This article discusses consumer-directed technologies for health care and promotion in light of the rapid expansion of consumer-oriented tools and technologies, which has redefined telehealth. The difference between traditional telehealth services focused on supporting or augmenting institutional-based health care activities, and consumer-directed telehealth activities more linked to individuals are presented, the 3 orders of consumer-directed telehealth are described, and technical issues inherent in telehealth programs are discusses.
What if physical space and time were no longer limiting factors influencing access to health care? What if those who were ill or seeking the best health information or advice could do so in their local community instead of having to go somewhere else, sometimes never having to leave their own home? Telehealth services provide the means for anyone with access to simple technologies to receive care, learn about health issues, and engage with other citizens (patients, providers and policy makers alike) at times and locations that are convenient and safe. This is not a utopian vision, but a reality for a growing number of people throughout the world, and something that has remarkable potential to support otolaryngology. Telehealth, the application of information and communication technologies to connect people to health resources, is a relatively new field of practice and research and has traditionally focused on connecting health care centers together; however, the rapid expansion of consumer-oriented tools and technologies beginning with the World Wide Web has redefined telehealth as something equally suited to consumers.
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Consumer-oriented telehealth bridges the gap between traditional medical informatics and public engagement in health care.
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The manner in which consumer-oriented telehealth is organized is along 3 orders that go from a simple, technology-based model (first order), to one in which technologies complement one another in providing information and services (second order), to one in which the technology is embedded as an essential part of a larger program (third order).
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To fully engage with this new form of telehealth, the public (patients) and health care professionals alike require new skills and knowledge that evolve along with the technology. This skills set, or eHealth literacy, represents an amalgam of generic and context-specific skills required to use technology effectively to address health issues in practice.
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Although technology is often highlighted as the focus of telehealth, it is human skill and the ability to work together that is the critical factor in determining the success of efforts to use information technology effectively to support health service delivery.
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Web 2.0 and social media now allow anyone with basic Internet skills to create, distribute, and modify content online, which is fundamentally changing the way communication is made through technology and the roles that both the public and health professionals play, introducing new opportunities for engagement and ethical challenges.
History and definitions of telehealth
The information and communication technology boom that took place in the latter part of the twentieth century opened up new avenues for delivering information directly to consumers on demand through the telephone, computer screen, and mobile handset. This expansion of tools designed to facilitate communication provided opportunities to extend health care beyond the traditional settings like clinics and hospitals into places where people lived, worked, and played. It also offered an opportunity to capitalize on the growing interest in health education and health promotion, providing means to support the public directly in self-care and prevention activities by linking primary care and specialized medicine with community/public health.
The Canadian Society for Telehealth (now part of COACH: Canada’s Health Informatics Association) defines this field as follows:
Telehealth has been defined as the use of information and communications technologies (ICTs), to deliver health services and transmit health information over both long and short distances. Telehealth helps eliminate distance barriers and improve equitable access to services that often would otherwise not be available in remote and rural communities. It is about transmitting voice, data, images, and information rather than moving patients or health practitioners and educators. Telehealth can best be described as the sharp end of e-health. It is where the information or data generated through the related discipline of health informatics is used in some form of direct (eg, one on one) or indirect (eg, Web site) interaction with a well citizen, ill patient, or fellow health care provider in any location.
As the definition suggests, telehealth and eHealth are similar to each in other in many ways. eHealth has struggled with creating a definition, with multiple versions having been introduced in the leading journal in the field. Consumer-directed telehealth adds a new element to this discussion, by focusing less on the informatics components emphasized in the discourse on eHealth applications, and more on the experience of the tools themselves and their impact on health knowledge, attitudes, behavior, and skills. The earliest study citing consumer-directed telehealth appeared in 2003, with the first explicit use of the term appearing in 2006. Since then, telehealth has continued to be explored as a means of addressing problems posed by distance, cost, and health care coverage.
Unlike most traditional telehealth services, which are focused on supporting or augmenting institutional-based health care activities, consumer-directed telehealth activities are less tied to settings and more to individuals. Peer-to-peer networking is a central feature of consumer-directed telehealth services, characterized by an individual practitioner, peer support resource, or third-party content provider to connect directly to the consumer without requiring any institutional or professional intermediary. Consumer-directed telehealth reaches people where they are physically, technologically, educationally, and in terms of psychosocial readiness.
Consumer-directed telehealth: 3 orders
Consumer-directed telehealth may be viewed as comprising 3 orders :
First order: stand-alone
Second order: complementary
Third order: integrated.
These 3 orders are discussed in this article, drawing on examples from the literature, particularly tobacco control, in which a large body of work on consumer-based telehealth exists and where there is a high level of relevance to otolaryngologists.
First-order Consumer Telehealth
A first-order telehealth service is designed to operate independently of any other resource or application. A first-order resource may include Web sites, message services (eg, short message service [SMS]), or peer-to-peer interaction opportunities designed solely to function on its own, without any additional services required to add value. These resources may refer to other services via links to Web sites or reference sources like books or telephone services; however, these additional elements are not considered essential for the telehealth service to function. This factor is what distinguishes first-order telehealth resources from second-order or third-order ones, which are discussed in greater detail later.
First-order resources represents the simplest application of consumer-directed telehealth and can comprise free or low-cost tools to more sophisticated paid models; however, the consistent factor is that the service is based solely on a technological platform. Within the range of different technological options, this platform could be a Web site, a text or video message, an audio or video podcast, streaming media, or voice-enabled delivery system. Although these services may facilitate some form of live interaction, the scale and scope of services may be limited during certain hours. In the case of social media such as social networking platforms, in which the value is almost exclusively drawn from the users of the site, the opportunities are immense and diverse.
Examples of a first-order telehealth resource for consumers include Web sites that provide smoking cessation services or providing a text-message service to do the same. In both cases, the telehealth services are self-contained and require no additional resources to be effective.
Second-order Consumer Telehealth
A second-order consumer telehealth service is one that is deployed in conjunction with another type of resource (eg, telephone helpline) or face-to-face clinical intervention. Second-order consumer telehealth services are different from first-order ones in that they are designed to play a complementary role to other forms of service. This role could mean a Web site or Web appendix to complement a printed book or a public health information hotline that is used alongside of other campaigns delivered in the community.
A second-order consumer telehealth service can also be designed as a cluster of different telehealth resources that offer different ways to connect to the same information. One example of this is the Canadian Cancer Society (CCS) Smokers’ Helpline Web site ( http://www.smokershelpline.ca ), which follows the previous smoking cessation examples. The Smokers’ Helpline was originally developed as a telephone-based telehealth resource; however, with the growth of the World Wide Web, the CCS opted to expand the service to the Internet and later to text messaging and use of social network tools like Facebook. The CCS Smokers’ Helpline is staffed by trained smoking cessation professionals who provide information, quitting tips, and links to self-help resources and health services that can aid individuals looking to stop using tobacco or who wish to support someone else.
The use of different modalities of service offers the CCS a means of reaching people through methods that fit their lifestyle that acknowledges genuine resource constraints. For example, the telephone support service is available mostly during the day, with limited availability in the evenings. Although the Web site is available 24 hours a day, it favors those with access to computers, which is where the text-messaging service is most effective because it can reach people who are not able to go online. Whenever possible, the various modes provide overlapping services that complement one another to provide the greatest amount of reach and opportunity for the public (or patients) to engage with the telehealth resource.
Third-order Consumer Telehealth
A third-order consumer-directed telehealth service is one that is fully integrated into an existing program of activity. Unlike second-order interventions, third-order consumer telehealth services are embedded within a larger programming structure in which the resource is not viewed as complementary or stand-alone, but integral to the activities performed using different methods. Third-order telehealth services require a more sophisticated approach to service delivery and enhanced coordination above that of most activities in a first-order and second-order intervention or resource. Because they are embedded within other programs, a level of coherence and synergy between the different components is necessary for the service to operate effectively. However, the result of these efforts can produce a program that is more detailed, intense, and able to be tailored to the needs of specific consumers or conditions. Computer-based clinical assessments can serve as a starting point for such third-order interventions, by providing a means of linking patient data about a visit before the clinical encounter.
One organization that has developed an array of tools and resources using third-order telehealth is TakingITGlobal, a Toronto-based nongovernmental organization that seeks to engage young adults and educators using new technologies. TakingITGlobal’s integrated virtual classroom initiative for providing health education and promotion support to teachers (TiGEd) provides an example of a third-order consumer-directed telehealth intervention directed to secondary schoolteachers in countries around the globe. TiGEd features a series of virtual classrooms on a variety of health topics including food security, human immunodeficiency virus/AIDS stigma, and tobacco control. For example, The Virtual Classroom on Tobacco Control was cocreated in partnership with the Youth Voices Research Group at the University of Toronto. The Virtual Classroom is designed for both young smokers and nonsmokers (ages 12–24 years) and intended for delivery in educational settings. This school-based telehealth resource is designed to provide interactive resources to support the teaching of health in secondary schools, either through electronic connectivity with students directly accessing the Web site, or by providing teachers with a means to download materials for use in face-to-face lectures. This strategy enables the resource to be used in areas of high connectivity and low.
The Virtual Classroom was built around a comprehensive telehealth resource, The Smoking Zine , which was evaluated in a large, school-based randomized controlled trial. The Smoking Zine , originally designed as a first-order consumer-directed telehealth resource, has been since modified into second-order and third-order interventions to suit a variety of circumstances and settings. Taken together, The Virtual Classroom provides a means of offering multiple options for teachers and takes advantage of the strengths of different modes of communicating health information to consumers.
Facilitators and Limitations
Literacy
One of the most overlooked issues in telehealth is literacy, particularly when the delivery mechanism includes text. Literacy in the case of telehealth is a complex process that goes beyond simple reading and writing and includes the basic skills needed to operate the tools and software, and the ability to place health information into the proper context, a skill set called eHealth literacy. eHealth literacy is a composite skill that is made up of 6 literacies organized into 2 central types: analytical (traditional, media, information) and context-specific (computer, scientific, health). These basic skills are described in the following paragraphs.
The analytical component involves skills that are applicable to a broad range of information sources irrespective of the topic or context, whereas the context-specific component relies on more situation-specific skills. For example, analytical skills can be applied as much to shopping or researching a term paper as they can to health.
Context-specific skills are just as important; however, their application is more likely to be contextualized within a specific problem domain or circumstance. Thus, computer literacy is dependent on what type of technology is being used and its operating system, as well as its intended application.
Scientific literacy is applied to problems in which research-related information is presented, just as health literacy is contextualized to health issues as opposed to shopping for a new television set. Yet, both analytical and context-specific skills are required to fully engage with electronic health resources.
This complex set of overlapping skills is one of the central challenges facing consumer-directed telehealth. Drawing on the author’s experience evaluating telehealth programs in continuing education and health promotion, the most salient challenge in connecting any remote site to another is ensuring that local expertise is available to manage the connection and tools on each side of the transmission.
Technical Issues
As with any system that relies on technology, consumer telehealth is beset with both technical and human limitations. Bandwidth constraints and wireless coverage are some of the major barriers to using these tools. Technical connectivity is another. Without reliable high-speed broadband access, only the most basic telehealth services are likely to be successful. The one exception to this is in the area of text-messaging (SMS) enabled telehealth services, in which information can be delivered reliably, inexpensively, and efficiently using technologies that are widespread and often reach into areas where broadband access is nonexistent.
Compatibility is another issue that limits telehealth. Although it may be easy to select technologies that meet the standards of the day, developing strategies to enable these tools to evolve over time in a manner that maintains their compatibility is a different problem. One of these issues is selecting between tools and devices that are platform-dependent or vendor-dependent. For example, Apple’s operating systems (OSs) are not designed for use on any computer other than a Mac, whereas the Blackberry OS is designed only for devices manufactured by Research in Motion. Vendor-specific options provide stability and limit flexibility.
An alternative option is to move toward open-access and open-source software platforms. Open source refers to the ability for others to access the source-programming code that underlies the telehealth resource, which includes the potential to have this code copied, modified, or replaced. These solutions, such as the Firefox Web browser, Linux OS, or Google’s Android mobile platform, are often more responsive and innovative than their closed-source peers; however, such open-source models are also vulnerable to bugs and instabilities in early releases.
One example of how this model has worked in telehealth and eHealth is the Journal of Medical Internet Research ( http://www.jmir.org ), which has become the highest-impact publication in eHealth and the second highest within health services research within 10 years of its launch. Although this is impressive for an author-funded publication, JMIR has gone so far as to offer its entire journal publishing platform for free to anyone wishing to adopt it to create a new journal using the source code created by the developer.
Web 2.0
The concept of Web 2.0 was coined by Internet business leader Tim O’Reilly to describe the move from a largely static form of the Internet in which content developers had to possess some technical programming language to build a Web site. Although the basic Web-programming skills were easy to acquire, they did pose a barrier to those not interested in programming. The advent of Web 2.0 changed that situation. It enabled people to generate content online with limited knowledge of the mechanisms behind the programming. Thus, if you could use a word processor or Web browser, you could add content. Web 2.0 tools include social networking Web sites (eg, Facebook), wikis (editable Web forms for collaborative writing), and direct-to-Internet publishing such as blogs or microblog services (eg, Twitter).
Included in this Web 2.0 revolution is the concept of social media. Social media is the term used to describe content the value of which is derived from social interaction in an electronic space. Social networks such as Facebook and MySpace or microblogging networks like Twitter are examples of social media. This technology represents a radical departure for those using telehealth services, given the emphasis on interactive content. Social media and Web 2.0 represent a fundamental shift in how and where power and influence are exerted in the relationships in health. In educational environments using Web 2.0, no longer is content generated and passively absorbed by students, it is cocreated and recreated as learner-generated content, and feedback adds to the initial presentation. This type of interaction requires that teachers acknowledge the skills and limitations of their audience as they jointly become prosumers (producers and consumers of content). The fundamental change in using these second-generation Web tools is not so much the technology, but adopting a position of openness and flexibility in using it and engaging with users regardless of their social position. Social media is about relationships, connectivity, and knowledge and less about social position and hierarchy, which often serve as a foundation for much of traditional medical environments.
Mobile Connectivity
Mobile applications for telehealth represent the future of the field, with mobile devices representing the greatest area of growth in the consumer market worldwide. Most new mobile handset telephone devices are Web-enabled, providing a rich-text means of communicating when appropriate wireless networks exist. Mobile tools provide new ways of getting information to consumers in settings that are often difficult to wire for Internet or where reliable connectivity is lacking. Mobile devices are also typically more affordable that desktop or laptop computers, providing an economical as well as portable means of creating or consuming content.
The introduction of the iPad and other tablet and mobile reading devices such as the Amazon Kindle, Blackberry Playbook, and Sony e-reader has opened up a new possibility for consumer-directed telehealth. These tools require relatively little knowledge of computers and cost less than typical laptops or desktops, yet have more functionality than mobile phones and are easier to read from or view rich-content materials like videos and photographs/images. As these technologies develop and their cost decreases, the opportunities to create truly sharable computing for delivering consumer-directed telehealth interventions will increase.
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