicine will continue to grow (18). As many smartphone-based applications are compatible with low bandwidth internet, this makes them more applicable to conduct telemedicine than computer-based forms in rural and hard-to-reach areas, especially in LMIC (19). Furthermore, smartphones can have their own internet data, making them less dependent on internet sources, which is another advantage for low-resource settings. Smartphones are easier to transport and can fit in a provider’s pocket rendering them suitable for outreach programs and mobile clinics (20). With the high penetration of smartphones worldwide, ease of use and familiarity with the device add more applicability to smartphones for telemedicine with high efficiency (21). With ease of use, transport, and lack of need for sophisticated infrastructures, smartphone-based telemedicine is an optimal option for low-resource settings and LMIC with high acceptability among both patients and providers (22).

Lower cost, same impact

Cost is a factor to consider when operating telemedicine, including direct and indirect costs along with cost-effectiveness (23). When comparing telemedicine via computers to smartphone-based telemedicine, computer-based telemedicine has added items of equipment, supplies, training, staffing, and is less efficient (24). Then, there are direct and indirect costs. Direct costs are easily billable while indirect costs become a challenge to calculate. Luckily, billing regulations for telemedicine became clearer and more flexible after the COVID-19 pandemic in the US (18). Overall, telemedicine is documented to lower indirect costs and have higher net of cost savings for both providers and patients (25). Further research is needed to examine the role of smartphones in cutting indirect costs and allowing more cost savings. Beyond billing dilemma and cost, mHealth was documented to be cost-effective in certain diseases while providing additional gains in quality of life particularly increasing quality adjusted life years (QALYs) (26).

Smartphones can make medicine more convenient and easier to access

For people living in rural areas or underserved areas where access to care is not available, telemedicine can offer great benefits by providing virtual medical services. However, this can only be successful if infrastructures are in place to help with the promotion and applicability of telemedicine services (27). Smartphones with high penetration rates can make telemedicine more accessible and equitable (28). Smartphones for teleconsultations are not only convenient, but they can also save lives and lower mortality rates (29,30).

Along with the convenience of using smartphones for conducting telemedicine, it is especially useful for conditions that may require frequent follow-ups like many NCDs. A study tested the feasibility of telehealth visits in patients with migraine, and results were aligned with the expectations, increased appointment adherence, element of convenience, high patient satisfaction, and no travel requirements (31). However, smartphone-based telemedicine cannot overcome the shortage of medical supplies or poor infrastructures despite its ability to improve access to care and patient satisfaction.

Smartphones can be used for healthcare purposes in the comfort of home. A study done in adolescents reported that most participating youths felt less vulnerable, regarded their tele-visits as private, and were able to participate in discussions with their healthcare providers in a confidential manner. Given the increased rates of missed in-person visits among teens, virtual appointments allow this patient population to participate in making decisions about their health in a more proactive fashion (32). From a patient’s perspective, in-person appointments can be demanding and time-consuming, including the commute to the time spent in the clinic while waiting to see the physician. Healthcare providers also benefit as they can spend a shorter amount of time per patient without compromising on the quality of care in addition to understanding different perspectives of patients’ lives like their housing condition (33). Moreover, it also benefits patients in communicating medical information more suitably and securely, decreasing vulnerability and enhancing trust between patients and physicians. Additionally, smartphones can provide translation services allowing better communication with all patients cost-effectively, with more flexibility and higher availability (34). Although this is applicable for both computer-based telemedicine and smartphone-based telemedicine, smartphone-based telemedicine allows providers more flexibility in the location of where they can conduct tele-visits.

Disadvantages of smartphone-based telemedicine and challenges

One of the major disadvantages of using smartphones as a medium to conduct telemedicine is the repercussions related to the device being misplaced or lost. Since it contains sensitive patient information, it becomes vital to have policies in place to regulate the use of smartphones within a healthcare system. In a study by Seh et al., patients and multiple stakeholders had concerns about the use of their personal information, cyberattacks, and sharing of medical data through mobile phones (35). The prior issue is seen both in patients requiring short-term and long-term follow-up. The healthcare sector is regarded as one of the most common ones to be affected by cybersecurity incidents. Different types of data breaches have been reported including saving patient-related information on personal smartphones, sharing passwords with colleagues, loss of equipment, and use of personal devices at work settings. Data breach affects the trust of patients in the healthcare system and lead to compromise in the quality of services (36).

Even though the Health Insurance Portability and Accountability Act (HIPAA) law exists in some countries to protect patient’s data and privacy, there are gaps. Furthermore, healthcare policies vary from state to state and country to country. To protect patients’ data while using smartphones for telemedicine, mandatory user authentication for accessing valuable data and encryption techniques to decrease data breaches must be implemented. Expanding HIPPA’s laws should also be considered keeping in mind the increasing use of smartphones and health-based applications. Anti-virus programs must be actively used to prevent cyberattacks. Similarly, other solutions include frequent backing up of data, designing systems such that in case of a possible theft, and options should be available to erase the data (37).

Despite its convenience, one of the factors limiting its use is the digital divide. The accessibility and use of technology are influenced by several factors, including socioeconomic factors, literacy rates, income levels, and cultural values (38). With the advancement of technology and increased affordability, smartphone penetration is expected to grow, making patients more accessible and reachable. Another significant challenge is ensuring a stable and secure internet connection, which is crucial for effective virtual consultations. Smartphone-based applications might be more compatible with low-bandwidth internet and the phone can provide additional data by connecting directly to the internet without the need for a router. Furthermore, a study conducted in one of LMIC demonstrated that owning a smartphone is often gender-specific, with males having greater access to such amenities than females (38). This might put female patients at a disadvantage. However, the penetration rate has consistently increased globally, approaching 120% for the European Union and currently at 70% for sub-Saharan Africa (39). This high penetration rate reflects the increased number of people with the availability of smartphones to close the gender gap in the near future. A study conducted in rural areas of Pakistan found the limiting factor was the use of ‘featured cellphones’ as opposed to smartphones. Use of non-smartphones does not allow the full functionality and practice of telemedicine as certain services are not available and non-compatible with such phones (40). However, featured cellphones still can allow some forms of telemedicine and might be the only form of healthcare in such low-resource settings. A similar study also mentioned low literacy rates as a barrier to the use of smartphone-based telemedicine (41). Even if accessibility to smartphones is not a barrier, some patients might not be comfortable adapting to a new technology, as it involves learning a new system, especially involving older patients (42). Resistance to using new technology and low health literacy can be very challenging for smartphone-based telemedicine. Likewise, telemedicine might ease access to care but it does not initiate it and has no impact on medical-seeking behavior.

Constantly replying to messages and receiving calls on smartphones can be a source of burnout for physicians. Burnout was reported among physicians using smartphones for conducting telemedicine as it involved more time spent on the device, comprehensive charting, and may include administrative tasks such as scheduling, which are resource intensive. Because the aforementioned responsibilities lie with the provider, it may be one of the factors contributing to the burden on the physician. Besides the risk of burnout, some physicians resisted the use of smartphones for telemedicine. Compared to younger providers, older providers showed greater reluctance towards practicing telemedicine using smartphones (43). Training workshops on using technology and software, as well as hiring more staff to perform clerical duties, can address these concerns. As a result, not only will healthcare professionals be able to integrate telemedicine effectively, but they will also ensure a similar level of operation among their colleagues, at the very least within the same organization.

The whole idea of practicing medicine traditionally revolves around patient and physician interaction, which is now being replaced by technology reducing physician satisfaction with patient care. Likewise, progressing from conventional medicine to telemedicine has also been evidenced to instill feelings of low accomplishment amongst providers further leading to physician burnout. Healthcare providers should be allowed a certain degree of autonomy in managing a balance between both ways of practicing medicine to avoid emotional fatigue (44).

Platforms like instant messaging apps like WhatsApp and Telegram can be quicker, faster, and cheaper ways to use for teleconsultations, but it has also been found to have certain disadvantages. Firstly, the application was not designed to be safeguarded to conduct telemedicine. Secondly, the non-formal language used for communication between the physician and the patient can be interpreted differently. Misinterpretation and misdiagnosis using multimedia are also a concern as they may lead to erroneous diagnosis and mistreatment (45). In the US, WhatsApp is not HIPPA-approved for telemedicine. However, their use can be appealing for many practitioners in LMIC and there was an example of successful telemedicine using WhatsApp that can be followed and scaled up (46).

With easier access and convenience of use, overutilization is a concern of smartphone-based telemedicine (47). Overutilization might cause harm by over-medicalizing each issue and can drive the cost of care higher. Still, overutilization of healthcare does not improve general health (48). However, overutilization can put providers at higher risk of burnout and lower quality of care (49).

Future direction for smartphone-based telemedicine

Smartphones are getting smarter and smaller every day. With the expansion of the global market, they are becoming more affordable and widely available. Their use in medicine is expanding every day. Today, they can capture medical imaging directly, including point-of-care ultrasound (POCUS) (50). Additionally, smartphone information gathering can be augmented by artificial intelligence (AI). The use of AI in medicine is expanding daily (51). The ability to read X-rays by AI can be used to provide radiology teleconsultation which was proven accurate (52). This can be an example of a full machine-learning form of telemedicine. Combining AI with smartphones carries unlimited potential while overcoming the shortage of human resources. This can lower costs further while improving care for all. Machine learning is not the only education. Smartphone-based telemedicine can support and enhance. It can be used as a platform for medical education, capacity building, and connecting medical educators from the global north with learners from the global south to overcome geographic and visa barriers. Medical conferences are already changing and allowing smartphone-supported applications to allow more attendants to participate from all over the world. Furthermore, it can be a platform for health promotion among patients and influence lifestyle changes. The potential of smartphone-based telemedicine in medical education and health promotion is huge with a better view of data and virtual reality applications.

Conclusions

The prospect of implementing smartphone-based telemedicine globally is paving the way for equal and accessible care for all people. The COVID-19 pandemic increased acceptability and removed many barriers of using smartphones for telemedicine. The utility of this form of telemedicine is numerous and includes patient monitoring, improving health behavior, remote delivery of care, easier access to specialty providers, flexibility in scheduling, and individualized care. The convenience factor of smartphones might be contaminated by overutilization. In high-income countries and LMIC, the inclusion of these forms of healthcare can be vital. However, it plays a more impactful role in LMIC. Smartphones offer affordable platforms for telemedicine with a limited need for robust infrastructures, rendering them suitable for many LMIC. They have high potential with the advancement of technology to meet many needs and demands of various healthcare systems. With the possibility of pairing them with AI, even a shortage of expertise can be overcome at lower cost and good accuracy. However, not all forms of telemedicine using smartphones are applicable for use in LMIC. With high cost and controversial effectiveness, complex mHealth applications might not be optimal to be implemented in many LMIC, especially in low health literacy areas. Furthermore, smartphone-based telemedicine is not free of adverse effects. It might disrupt routine clinical care, increase the risk of burnout and jeopardize patients’ privacy. Still, new regulations and policies can be employed to safeguard both patients and providers. Eventually, new technologies have transformed our daily lives and it’s time for LMIC to adopt smartphone-based telemedicine to increase equity and equality for all through improving access to care, lowering cost, improving efficiency, and offering it to all.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.