By Cigna Global Wellbeing Solutions
Background and effectiveness
The global challenges of modern healthcare include an aging population; increased duration and comorbidity of chronic diseases; and predicted shortage of healthcare personnel resulting in an ever- increasing demand on services. Against this backdrop, what role can telehealth, a provision indicative of an increasingly connected age, play in supporting healthcare delivery?
Recently three of Cigna’s Medical Directors from different global regions - Dr. Lior Baruch, North America; Dr. Peter Mills, UK and Europe; and Dr. Inge Schrever, International Organizations, Governmental Organizations, and Africa - came together at the Cigna GWS Wellbeing Insights Forum to look at the barriers to and opportunities for telehealth in delivering healthcare to Cigna customers. Or as Dr. Lior Baruch eloquently phrased it: “How can we make their day better through telehealth?”
What is telehealth?
Telehealth has been defined by the World Health Organization as “the use of telecommunications and virtual technology to deliver health care outside of traditional health-care facilities.” The three main modes of telehealth can be summarised as1:
- Clinician to clinician. Teleradiology is probably the most common example; the exchange and analysis of patient radiological images with other clinicians, across locations.
- Clinician to patient. Consultations via phone or online, often in the treatment of chronic conditions.
- Patient to mobile health technology. Monitoring key measurements such as blood glucose or blood pressure, or recommended lifestyle changes via wearable technology or smartphone apps.
Barriers to uptake
Despite its potential, telehealth still has a low uptake within health systems. There are several known barriers that can go some way to explaining this. They include:
A key advantage of telehealth is the ability to work across borders. However, each country – and sometimes even different areas within countries, such as states within the US - have different regulations and licensing. Therefore a telehealth service can face an onerous challenge in complying with several different regulations.,,
Reimbursement by healthcare providers is commonly cited as a major barrier for telemedicine. It is speculated that restrictions result from provider fears that telemedicine will lead to overutilisation and additional costs.3 Even in state-run health systems such as the UK’s NHS, costs can deter implementation.
While examples of telehealth date back 50 years or more, in terms of research it is perceived as a relatively new commodity. Studies have found improved outcomes with telehealth, including efficacy in treating chronic diseases such as type 2 diabetes and heart failure., Importantly, telehealth is generally regarded as safe; no evidence has so far indicated that telehealth is harmful.8 However larger scale reviews have exposed evidence gaps compared to traditional approaches, which can hinder advocacy of adoption.3,, The faster pace of technological change can also be at odds with the traditional approach of building up an evidence base of publications over time to prove efficacy.5
Adoption by patients and health professionals
For the uptake of telehealth to be successful, both patients and healthcare professionals must embrace a new mode of communicating. This is something Dr. Peter Mills sees as important; “one of the key factors is the acceptance...by medical professionals. It’s never really been something that has been championed or even accepted as being a viable option by many people within the medical community.” Patients can also be reluctant to engage with the technology, especially older generations and those of a lower education level.
Access to reliable broadband can be a barrier in rural areas or developing countries.3 Using simpler technology to improve access can sometimes be the most effective approach.4 Dr. Inge Schrever agrees that for remote populations, “We should not forget the phone call; that’s of great value. It gives them access to something more than just the local clinic.”
Future opportunities for telehealth
Fortunately, it is likely that these barriers will lessen in the future. This is due to a range of predicted changes in the healthcare system, patient experience, and level of expectation1,11:
Changes in patient experience and expectation
Recent generations have an ever-closer engagement with technology. They are increasingly connected virtually, and are therefore more likely to form new communication norms around contact with health professionals. The Medical Directors have already noticed examples of this trend in their respective markets. Dr. Inge Schrever comments on mobile use in Africa: “In terms of office-based local staff, you won’t see a difference compared to Europe. In fact, some of them use mobile phones even more. In some countries they use mobile phone apps that we don’t do in Europe, and that shows how fast things can evolve.” While Dr. Lior Baruch, based in North America, confirmed that “the world has shifted, the technologies are becoming embedded.”
Research shows that telehealth is often supported by good satisfaction rates for the patient. A systematic review found that telehealth is associated with approval of improved outcomes, ease of use, lower costs, better communication, and less need to travel.11 Today there is instant access to most services, including banking, leisure, and retail. Arguably there is a prediction that this will lead to a growth in consumerism within healthcare, alongside an increased demand for convenience. While younger generations tend to feel more comfortable utilising connecting technology, it is conversely older generations who may benefit more. As Dr. Peter Mills explains, “Younger people are familiar with the technology but aren’t sick very often. If you’re older and have a chronic condition and are still in work - that can have a real major impact on how you’re functioning in the workplace.”
Advances in handheld technological are also facilitating an upturn in use of clinician to patient telehealth. As is innovation in consumer technology; such as wearables, that can be used for patient to mobile telehealth.
Telehealth is also benefitting and enabling global movement; meeting the requirements of the ever-growing number of people living outside their country of origin who are eager to have access to a clinician who speaks their own language.
Changes within the healthcare systems
Within healthcare systems, there are several changes underway that could also increase telehealth use. Projected shortages in the health professional workforce and a need to reduce - or at least maintain - healthcare costs means there is an ever-greater need to work more efficiently.1 Telehealth can enable limited resources to go further.
This requirement to be ever-efficient is likely to increase investment in electronic health records, which can in turn facilitate telehealth schemes. Telehealth use allows for more opportunity to build the evidence base, which will help to overcome the aforementioned barrier. Furthermore, more widespread acceptance and use of telehealth could arguably create demand and an impetus to streamline regulation and thus reduce another known barrier to telehealth uptake.
Dr. Peter Mills predicts that the combination of several changing factors will have an impact. “We now do have the devices that are capable of having a satisfactory telehealth conversation. We’ve also got providers of care that are starting to see an opportunity outside of the four walls of their establishment. And we also have the insurance companies, the companies that are paying for the care, whether it’s the nationalised model such as the NHS or the private insurers such as Cigna, they’re seeing there’s an opportunity here not to just to manage costs but to also drive quality. Those three things coming together are very important.”
Finally, reluctance of health professionals to engage with technology is recognised in the literature as a potential barrier.6 However Dr. Peter Mills relates that “gradually we are starting to see a shift in attitudes within the health care professions.” He predicts acceptance will continue to grow, “It’s going to be a generational thing; the next generation of doctors coming through are going to be much happier with this new way of interacting with patients.”
Successful integration into existing healthcare
Each of the Medical Directors had a slightly different experience of how telehealth is integrated into Cigna’s existing business healthcare offering according to their geographical area of business. However they all agree with Dr. Peter Mills when he summarised “We’re in the early days of telehealth [but] … this is not an all or nothing, this is not telehealth or nothing; it’s actually telehealth as part of your longitudinal health care needs.”
Dr. Inge Schrever affirmed: “We have found that we do not need to convince clients of the benefits of telehealth. They have access; they have peace of mind. They get reassurance”.
Dr. Lior Baruch added that in North America, “telehealth can be used as a funnel; they are screening the cases and advising a customer where or not to go to an emergency room. A recent example I heard about was a case of new parents with a newborn presenting a case of diarrhoea. A paediatrician jumped onto telehealth, asked the parents to show them the contents of the diaper via the camera, assessing the colour, and being able to give advice to the new parents, over the following six, 12, 24 hours. Therefore they avoided making the trip to the ER.”
He continued: “In Chile, users were using telehealth to get their services scheduled. They would call telehealth, give their symptoms, and the physician on the line would refer them to the relevant specialist, so there are several other utilisations that are possible through telehealth, as well as providing access.”
While there are regional variations, it is clear that for Cigna, telehealth forms an additional, integral service that can support our customers and ultimately make their lives easier. Telehealth is not intended as a replacement, but as a supplementary medical provision.
In addition to the convenience and filtering uses previously discussed, telehealth can bring wider societal benefits. Traditionally, rural populations can be subject to health access inequality.3 Telehealth has the potential to reduce this, and Dr. Inge Schrever has also found this to be the case: “It’s having their back; it’s an additional service that we can offer, especially in those to the most remote areas.”
Telehealth can also lead to environmental benefits by reducing travel and corresponding CO2 emissions. Dr. Inge Schrever adds that “Previously, it was difficult to decide, especially for customers staying in remote areas, they were doubting, should they stay with a risk of having their symptoms getting worse, or should they take the car and drive for a few hours, sometimes over 400km, to come to the conclusion that there is nothing wrong with them.” Telehealth gives users the chance to discuss the situation with a professional before making that decision.
Bearing in mind its potential, telehealth adoption - and resulting evidence base - is currently fairly low. However, the scope and opportunities for expansion are broad and predictions are optimistic. The market potential of telemedicine is forecast to be strong; it is expected to grow at a compound annual growth rate of 19.2% over the next six years. The changes in consumer expectations, technological advances, and impetus to meet healthcare challenges all indicate a rapid increase in the adoption of this opportune medium. We have seen at Cigna that telehealth can serve as supplementary, convenient access to healthcare professionals that can enhance the patient experience. Telehealth holds a great deal of potential for the future of health care.
 Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med 2017; 377:1585-1592. doi: 10.1056/NEJMsr1503323.
 Telehealth. The World Health Organization. Accessed 1 October 2019. https://www.who.int/sustainable-development/health-sector/strategies/telehealth/en
 Board on Health Care Services; Institute of Medicine. The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary. Washington (DC): National Academies Press (US); 2012 Nov 20. 4, Challenges in Telehealth. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207146. Accessed 22 August 2019.
 Saliba V et al. Telemedicine across borders: A systematic review of factors that hinder or support implementation. International Journal of Medical Informatics.2012; 81. 12, 793-809. doi: 10.1016/j.ijmedinf.2012.08.003.
 Michie S, Yardley L, West R, Patrick K, Greaves F. Developing and Evaluating Digital Interventions to Promote Behavior Change in Health and Health Care: Recommendations Resulting From an International Workshop. J Med Internet Res. 2017;19(6):e232. Published 2017 Jun 29. doi:10.2196/jmir.7126.
 Kruse SC, Karem P, Shifflett K, Vegi L, Ravi K, & Brooks M. Evaluating barriers to adopting telemedicine worldwide: A systematic review. Journal of Telemedicine and Telecare, 2018; 24(1), 4–12. doi: 10.1177/1357633X16674087
 Ekeland AG, Bowes A, Flottorp S. Effectiveness of telemedicine: a systematic review of reviews. Int J Med Inform. 2010;79(11):736-71. doi: 10.1016/j.ijmedinf.2010.08.006.
 Hanlon P, Daines L, Campbell C et al. Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer. J Med Internet Res. 2017;19(5):e172. Published 2017 May 17. doi:10.2196/jmir.6688
 Mistry H. Systematic review of studies of the cost-effectiveness of telemedicine and telecare. Changes in the economic evidence over twenty years. J Telemed Telecare. 2012: 1;18(1):1-6. doi: 10.1258/jtt.2011.110505.
 de la Torre-Díez I, López-Coronado M, Vaca C, Aguado JS, de Castro C. Cost-utility and cost-effectiveness studies of telemedicine, electronic, and mobile health systems in the literature: a systematic review. Telemed J E Health. 2015;21(2):81–85. doi:10.1089/tmj.2014.0053.
 Kruse CS, Krowski N, Rodriguez B, et al. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open 2017;7:e016242. doi: 10.1136/bmjopen-2017-016242.
 Global Telemedicine Market size to exceed $130.5 Bn by 2025. Global Market Insights. Updated 16 March 2019. Accessed 22 August 2019. https://www.gminsights.com/pressrelease/telemedicine-market.