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definingtele.pdf
Defining and Delimitating Telemedicine
and Related Terms - n Ontology-Based
Classification
Lena OTTOa,1, Lorenz HARSTb, Patrick TIMPELc, Bastian WOLLSCHLAEGERd,
Peggy RICHTERa, and Hannes SCHLIETERa a
Chair of Wirtschaftsinformatik, esp. Systems Development, Technische Universität Dresden, Dresden, Germany
b Research Association Public Health Saxony, Center for Evidence-Based Healthcare, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden,
Germany c
Prevention of Care of Diabetes, Department of Medicine III, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
d Chair of Technical Information Systems, Technische Universität Dresden, Dresden,
Germany
Abstract. The way health care is delivered changes continuously and is increasingly supported by digital technologies, such as telemedicine. Many terms in that context
exist, which are not defined consistently and therefore used ambiguously. This
makes it difficult to assess the evidence base. Ontologies bring structure and clarity to the discourse around telemedicine and related terms. We use this tool to provide
definitions of relevant terms and show their interrelations. The results provided will
be applied to different case studies to show their applicability. We aim to provide a more evidence-based understanding of relevant terms in digital health.
Keywords. Ambient assisted living, digital health, ehealth, integrated care,
ontology, telemedicine
1. Introduction
Demographic change is one of the big challenges health care systems currently face [1],
as it leads to a rise in chronic non-communicable diseases. In response to these
developments, the World Health Organization (WHO), in its Ottawa Charta, has
demanded a stronger focus on prevention instead of treatment. [2]. Prevention, especially
of chronic diseases, is a task for a multi-disciplinary care team, predicated on
strengthening measures of integrated care [3]. However, it also demands active health
behaviour change from any individual targeted by preventive measures, which is, in turn,
based on a patient empowered by feelings of self-efficacy [4]. eHealth as a broad term
came with the promise of enabling patient empowerment and therefore shared decision
making [5], among others. As it also aids in overcoming geographic distances [6],
1 Corresponding Author, Lena Otto, Chair of Wirtschaftsinformatik, esp. Systems Development, TU
Dresden, Münchner Platz 3, 01062 Dresden, Germany; E-mail: [email protected].
A
Information Technology Based Methods for Health Behaviours A.J. Maeder et al. (Eds.) IOS Press, 2020 © 2020 The authors and IOS Press. All rights reserved. doi:10.3233/SHTI200010
113
eHealth not only ensures access to care, but also helps to interconnect health care
providers involved in chronic care [7]. Thus, it enables integrated care [8] and thereby
helps to deliver health care more effectively. Telemedicine in particular, another term in
the eHealth context, is already used in many countries [9], e.g. to monitor patients in
their home or connect health care professionals and patients via the internet to improve
access to and quality of health care [10]. Mobile telemedicine applications allow for
individualized tailoring of both preventive messages and interventions [11], and thus are
especially suited for behaviour change measures [12]. Yet, in order to implement digital
applications in preventive behaviour change as well as in integrated chronic care, a
common and unambiguous understanding of terms in the domain is essential. Many
ambiguous and overlapping terms surrounding telemedicine exist [13], and they are not
defined consistently [14,15]. As the “digital health market” is a constantly evolving field,
existing approaches to classify the field of telemedicine and related terms are neither
exhaustive nor comprehensive [16]. Ontologies are an appropriate tool in terms of a
scheme for structuring domain entities and explaining their relationships [17]. They can
provide and share a common understanding of a domain and relating concepts [16]. We
aim to apply an ontology-based approach to structure and clarify the telemedicine
discourse, including (1) the definition of relevant terms and (2) their interrelations as
well as (3) a description of specific application types of telemedicine. This will improve
the understanding of relevant terms and working with the related concepts consistently.
This paper provides a revision and extension of a previously developed ontology [16].
In order to demonstrate the applicability of the ontology, we will apply the presented
approach to case examples.
2. Method
According to a typology of reviews provided by Grant and Booth, literature reviews are
an apt method to examine current literature from a wide research field. Owing to the
diversity of such wide research fields, literature reviews do not warrant comprehensive
searching [18]. Such, we deemed a literature review the most appropriate method for
systemizing somewhat conflicting terms.
Starting from the term “telemedicine”, the review was conducted to collect all
relevant concepts, their definitions and interrelations. Identification of relevant concepts
was primarily done by screening research papers as well as official communication of
national and international associations (e.g., European Commission (EC), U.S. Food and
Drug Administration (FDA), and WHO). Terms were included as far as they represented
a concept in the area of digitization in health care and described the context of their
application or underlying technology. Results of the search were first synthesized in a
narrative manner, as common for literature reviews [18]. Afterwards, and also in line
with the methodology, we conceptually analysed the interrelations and delimitations of
the terms reported in the results. To further illustrate the variability of the concept of
telemedicine as one example, telemedicine application types were analysed, derived
from a taxonomy based on quantitative content analysis [19]. Using selected examples
of digital health innovations applied in common chronic conditions, the developed
ontology was applied and checked for applicability.
L. Otto et al. / Defining and Delimitating Telemedicine and Related Terms114
3. Conceptual Understanding
The ontology provided consists of terms (displayed in bold in the following text)
describing health technology applications or their underlying technological concepts, as
well as terms describing the care delivery and location context of these applications. Each
of these groups (underlined) is separately introduced in the following.
Telemedicine, as the core term of our investigation, as well as closely related health
technology applications (telehealth, mHealth, eHealth, digital health, health IT) are
defined. Sood et al. [10], who reviewed 104 articles defining telemedicine, conclude that
the delivery of health care services and/or medical education over distance using
information and communication technology (ICT) are main characteristics of
telemedicine solutions. This is in line with the WHO’s definition, who further add that
“all health care professionals” [20,p.10] can be involved in the health care service
delivery. Telemedicine is a subclass of the concept telehealth [10]. As the WHO states
in its constitution, “health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity” [21]. Accordingly, telehealth
broadens the concept of telemedicine by including the aspect of well-being into health
service delivery and such also encompasses preventive and health promotion measures.
While health care professionals are explicitly involved in both telemedicine and
telehealth, mHealth adds a further dimension by additionally including the individual as
executing person for the service [22] into the “use of mobile communications for health
information and services” [23,p.1]. Such, mHealth explicitly incorporates the active and
empowered patient targeted by preventive measures.
The three introduced concepts telemedicine, telehealth, and mHealth are partly
related to each other. Furthermore, each of the terms independently forms a subclass of
the term eHealth [10,23,24 as cited in 16]. In 2015, the European Commission defined
eHealth on their website [24 as cited in 16], which is now replaced by an almost word-
identical definition of digital health (and care), describing “tools and services that use
information and communication technologies (ICT) to improve prevention, diagnosis,
treatment, monitoring and management of health and lifestyle” [25]. This is in line with
the observation by Scott and Mars that only from 2016 onwards the usage of digital
health as term increased [15]. Similarly to telehealth, digital health encompasses both
“health services delivery and personal health and wellbeing” [26]. As the FDA
underlines, mHealth, telehealth and telemedicine as well as health IT are also subclasses
of digital health [27], which supports the interchangeable use of the terms digital health
(and care) and eHealth. Health IT, as fourth subclass of digital health within the scope
of our chapter, describes “the application of information processing involving both
computer hardware and software that deals with the storage, retrieval, sharing, and use
of health care information, data and knowledge for communication and decision making”
[28,p.38].
The common underlying technological concepts are ICT and digitization. Digital health as well as its subclasses use ICT as technological basis [10,16,23,25]. ICT is
defined as “all technical means used to handle information and aid communication. This
includes both computer and network hardware, as well as their software” [29] and, e.g.,
telephones, smartphones, audio and video recording. Furthermore, ICT enables the
diffusion of digitization in every area of society. Not only in health care but also in other
areas of life, digitization changes the work processes from using analogue to digital
signals, which broadens the usage and possibilities of technological systems [30].
L. Otto et al. / Defining and Delimitating Telemedicine and Related Terms 115
When applied in care delivery processes, digital health affects different care models,
especially integrated care as connecting professionals mainly relies on technological
solutions. Generally, digital health affects care models by “complement[ing] and
enhanc[ing] existing health service delivery models” [31,p.1] and enabling new ones
[32]. Care models, i.e. a blueprint for health care provision, which is characterized by
existing standards and evidence-based practice [33], can also be represented by
integrated care [34]. In integrated care, the “inputs, delivery, management and
organization” [35,p.7] of health and care services are combined along the continuum of
health provision to improve different outcomes of these services (e.g., quality or
efficiency) [35]. When applied in the context of professional care provision, eHealth and
therefore digital health can support integrated care, especially for people with
multimorbidity [36]. The potential of digital health to “strengthen integrated, people-
centred health services” [31,p.1] was just recently highlighted by the seventy-first World
Health Assembly in Geneva.
Another context in which digital health services can be applied is the living space,
i.e. location context, of people, no matter if they are patients or individuals. Concepts
related to location context are Health Smart Homes as special types of Smart Homes and
Ambient Assisted Living. Equipping the living space of people with special needs for
health care purposes is called Health Smart Home (HSH) [37,38]. As the name implies,
it represents a health-focused Smart Home (SH) [37], which in turn generally describes
the equipment “of a living space […] with electronic devices and communications
infrastructure” [38,p.166]. In both cases, the aim is to increase the safety of occupants
by enabling “monitoring and control of the immediate physical environment” [38,p.166],
in general or related to their health status. Further related to SH are also Ambient Assisted Living (AAL) technologies, which extend the SH environment towards the
health care domain [39]. Even though AAL also represents a health technology
application, it was not previously explained as it is strongly dependent on the location
context. In contrast to HSH, AAL explicitly describes assistance applications, i.e.
“technological concepts, products and services for situation-dependent and unobtrusive
[…] assistance of people with special needs in daily life” [40,p.11].
AAL and HSH, both representing health-related SHs, are closely linked concepts.
Vacher et al. described this connection by stating that “one of the great challenges in
Ambient Assisted Living is to design health smart homes that anticipate the needs of its
inhabitant while maintaining their safety and comfort” [41,p.35]. As the Association for
Electronic and Information Technologies (VDE) states, AAL systems are “integrated
into people’s living environments” [40,p.11], i.e. are integrated into HSHs. Based on the
definitions above, it can also be said that AAL uses ICT [40] and can incorporate digital
health (and care) solutions, as they focus not only on health but also on lifestyle [25].
Increasing the comfort, safety and quality of life is a goal inherent to all three concepts,
SH, HSH and AAL, framing the terms [37,38,40]. A complete overview of the terms
included and their interrelations is given in Figure 1.
L. Otto et al. / Defining and Delimitating Telemedicine and Related Terms116
Figure 1. Ontology for telemedicine and related terms (Note: [24] refers to [24 as cited in 16]) – Legend: dark
grey describes health technology applications, white terms are related to care delivery, light grey terms describe
the location context and black refers to underlying technological concepts. Characteristics of classes are passed
on to subclasses.
To facilitate the understanding and delimitations of the terms, Table 1 shows important
differentiation characteristics and their specification for the terms related to health
technology applications.
Table 1. Delimitation of terms related to health technology applications – “x”: characteristic is always
fulfilled, “(x)” characteristic can be fulfilled.
Term Delimitation
Health IT mHealth Tele-
medicine Tele-
health Digital health AAL
Use of ICT
Across distances
Mobile
x
(x)
x
x
x
x
x
(x)
x
x
(x)
x
(x)
(x)
x
(x)
(x)
Medicine
Well-being
x
x
x
x
x
x
x
x
x
x
x
Professional involvement x (x) x x (x) (x)
Living space x
The presented ontology helps define the included terms and delimitate them from
each other. However, the definitions are quite broad and can cover various combinations
of specific services or people involved. This can be seen using the example of
telemedicine. Telemedicine projects have different characteristics (e.g. application type,
personnel involved or setting), shown in previous work where a taxonomy was applied
to a German telemedicine project database [42]. Regarding the ontology provided, the
application types of telemedicine are particularly relevant as they represent the different
phenotypes to be subsumed under the concept of telemedicine. A telemedicine project or
L. Otto et al. / Defining and Delimitating Telemedicine and Related Terms 117
initiative can be either tele-consultation, -ambulance, -diagnosis, -monitoring,
-rehabilitation, -health education, digital disease-management or a combination of them
[19].
4. Application of the Ontology
In the light of this primarily theoretical perspective on the delimitation of relevant terms,
the following two case studies illustrate their application in different chronic patient
cohorts: (I) patients with diabetes and (II) patients with stroke. Due to the need for
intensive, individualized and continuous support and care, patients with chronic diseases
are seen as the ideal target group to develop and implement telemedicine strategies
[43,44]. The presence of multi-morbid conditions further requires the attention of more
than one medical specialist, which is why chronic diseases are also the ideal target for
integrated care interventions.
(I) According to the American Diabetes Association, patients with diabetes require
“[e]ffective diabetes self-management education and support [, that] should be patient
centered, may be given in group or individual settings or using technology, and should
help guide clinical decisions” [36,p.38]. In their consensus report, the European and
American diabetes associations summarize that applying telemedicine in patients with
diabetes is associated with a modest improvement in glycaemic control [45], e.g. through
tele-monitoring. Output data on HbA1c and times spent below, in and above range can
be quantified, explained and visualized in a patient’s application in real time [46].
Furthermore, health care providers can easily give feedback on each value and respond
quickly in case of dramatic and potentially life-threatening changes [47]. Such, based on
a monitoring of the transferred clinical outcomes, the responsible health care professional
(e.g. physician, diabetologist, or diabetes educator) is able to provide individualized
telemedical care [48] and digital self-management support [49] from a distance.
Moreover, as feedback on the values can be tailored to the individual patient due to
her/his preferences and disease history [50], they enable the patient to adjust her/his
health behaviour accordingly [51]. This is achieved by tailored tele-health education,
which can also be delivered via web-sites and mobile phones [52].
The number of available lifestyle apps promoting physical activity and healthy diet
in the App Store or Google Play Store is continuously increasing [53,54]. When looking
for applications targeting patients with diabetes or diabetes-associated risk factors like
unhealthy diet, obesity or low levels of physical activity, the identified apps cover
different functions and features. For example, there are apps exclusively delivering
educative content on the disease itself (including its pathogenesis, diagnosis or treatment
options) in plain language, digital diaries to monitor eating habits, or educative
motivational videos to improve physical activity. Consequently, our ontology would
qualify them as mHealth or telehealth (depending on the devices used).
(II) Another example for potential telemedicine support is stroke. For example, tele- diagnosis can support the early detection of a potentially life-threatening condition due
to a stroke [55] by linking emergency care units (tele-ambulances [56]) and hospitals.
Reducing the time between onset and diagnosis may lead to faster emergency measures
in tele-ambulance [57]. Apart from emergency settings, tele-consultation is a useful tool
in stroke care to enable primary physicians in remote or rural locations to contact experts
and such enable integrated care. Experienced neurologists can examine the patient
remotely through live video feeds or study a computed tomography, thereby assisting the
L. Otto et al. / Defining and Delimitating Telemedicine and Related Terms118
primary physician in giving the accurate diagnosis and determining the appropriate
treatment [58]. Tele-consultation can also be used by the patient directly, in order to gain
access to remote physicians, even more so in case of immobility [59]. Furthermore, tele- rehabilitation has proven to be an effective tool to support improved limb and cognitive
function [60].
5. Discussion
The present manuscript provides an updated overview of terms and concepts in the area
of telemedicine. The definition of terms and their interrelations was based on scientific
literature or insights from national and international associations. Therefore, the
systematisation of relevant terms in a consolidated ontology and their application in
specific use cases have the potential to improve the understanding of relevant terms.
Some interrelations were not included explicitly as they are implicitly represented
in the provided ontology. One example is the connection between integrated care and
HSH. Rialle et al. [37] state that HSHs can be part of integrated care. This connection is
implicitly given by the ontology provided. Here, HSHs integrate AAL, which in turn use
digital health, which can support integrated care. As only the AAL/digital health part of
the HSH is related to care delivery, this interrelation mirrors the Rialle et al’s statement.
Additionally, other terms related to the ones already included, exist, e.g., telecare,
wearables, e-prescriptions, teleprevention, robotics, or internet of things. Telecare, for
example, is seen as another subclass of eHealth [61], while virtual care is seen as part of
telehealth [62] and wearables and e-prescriptions are specific components within the
domain described. Nevertheless, these concepts did not add much information to the
knowledge base. Potential changes to the ontology in the future could also arise from the
growing use of telemedicine applications based on artificial intelligence, such as Amazon
Alexa. On the one hand, they can help improve accurate tele-diagnosis and monitoring,
for example in blood pressure management [63]. As for preventive care, automated
interactive voice response systems have shown the potential to support health behaviour
change, for example uptake of screening or immunisation measures [64].
A consolidated understanding of telemedicine-related terms and their scope is
important for the evaluation and standardisation of digital health solutions [65,66].
Therefore, newly developed digital health interventions and applications can make use
of this consolidated ontology, which may also inform the evidence base needed for
successful implementation [67]. For example, the evidence standards framework for
digital health technologies by the National Institute for Health and Care Excellence
differentiates three evidence tiers, with simple digital health applications such as
Electronic Health Records being on the lowest tier where no clinical effectiveness has to
be proven [67]. The ontology provided can serve as a starting point for this regulatory
process and guide the clear definition of concepts and services.
Though being grounded in existing literature and evidence, the present work has
several limitations. The selection of terms was applied by the listed authors and is
therefore prone to selection bias. As such, no systematic procedure was chosen and
additional terms could be missing. Nevertheless, the consolidated ontology should be
seen as a terminological basis to be reviewed and updated continuously. Established
high-quality literature provided by national and international associations as well as
scientific papers should be used to update the terminological basis for the proposed
ontology in the future.
L. Otto et al. / Defining and Delimitating Telemedicine and Related Terms 119
6. Conclusion
Based on a literature search, we provide an updated ontology for telemedicine and related
terms and support the overall understanding with specific application types. With the
help of use cases, we highlight the applicability of the proposed ontology and outline
how developers of digital health interventions, regulatory bodies or funding agencies can
make use of this terminological resource. Due to the emerging development of
subcategories and trends in digital health, continuous updates of the terminological
nomenclature are needed to ensure its contemporary validity.
Acknowledgements
We would like to thank Stephanie Champion for her proof reading. The work for this
chapter was funded by the European Social Fund and the Free State of Saxony (Grant
no. 100310385).
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