Telehealth in Primary Health Care: A Scoping Review of the Literature

Abstract

Background

The use of telehealth as a viable mobility to deliver quality services steadily increases in various levels of the health system. Despite the increasing use of telemedicine in secondary and tertiary health care services, there is a long way to go in the use of this technology in public health and primary health care (PHC). This study aimed to explore the features, approaches, and various dimensions of telehealth in PHC.

Methods

A scoping review was conducted using the Arksey and O'Malley framework. A search was conducted in three bibliographic databases including PubMed, Web of Sciences, and Scopus and in Google Scholar to collect papers published in November 2018 to 2000. Data were extracted according to a predefined form and check for completeness and accuracy by a second reviewer.

Results

Through reviewing papers, the authors extracted information on the general characteristics and features of telehealth services, kinds of PHC services delivered via telehealth, hardware and software facilities used for providing health care through telehealth services packages, as well as their benefits, outcomes and obstacles.

Conclusion

Telehealth can be used for different purposes of PHC through deploying a full range of communication channels available to the public. Due to the opportunistic use of existing devices and platforms, telehealth can provide scalable PHC services nationwide and worldwide. However, implementing telehealth in PHC faces challenges from technical, organizational, and human perspectives. Digital equity (in terms of technology access and e-health literacy) is required to expand telehealth services to the populations in underserved areas.

Introduction

Advancement and accessibility of healthcare services are among the measures of a society's development. Recent progress in telecommunication technologies has further emphasized the global importance of access to healthcare. It has impacted the methods of medical care and healthcare delivery and, as a result, remote access to health-related services known as telehealth has emerged as one of the most effective paradigms to improve the accessibility of health services.¹, ², ³, ⁴, ⁵

National healthcare systems are under pressure to provide prompt, accessible, and high-quality healthcare in cost-efficient ways.⁶, ⁷ By bridging the distance between care providers and receivers, telehealth can provide healthcare to hard-to-reach areas and help solve some of the issues patients face within the healthcare system. Telehealth is a new approach to delivering remote health services via real-time communication between the patient and the healthcare provider, using electronic audio and visual means.⁷,⁹, ¹⁰, ¹¹ With telehealth, information is exchanged over communication networks to monitor the health status of patients and to offer clinical recommendations, consultations, treatment, education, and administrative services.¹, ², ⁵, ¹², ¹³, ¹⁴

Telehealth has various benefits in primary health care (PHC), ranging from seamless access to health services for people in remote places to self-management promotion, patient empowerment, cost reduction of unnecessary referrals, and decreasing the need for commuting to seek medical care. Physicians can share information via telehealth channels for better clinical education, faster diagnosis, disease prevention and quicker therapeutic interventions.¹, ², ⁵, ¹¹, ¹², ¹³, ¹⁵, ¹⁶, ¹⁷, ¹⁸ Telehealth services also open up a new way of communication among patients and family caregivers and improve the sharing of critical information and experiences.¹⁴ Use of this technology can also incentivize physicians to recruit and retain in remote and rural areas by allowing them to remotely communicate with their colleagues and take advantage of long-distance education.¹⁹ The health system can also overcome the issue of limited resources and facilities by utilizing telehealth.²⁰

In PHC, telehealth can usually be offered when a patient is seeking the doctor's advice about a non-emergency medical problem. It does not replace face-to-face consultation, but complements it by offering timely PHC services in areas facing logistical hurdles to receiving secondary health care.¹, ², ³ PHC as the first contact point of population with health system aims to achieve the equity in population access to the health services.²¹, ²² Telehealth can contribute to this aim and overcome the challenges.²³, ²⁴, ²⁵

In this paper, we aim to determine the characteristics and components of telehealth packages through a scoping systematic review by answering the following questions:

1. What are the general characteristics of telehealth in PHC?

2. What kinds of PHC services can be offered in the form of telehealth?

3. What facilities are used for providing PHC through telehealth?

Methods

This study is a scoping systematic review, and the methodology for this review was based on the framework outlined by Arksey and O'Malley.²⁶ The researchers carried out a preliminary scoping search to determine a terminology for establishing the search terms of the study.

Data Sources and Search Strategy

We searched three electronic databases including PubMed, Web of Science, and Scopus. Google Scholar was also searched for relevant articles published in November 2018 to 2000. The combination of the following keywords, including Telemedicine, Telehealth, Primary Care, General Practice, Family Doctor, Services, Guideline, Package, Primary Health Care, Primary Healthcare, were used to find the studies.

Figure 1 shows the process of articles’ selection.

Figure 1.

Flowchart of Selecting Studies for Telehealth Services in Primary Health Care

Inclusion criteria:

• The focus of the study is on the telehealth in PHC

• All types of the study

Exclusion criteria:

• Non-English studies

• Papers where the full text was not available

Data Extraction

Two of the researchers (LB and LRK) examined the full text of all the included studies independently. They extracted data from fully eligible studies into a predefined form. The data extraction form was used including information on: title of the study, author(s)’ name, study type, stud year, study population age, tools/equipment used to provide telehealth, telehealth mode (synchronous or asynchronous), providers involved in telehealth, period of the telehealth delivery, intervention group, control group/s if applicable, the reason for telehealth, intervention type, telehealth outcome, target group of telehealth, and clinical and non-clinical equipment parameters used in telehealth. Any disagreement about the extracted data was resolved by the third researcher (LD).

Results

Out of the 3,823 articles identified from the electronic literature search, 115 were duplicates and were therefore eliminated. After screening the title, abstract, and full text of the papers, a total number of 43 were included for the final review (Figure 1).

Table 1 presents the characteristics of all 43 included studies.²⁷, ²⁸, ²⁹, ³⁰, ³¹, ³², ³³, ³⁴, ³⁵, ³⁶, ³⁷, ³⁸, ³⁹, ⁴⁰, ⁴¹, ⁴², ⁴³, ⁴⁴, ⁴⁵, ⁴⁶, ⁴⁷, ⁴⁸, ⁴⁹, ⁵⁰, ⁵¹, ⁵², ⁵³, ⁵⁴, ⁵⁵, ⁵⁶, ⁵⁷, ⁵⁸, ⁵⁹, ⁶⁰, ⁶¹, ⁶², ⁶³, ⁶⁴, ⁶⁵, ⁶⁶, ⁶⁷, ⁶⁸, ⁶⁹ Fourteen out of all the studies were the randomized controlled trial.³³, ³⁶, ³⁷, ⁴⁰, ⁴¹, ⁴⁴, ⁴⁷, ⁴⁹, ⁵⁰, ⁵², ⁵⁴, ⁵⁷, ⁶², ⁶⁹ The focus of the studies was the population with over the age of 18, except for one study that focused on children.⁴³

Table 1.

Basic Characteristics and Main Features of the Telehealth Services Provided or Used for Primary Health Care

First Author	Type of Disease	Country	Purpose of telehealth	Telehealth Delivery	Telehealth Staff	Population Type	Telehealth Services Receiver	Type of study	Age of participant	follow up (month)
Chan27	Type 2 DM	China	Education, monitoring and controlling disease	Two-way synchronous	Primary care group, Specialist	NM	Patient	NM	Elderly(Average age: 73.3)	2
Cottrell28	Hypertension	UK	Managing hypertension	Synchronous	GP	NM	Patient	Observational	Adults	6
Calvoa29	COPD	Spain	Telemonitoring and follow-up	Asynchronous	GP, Pulmonologist, Nurse	Urban	Patient, Primary care physician	Controlled trial	Elderly	7
Schuttner30	Population based primary health care	Zambia	Referral, follow up, and outreach service	Synchronous	Community health workers, GP	Rural	Care Provider	Observational	NM	8
Klein-Wiele31	Palpitation	Germany	Detecting arrhythmia	One-way asynchronous	GP, Specialist	NM	Patient	Observational	17-82	1
Huis in ‘t Veld32	Neck–Shoulder Pain	Netherlands	reduce pain, reduce disability	Synchronous	Myo-feedback therapist, Technician	NM	Patient	Qualitative study	NM	1
Tabak33	COPD	Netherlands	Support treatment of COPD through self-management	Two-way	Specialist, Nurse	NM	Patient	RCT	NM	9
Uscher-Pines34	Minor illnesses	USA	Examining impact of telemedicine services on care	Two-way synchronous	Physician	NM	Patient	Observational	NM	11
Harrison35	Diseases related to 10 different specialties	UK	Teleconferencing outpatient consultations	Two-way synchronous	GP, Specialist	Urban	Patient	Observational exploratory feasibility study	NM	5
Izquierdo36	Diabetes	USA	Following the recommendation of remote diabetes team by GPs	NM	GP, Specialist	Rural	Patient	RCT	55 years of age or older	7 years
de Lusignana37	Chronic Heart Failure	UK	Home telemonitoring	Synchronous/asynchronous	Nurse, Cardiologist, GP, Clinical physiologist	NM	Patient	RCT	Between 65 and 80	6
Anogianakis38	Primary care in prison	Greece	To assist primary care team for delivery of health care in prison	NM	GP, Paramedics, Specialist, Nurse	Urban	Patient	Observational (cross-sectional)	NM	9
Trief39	Diabetes	USA	Improving diabetes control	Synchronous and asynchronous	Dietitian, Nurse, Specialist	Rural	Patient	Observational	Elderly patients	12
Glynn40	Physical activity	Ireland	Promoting physical activity in primary care	Synchronous and asynchronous	Primary care team	Rural	Young population	RCT	>16 age	8
Mussulman41	Smoking Cessation	USA	Examining teledelivery of effective tobacco treatment	Synchronous	Counselor, Receptionist, Nurse	Rural	Patient	RCT	>18	12
Pratt42	Mental illnesses	USA	Improving self-management	Synchronous and	Nurse	Urban	Patient	Observational	aged 18 and older	6
	and chronic illness			asynchronous
Levy43	Spina Bifida	UK	To support continence self-care deficits	Two-way	Nurse	NM	Patients’ family	Observational	12-18 years	NM
Bove44	Hypertension	USA	Self-monitoring	Two-way	GP, Nurse	Urban, Underserved	Patient	RCT	>18	6
Al Alawi45	Diabetic retinopathy	Bahrain	Screening	NM	Ophthalmologist, Ophthalmologic technician	NM	Primary care physician	Observational	24-84 years	NM
Hatef46	Diabetic retinopathy	USA	Increasing the completion of the annual eye examination	NA	GP, Specialist	Urban, Underserved	Patient	Observational	18-75 years	NM
Odnoletkova47	Type 2 DM	Belgium	Coaching	NA	Certified diabetes nurse educator	NM	Patient	RCT	18-75 years	18
Quinn48	Type 2 diabetes	USA	Evaluate self-efficacy for diabetes self-management	Two-way	Certified diabetes educator, Patient coaching system	NM	Patient	Observational	seven older adults (mean age: 70.3 years)	2
Wakefield49	Diabetes and hypertension	USA	Evaluating the efficacy of remote monitoring	NA	Nurse	Urban	Patient	RCT	40-89 years	6 and 12
Deen50	Depression	USA	Evaluating acceptability,	Two-way	Nurse, Psychologist	NM	Patient	RCT	Mean: 47	12
			initiation and engagement in telepsychotherapy		Psychiatrist, Pharmacist
Tudiver51	Diabetes	USA	Evaluating acceptability	NA	GP, Dietitian	Mostly rural, urban	Patient	Observational (longitudinal survey)	Mean: 48	12
Nagrebetsky52	Type 2 diabetes	UK	Feasibility self-monitoring	Synchronous	GP, Nurse	NM	Patient	RCT	Mean: 58	6
Bujnowska-Fedak53	Primary care	Poland	Support real time consultations	Two-way synchronous	GP, Academic	Urban, Rural	GP, Patient	Descriptive	NM	3 years
					family medicine specialist
Huber54	Obesity	USA	Improving lifestyle	NM	Wellness coach	NM	Patient	RCT	18-55	6
Etherington55	Cervical Cancer	UK	Screening cervical cancer	Asynchronous	Nurse, Specialist	Urban	Women with minor smear abnormality but normal cervices	Observational	19-50	2 weeks
Ruas56	Primary Care	Brazil	Increasing the ability of primary care providers and educating them	Asynchronous	Specialist	NM	Primary Care Physician	Observational (descriptive)	24-61	NM
Salisbury57	Cardiovascular Disease	UK	Reducing risk of cardiovascular disease	Asynchronous/synchronous	GP, Nurse	Urban/Rural	Patients	RCT	40-74	12
Salisbury58	Chronic Health Conditions	UK	Developing conceptual model for telehealth	NM	GP	NM	Patients, Healthcare professionals	Mixed methods	NM	NM
Iannitto59	Diabetes Type II	USA	Managing insulin	NM	GP, Nurse	NM	Patients	Observational (cross-sectional)	>18	12
Langkamp60	Children with Developmental Disabilities	USA	Evaluate benefits of school based telemedicine for treating minor illnesses	Asynchronous	GP, Nurse, Certified telehealth assistant in school	Rural	Patient (school-age children with a disability)	Observational (cross-sectional)	3-21 years Mean: 9.2 years	12 months
Larsen61	Type 2 diabetes	UK	Adjusting the insulin dose to improve glycemic control	Asynchronous/Synchronous	Nurse/GP	NM	Patient	Observational	Mean: 57	6
Dario62	Type 2 diabetes	Italy	Telemonitoring for improving health-related quality of life	Synchronous/Asynchronous	Specialist	NM	Patient	RCT	Mean: 73	12
Blomdahl63	Disorders in the anterior part of the eye	Sweden	Evaluate technical quality of teleophthalmology	Two-way synchronous	GP, Specialist	Urban	Patient	Observational	NM	24
Thijssing64	COPD	Netherlands	Improving quality and efficiency of care	Two-way	GP, Specialist	NM	GP	Observational	Mean: 52	28
Hussain65	Urinary tract symptoms	UK	Training and supervising	Synchronous	GP, Specialist	NM	GP	Observational	NM	NM
Backman66	Cardiac disease	UK	Management	Two-way, synchronous/Asynchronous	Specialist, Nurse	Rural	NM	Review	NM	NM
Pecina67	Dermatologic conditions	USA	Evaluation of telehealth app	Asynchronous	GP, Specialist	NM	NM	Retrospective	Mean: 44	1
Cottrell68	Chronic kidney diseases or blood pressure	UK	Evaluate, Management	Asynchronous two-way	GP, Nurse	Underserved, Urban	Patient	Prospective	>50 years	3-6
Bujnowska-Fedak69	Type 2 diabetes	Poland	Improve quality of life and health status	Two-way	Care provider (mostly GP)	NM	Care provider (mostly GP)	RCT	18-75 years	NM

• NM: Not Mentioned

The studies included in this review originated from 15 countries around the world. The majority of the studies originated from the United States (n=15)³⁴, ³⁶, ³⁹, ⁴¹, ⁴², ⁴⁴, ⁴⁶, ⁴⁸, ⁴⁹, ⁵⁰, ⁵¹, ⁵⁴, ⁵⁹, ⁶⁰, ⁶⁷, and the United Kingdom (n=12). ²⁸, ³⁵, ³⁷, ⁴³, ⁵², ⁵⁵, ⁵⁷, ⁵⁸, ⁶¹, ⁶⁵, ⁶⁶, ⁶⁸ Only three studies were from Asian and African countries.²⁷, ³⁰, ⁴⁵ Diabetes and hypertension were the most frequently targeted diseases²⁷, ³⁶, ³⁹, ⁴⁵, ⁴⁶, ⁴⁷, ⁴⁸, ⁴⁹, ⁵¹, ⁵², ⁶¹, ⁶², ⁶⁹ by the telehealth PHC services.²⁸, ⁴⁴, ⁴⁹, ⁶⁸

In 26 studies, general practitioners were the primary providers of telehealth services.²⁸, ²⁹, ³⁰, ³¹, ³⁴, ³⁵, ³⁶, ³⁷, ³⁸, ⁴⁴, ⁴⁶, ⁵¹, ⁵², ⁵³, ⁵⁷, ⁵⁸, ⁵⁹, ⁶⁰, ⁶¹, ⁶³, ⁶⁴, ⁶⁵, ⁶⁶, ⁶⁷, ⁶⁸, ⁶⁹ A total number of 19 studies used the real-time (synchronous) approach for providing telehealth services.²⁷, ²⁸, ³⁰, ³², ³⁴, ³⁵, ³⁷, 39-42, ⁵², ⁵³, ⁵⁷, 61-63, ⁶⁵, ⁶⁶ Patients were found to be the primary receivers of telehealth services (n=32).²⁷, ²⁸, ²⁹, ³¹, ³², ³³, ³⁴, ³⁵, ³⁶, ³⁷, ³⁸, ³⁹, ⁴¹, ⁴², ⁴⁴, ⁴⁶, ⁴⁷, ⁴⁸, ⁴⁹, ⁵⁰, ⁵¹, ⁵², ⁵³, ⁵⁴, ⁵⁷, ⁵⁸, ⁵⁹, ⁶⁰, ⁶¹, ⁶², ⁶³, ⁶⁸

The aim of providing telehealth services was various. In some studies, the aim of telehealth was to follow up with patients²⁹, ³⁰ and monitor disease,²⁷, ²⁹, ³⁷, ⁴⁴, ⁵², ⁶² empower people,⁴³, ⁴⁴ train patients,²⁷, ⁴⁷ and provide quick and easy access to meet medical needs.³⁰, ³¹, ⁴³, ⁵³, ⁶¹ However, some telehealth services aimed to train and supervise healthcare providers and give a second opinion or consultation. The studies included in this review originated from 15 countries across the world.⁴⁵, ⁵³, ⁵⁶, ⁶⁴, ⁶⁵

Equipment and devices used for delivering telehealth services included television,²⁷ telephone,³⁴, ³⁵, ³⁹, ⁴¹, ⁴⁴, ⁴⁶, ⁴⁸, ⁵⁰, ⁵⁴, ⁵⁷, ⁵⁹, ⁶⁶ glucometer,⁵², ⁵⁹, ⁶² camera,²⁷, ³⁵, ³⁶, ⁴⁵, ⁴⁶, ⁶⁰, ⁶³ mobile phone, ⁴⁰, ⁴³, ⁴⁸, ⁵², ⁶¹, ⁶⁸ spirometer,²⁹, ⁶⁴ pulse-oximeter,²⁹ heart rate monitor,²⁹ computer,³⁰, ³³, ³⁹, ⁴¹, ⁴⁵, ⁶⁹ digital otoscope,⁶⁰ and telephonic stethoscope.⁶⁰

Disease management,²⁸, ³⁶, ⁶², ⁶⁹ healthcare support in rural areas,³⁰, ⁴¹ self-management,²⁷, ³³, ³⁹, ⁴², ⁴⁸, ⁵¹, ⁵⁸, ⁵⁹, ⁶¹ and cost reduction³⁵, ³⁸, ⁴⁶ were the most critical achievements of telemedicine services in the reviewed studies.

The critical challenges reported for implementing telemedicine services include lack of resources,²⁷, ⁶⁹ lack of awareness,²⁷, ³⁰, ⁴⁸ staff resistance,³⁸, ⁵⁰ lack of privacy criteria,²⁷, ³³, ⁴³ and lack of access to technology.⁵⁷, ⁵⁸, ⁶⁴ (Table 2)

Table 2.

Advantages, Outcomes, Obstacles, and the Required Facilities Reported for Telehealth Services in PHC

Author	Reported advantage/ benefit	Obstacle	Hardware/software/facilities
Chan27	Easy to use, empowers patient	Lack of enough resources; lack of awareness; privacy; standard-based encryption	A dual-monitoring Tandberg 880 videoconferencing set-top unit; large screen television; high-resolution portable Canon camera
Cottrell28	Flexible, convenient, easy to use, and acceptable means for managing hypertension with collaboration with responsible health professionals	Not all patients provided feedback using all the means employed; some missing data	Home electronic BP measurements and mobile phones
Calvoa29	Improved the care of patients with severe COPD; improvement in many clinical outcomes; reduction in emergency room visits, hospitalizations, and length of stay	NM	Spirometer; pulse-oximeter; heart rate monitor; blood pressure monitor; modem and telephone line
Schuttner30	Assisting to clinical care in rural areas and potential for epidemiologic and health system applications; improved service outreach; guided clinical activities; and facilitated data collection	Required multiple updates; required literacy and technological proficiency levels	Computers; network; cellular local server; cellular modems; mobile phone
Klein-Wiele31	Decreased hospital admissions, decreased emergency treatments and cardiology referrals	Inability to activate the device and send symptoms	Tele-EKG-Card 100IRTM (Vitaphone, Mannheim, Germany)
Huis in't Veld32	Ease of use, usefulness, time saving, positive impact on the perception of pain intensity and disability	NM	Local area network (wearable sensor, processing unit, feedback unit), wireless communications platform, server
Tabak33	Increased self-care, enhanced motivation for exercise, and ease of consultation	Security; internet access; computer access	Computer and internet access
Uscher-Pines34	Simple and inexpensive, easy to access, and easy to use	Lack of covering all symptoms related to disease in the Teladoc program	Phone or video via internet
Robert Harrison35	Improved communication among physicians of primary and secondary care for enhancing the quality of health care, continuous education of health care providers; cost-effectiveness of health services; and high satisfaction by patients, specialists, and general practitioners	Technical failure such as loss of voice or image; inability of consultants to perform a virtual physical examination	Standard commercial videoconferencing equipment for desktop PCs. This consisted of screen call software, a card to go inside the computer, a telephone handset, and a small video camera that could be mounted on the top or side of a computer monitor.
Izquierdo36	Improved glycaemic control and achievement in behavioral change goals, and improved diabetes care	There was no access to the electronic health record, so the care team was unable to complete patient information.	Web camera, home glucose meter, and blood pressure cuff connected to the home telemedicine unit through an RS-232 serial port
de Lusignana37	Realization of home telemonitoring	Equipment failed due to battery failure that followed by a loss of data in the device memory; video consulting over ordinary telephone lines did not show sustained benefit and was not complied with.	TV-phone 8*8 inch (Model number VC105)
Anogianakis38	Reduced cost of transferring patients out of prison; improved the quality of care for prisoners	Resistance of health care personnel on the provision of support for telemedicine; Ministry of Health resistance; inability of National Health System to interface with the computerized record keeping system of the prison telemedicine program; prison staff resistance to implementation of telehealth; inadequate support from Ministry of Justice leadership and bureaucratic obstacles by low ranked personnel in justice system	Two beds, pharmacy, small clinic equipped with telemedicine network for consultation
Trief39	Improved self-management	Not generalizable	Phone and computer
Glynn40	Cheap, user-friendly technology to promote physical activity in primary care	Not generalizable	Smartphone
Mussulman41	Increased motivation, improved access to high quality smoking cessation treatment in rural areas	NM	Computers, web cams, printers; telephones; polycom PVX software, large bandwidth, a telemedicine technician for internet resource management
Pratt42	Improved self-management, reduced number of hospital admissions, reduced emergency room visits, improved quality of life	NM	Remote health device connected to the phone
Levy 43	Improve self-care	Safety and confidentiality of sensitive health data	Mobile; Skype software
Bove44	Better and faster treatment and management of hypertension; reduction of heart disease	NM	Sphygmomanometer; pedometer, telephone, internet, fax
Al Alawi45	Providing the efficient means of detecting and treating diabetic retinopathy; improving patient information sharing; improving patient status; educating family physicians	NM	Canon camera, computer, internet
Hatef46	Effective and efficient screening of diabetic patients in low-income areas covered by a family physician; screening people in primary care centers without the need for an eye specialist, promoting health, cost-effective	Improved screening	Camera, data transfer software, internet, phone
Odnoletkova47	Increased access to health services	NM	Package with information about the program, a book with advice on nutrition in diabetes and a waist circumference meter with a BMI calculator
Quinn48	Motivation and confidence in elderly people, for self-management; positive attitude towards mobile technology	Anxiety and literacy related to technology may be avoidable barriers	Internet, mobile, personal portal, personal communication service
Wakefield49	Enhanced detection of diabetes	NM	Standard telephone line, blood glucose measurements
Deen50	Improving access to psychotherapy services; patient satisfaction	Rejecting people	Telephone, video equipment in the primary care office
Tudiver51	Telemedicine may be a useful, effective way to deliver healthcare; enhanced patient knowledge; improved self-management	NM	Phone service, web portal, email, fax
Nagrebetsky52	Improved self-monitoring, improved clinical outcomes	NM	Mobile telephone, blood glucose meter, mobile 3G network, web-based monitoring system
Bujnowska-Fedak53	Improved access to primary healthcare; enhanced physician confidence; educating family physicians; making efficient use of expensive resources; and providing easier medical care	NM	Telephone transmission system, communication protocols, configuration equipment and communications, audio equipment, video and audio computers, high quality video systems, and dedicated lines
Huber54	Positive change in physical habits among obese primary care patients.	NM	Telephone
Etherington55	Ease of use	NM	Standard PC, video capture, ISDN connection
Ruas56	NM	NM	PC, the store-and-forward teleconsultation tool (BH Telessau´de), personnel management system of the municipal Department of Health
Salisbury57	Reduced cardiovascular risk, cost-effective benefit in cardiovascular risk reduction, feasibility of delivering an intervention on a wide scale at relatively low cost and using non-clinically trained health advisors supported by computerized algorithms, increases the capacity of the healthcare system to provide an intervention to large numbers of people	Lack of internet access	Telephone, internet, email address, computer systems
Salisbury58	Acceptable to patients and providers; cost-effective; promoted self-management; treatment optimization; care coordination	Not all patients in UK have access to reliable internet connections	NM
Iannitto59	Empowering patient to take an active role in managing their health; saving time for the primary care providers in delivering patient care; opening appointment slots for patients; improving ability to serve patients with diabetes by initiating insulin in a timely manner; high satisfaction with the telehealth system reported by patients and providers	Lack of reimbursement	Telephone and a functioning glucometer
Langkamp60	High level of satisfaction with the program; decreased stress to the child and the parents; increasing the likelihood of a successful medical examination due to greater cooperation by the child.	NM	Digital otoscope, telephonic stethoscope, digital camera, and videoconference camera.
Larsen61	Increased self-care	NM	Mobile phone with pre-loaded software; blood glucose meter and a Bluetooth cradle to link the meter to the phone
Dario62	Reduced hospitalizations; reduced emergency departments’ and specialty care visits; contributing to significant cost reduction; improved adherence to therapy; improved healthcare services’ efficiency through better	NM	Glucometer and a gateway for data transmission to a regional eHealth center.
	management of chronic diseases; diminished direct costs; decreased travel times for both health professionals and patients
Blomdahl63	Reliable system; economic benefits	NM	Three ISDN lines, video camera, Aslit-lamp microscope connected to a Sony three-chip video-camera
Thijssing64	Reduced physical referrals; improved quality of care for these patients; supported GPs in interpreting spirometry results, diagnosing patients and making treatment decisions; improved the communication between GP and pulmonologist	NM	Spirometer that could be linked to a computer, hypertext transfer protocol secured, web-based teleconsultation system-mail and phone
Hussain65	Assistance in training and supervision of GPs; support of GPs for understanding urinary tract ultrasound anatomy and gaining competency in the correct use of an ultrasound machine; provided opportunities for continuous professional development, accreditation and reaccreditations of the GP's ultrasound skills	NM	Ultrasound scanner and a uro-flowmeter, ISDN at 128 Kbit/digital ultrasound machine
Backman66	Supporting diagnoses by GP; assisting in clinical evaluation of cardiac patients; bridging the gap between primary care and specialists; reduction of referrals to secondary care; reduction of misdiagnosis; ease of use; time saving; money saving; benefits to physicians and patients in terms of accessibility, speed of diagnosis, efficiency of management, and resource release	Time consuming	Telephone line, email, or fax
Pecina67	Facilitated access to consultants; facilitated communication of primary care physicians with counselors	Problem in image quality	Any iOS 7.2 or higher device; iPhone operating system
Cottrell68	Reduced blood pressure of patients with hypertension; improved accuracy of diagnosis	NM	Electronic sphygmomanometer; mobile phone; software and BP recording devices
Bujnowska-Fedak69	Patient satisfaction; improved patient-physician communication; improved quality life; disease control	Lack of resources for actual analysis	Personal computer, internet, wireless glucose monitor, and transmitter

Discussion

This study aimed to investigate telehealth at the PHC level. Our findings revealed that the adults (18-60 years old) were the target of telehealth services in most of the studies. It shows that people of these ages are more willing to use this method, have the necessary technological know-how, and can easily use the tools involved in telehealth.¹⁷ The target group of telehealth services in some of the included studies were elderly adults. There is evidence that the telehealth applicability to the seniors has not been a barrier to receiving telehealth services, and older adults have an interest in using telehealth services. People in this age range are more likely to utilize telehealth services if they do not have an additional cognitive load.⁷⁰ The majority of the telehealth services provided in PHC originated from European and American countries. A possible explanation for this may be the leading position of this country in technical infrastructures and the equipment required for implementing such services.⁷¹

The results of our study revealed that the majority of telehealth services used various communication channels such as video conferencing, cellphones, telephones, the web, email, and Skype, considering the situation of the service receiver and the available tools. The variety of communication channels reveals the full range of options for delivering telehealth services. According to the findings of the study done by Dhillon et al., Skype and email were the most popular tools for receiving telehealth services among the participants.⁷⁰

Most of the participants in the included studies suffered from chronic and non-communicable diseases such as hypertension and Type II diabetes. Patients suffering from chronic conditions usually place substantial financial burdens on the health care system so that the utilization of telehealth services can reduce these pressures.⁷² Turning to the telehealth approach can act as a solution to the problem of managing care for chronic conditions among aging of the population in different communities. The investigation by Esperance et al. (2016) has concluded that self-management via telehealth services can improve patients’ access to physicians and the quality of care among diabetic patients. Despite being overall pleased with using the telehealth system, the patients in the mentioned study raised concerns on technical issues and the need to learn new information to use the system.⁷³

Xu et al. (2018) conducted a study on the efficacy of telemedicine in providing care to diabetic patients in rural areas. The patients who had used the telemedicine system experienced lower blood sugar levels, better access to health care, less waste of time, and a high degree of satisfaction with the method.⁷⁴ The higher success rate of telehealth services in this domain can be attributed to the broader adoption of telehealth for managing diabetes compared to other diseases.

Our findings implied that the healthcare providers who made the most use of telehealth services were family doctors. Telehealth can undoubtedly improve the quality of PHC offered by general practitioners through increasing access to physicians. General practitioners can use telehealth to perform examinations and provide consultations to their patients in any place and at any time without even having to go to their offices. This approach can reduce waiting times in doctors’ offices, deliver healthcare services to people living in remote areas, and allow physicians to increase their income through reimbursement systems intended for telehealth services.⁷⁵

The results revealed the most dominant approach to telehealth services was the synchronous form.²⁷, ²⁸, ³⁰, ³², ³⁴, ³⁵, ³⁷, ³⁹, ⁴⁰, ⁴¹, ⁴², ⁵², ⁵³, ⁵⁷, ⁶¹, ⁶², ⁶³, ⁶⁵, ⁶⁶ Real-time communication is considered an effective way of delivering telehealth services in PHC. In the synchronous mode of telehealth, there is a stronger sense of communication between patients and providers. What determines the suitable mode of delivering telehealth services are the patients and the type of disease they have. Moreover, telehealth is a technological phenomenon⁷⁶ and a directed approach for meeting individuals’ needs.⁷⁵Therefore, choosing between one-way or two-way as well as synchronous or asynchronous methods must be made accordingly.

Most of the included studies in this review have focused on investigating the effects of these services on rural and underserved areas since those are the areas facing problems with access to healthcare.⁷ Increasing accessibility and improving patient health can happen by establishing telehealth services in rural areas. However, the rollout of the technology in rural regions is usually slower due to the lack of technical support and lower budgets. Lack of adequate resources can be another barrier to deploying telehealth in underserved areas since they do not have dedicated technical support teams of experts like the large urban areas. Moreover, it should be noted that even though innovation is considered a competitive advantage, rural systems are usually resistant to change.⁷⁷

According to the findings of our review, it seems the clients mostly received the telehealth services directly by themselves. However, the study by Dhillon et al. found that the elderly preferred to receive telehealth services through the help and support of their families.⁷⁰ There is evidence that patients whom a supervisor supported were more successful in using this technology.⁷⁷

Reviewing the main obstacles to the implementation of telehealth revealed that lack of coverage by healthcare insurances and payment plans are among the primary problems holding back the adoption of telehealth networks.¹¹, ⁷⁸ Barriers also ranged from difficulty in acquiring permits to concerns about privacy³, ¹¹, ¹³ and the lack of enough information, user perception, skill, education, initial costs, and the providers’ reluctance toward new approaches of health care delivery.⁹, ⁷⁹ The study by Souza et al. identified additional factors such as low bandwidth, unsuitable networks, low signal quality, picture quality, and organizational issues as barriers to the implementation of telehealth services.⁸⁰ Furthermore, a study conducted by Fatehi reported technical, organizational, cultural, sociological, economic, and ethical obstacles.⁸¹ The barriers reported by Nesbitt et al. also are similar to the ones identified in our study.⁷⁸ Regardless of the disadvantages, there were a variety of advantages reported for telehealth services in primary healthcare. They range from self-care promotion to patient empowerment, decreased patient visits, cost reduction, and access improvement to the services. Additional benefits include patients’ time savings, higher commitment to showing up for appointments,⁷⁵ better clinical results, better access to specialist services, less need for travel, and better screening rates.⁸²

Conclusion

Telehealth can be used for different purposes of primary health care through deploying a full range of communication channels available to the public. Due to the opportunistic use of existing devices and platforms, telehealth can provide scalable primary health care services nationwide and worldwide. However, the implementation of telehealth in PHC faces challenges from technical, organizational, and human perspectives. It seems inevitable to transform the policy context and regulation if telehealth approach is a part of health system agenda. Respect for privacy and confidentiality principles is also crucial. Moreover, digital equity is required to expand telehealth services to the populations in underserved areas. Digital equity can be achieved through addressing existing disparities in internet and technology access and improving e-health literacy among low-income and underserved communities. Under such conditions, telehealth can strengthen primary health care system toward universal health coverage. Since no guideline was reported for implementing telehealth services in primary health care, future research may utilize the findings of this study as a basis for developing the guideline. Analysis of telehealth policies for primary healthcare in different countries could shed light on a deeper understanding of our findings. The current study is limited in this regard and future research may explore this to complement the findings of this study.

Declarations

Ethics approval

Ethical approval for conducting this study has been obtained from the Research Ethics Board at Tabriz University of medical science, Tabriz, Iran (No: IR. TBZMED.REC.1396.1251).

Competing Interests

The authors declare that there is no competing of interest.

Funding

This study was part of MSc thesis and funded by Tabriz University of Medical Sciences

Authors’ Contributions

LB: Data extraction, data organization, treatment of data, and drafting a manuscript. LRK: Data analysis, and manuscript writing, scientific revision and approval. LD: Data examination, writing of manuscript and scientific criticism as well as approval. MF: Data examination, scientific review and approval. All authors have read and approved the final manuscript.

Author Biographies

Leila Beheshti is affiliated with the Student Research Committee in the School of Management and Medical Informatics at Tabriz University of Medical Sciences.

Leila R. Kalankesh (Lrkalankesh@tbzmed.ac.ir) (corresponding author) is an associate professor of medical informatics in the Department of Health Information Technology in the School of Management and Medical Informatics, Health Services Management Research Centre, and the Research Centre of Psychiatry and Behavioral Sciences at Tabriz University of Medical Sciences.

Leila Doshmangir is an associate professor of health policy in the Health Services Management Research Centre in the Department of Health Policy and Management in the School of Management and Medical Informatics at Tabriz University of Medical Sciences.

Mostafa Farahbakhsh is an assistant professor and specialist in the Research Centre of Psychiatry and Behavioral Sciences at Tabriz University of Medical Sciences.