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Letter to the Editor

Letter to the Editor by Danielle Goeren and Laura Taylor, to “Telehealth: Promise or Peril?”

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November 14, 2014

Response by Danielle Goeren and Laura Taylor, to the topic “Telehealth: Promise or Peril?” (September 30, 2001)

Dear Editor:

In many rural areas, technology does not support ideal patient care (Advanced Development for Africa [ADA], 2011). Insufficient infrastructures, power supplies, and access to computers and Internet sources contribute to this disparity. Many rural areas lack up-to-date, reliable, and accurate information for providers to use in their practice. In fact, community health workers are usually the last to receive evidence-based knowledge, but are the first level of contact and interaction with patients (D’Adamo, Fabic, & Ohkubo, 2012). Due to the potential inexperience and regional isolation of the care provider and lack of infrastructure, patients are likely not to receive adequate health education and access to proper treatment. The technology infrastructure for improved communication is in place worldwide as over fifty million community members have access to or ownership of mobile phones (World Health Organization [WHO], 2012a). If 73% of mobile phone subscriptions worldwide come from developing countries, it is only logical to infuse mobile phones technologies, such as texting, video conferencing, and picture messaging to advance healthcare delivery systems and improve patient outcomes (ADA, 2011).

The current method of diagnostic communication across the majority of the underdeveloped nations is paper-based, which takes weeks for the data to be communicated and available to providers (WHO, 2012a). This approach creates a huge delay in the treatment and care of the patient and thus limits any chances of the patient engaging in early interventions and increases the risks of morbidity and mortality. One way to use mHealth to support and improve patient care in resource deprived areas is by using Short Messaging Service (SMS) or email to send lab and diagnostic results to the healthcare team. This method has been shown to promote data access and patient care management interventions in real time (Fraser & Blaya, 2010); promoting earlier and faster access to best treatment options and yielding a better prognosis for the patient. In fact, an observational study in Haiti demonstrated that emailing patient results to care providers warning them of low CD4 counts was linked to quicker implementation of HIV treatment (Fraser & Blaya, 2010). Moreover, due to the current healthcare provider shortage, the use of SMS messaging or emailing allows providers to be in remote locations and still able to respond to pertinent data in a timely matter. This just-in-time care delivery model has been shown to improve the quality, safety and efficiency of care in the developing world (WHO, 2012b).

One of the most important uses of mHealth is to encourage patient adherence and education of disease outbreaks and treatment regimens. A randomized control trial in South Africa suggests that using SMS messaging, specifically ten motivational messages, significantly encouraged patients by impacting adherence to treatment and having a 1.7-fold increased chance of getting tested and showing up to follow-up appointments (WHO, 2012a). Additional use of text messaging is sending SMS reminders to patients about appointments to ensure attendance and positive reminders of healthy behaviors. One study, a SMS messaging smoking cessation program “txt2stop,” with 5800 participants, suggests that after six months of the intervention the percentage of participants who quit smoking had more than doubled. This demonstrates the positive outcome of quitting smoking after having received the text interventions regularly (Piette et al., 2012). Another randomized control trial in Malaysia, used both text-message reminders and telephone calls to reach out to participants with chronic disease for follow-up appointments. The results showed that attendance rates increased among the patients with no statistical significance among the two methods of communication (Piette et al., 2012). These studies show that SMS messaging can impact patient adherence rates and outcomes as well as change current patient behaviors.

Additionally, SMS messaging can be used to monitor common diseases and treatments, to check drug authenticity, to observe disease outbreaks, to educate patients on knowledge level, to manage drug stocks, to prevent stock outs, and to send out reminder texts about medication pickups (ADA, 2011). For example, the RapidSMS system used in Malawi decreased the transfer time for data collected on pediatric patients from up to three months to only two minutes (Lewis, Synowiec, Lagomarsino & Schweitzer, 2012). Furthermore, in Kenya, providers use SMS messaging to ensure healthcare workers adhere to medical guidelines (Piette et al., 2012). These methods help to promote disease surveillance, disease prevention, early treatment, and positive effects on treatment outcomes.

Lastly, mHealth has been used to ensure providers in rural areas receive accurate and reliable information. ICT’s allow providers in underserved environments to communicate with specialists and providers in larger cities about diagnostic tests and advanced healthcare measures (Piette et al., 2012). Instant messaging, hot-lines, and videoconferencing are used to counsel with more experienced and knowledgeable doctors to gain medical advice (Piette et al., 2012). Some examples of Internet platforms include TeleDoctor, which gives access to physicians across Pakistan through a telephone hotline, and E Health Point, which uses videoconferencing to aid patient-doctor communication in India. Moreover, telephones and internet resources provide health workers in Peru with remote access to data collected on a wide variety of populations using instant messaging (Fraser & Blaya, 2010); and community workers in the United Republic of Tanzania with electronic versions of textbooks on mobile phones to direct them on how to perform medical assessments (WHO, 2012a). Similar to protocols that are available in most hospitals, having access to electronic textbooks will decrease the chance of errors. These examples break down extensive, geographic barriers that historically limit healthcare access and impair patient-provider communication (Lewis et al., 2012). By incorporating mHealth technologies, treatment can be increased by easily accessing doctors and resources elsewhere via mobile devices.

Overall in today’s society, it is impossible to avoid technology, especially mobile phones. Incorporating healthcare programs, information and education to such devices can only be beneficial and improve the quality of care received worldwide. mHealth offers access to information in a quick and reliable manner. Strategies that are actively using mHealth technology can offer a cost-effective approach to care in an existing cash laden system. It is a simple improvement that can make a huge change, particularly in rural and developing countries.

Danielle Goeren, RN, BSN
North Shore University Hospital
Long Island, NY

Laura Taylor, PhD, R
Johns Hopkins University School of Nursing
Baltimore, MD


Advanced Development for Africa. (2011). Scaling up mobile health [White Paper]. Retrieved from

D’Adamo, M., Fabic, M.S., & Ohkubo, S. (2012). Meeting the health information needs of health workers: What have we learned?  Journal of Health Communication: International Perspectives, 17(2), 23-29. doi: 10.1080/10810730.2012.666626

Fraser, H.S.F., & Blaya, J. (2010). Implementing medical information systems in developing countries, what works and what doesn’t. AMIA Annual Symposium Proceedings Archive, 232-236.

Lewis, T., Synowiec, C., Lagomarsino, G., & Schweitzer, J. (2012). E-health in low- and middle-income countries: findings from the Center for Health Market Innovations. Bulletin of the World Health Organization, 90, 332-340. doi: 10.2471/BLT.11.099820

Piette, J.D., Lun, K.C., Moura, L.A., Fraser, H.S.F., Mechael, P.N., Powell, J., & Khoja, S.R. (2012). Impacts of e-health on the outcomes of care in low- and middle-income countries: where do we go from here? Bulletin of the World Health Organization, 90, 365-372. doi: 10.2471/BLT.11.099069

Taylor, L., Abbott, P.A., & Hudson, K. (2008). E-learning for health-care workforce development. IMIA Yearbook of Medical Informatics, 83-87.

World Health Organization. (2012a). Measuring the impact of e-health. Bulletin of the World Health Organization, 90, 326-327. doi: 10.2471/BLT.12.020512

World Health Organization. (2012b). The bigger picture for e-health. Bulletin of the World Health Organization, 90, 330-331. doi: 10.2471/BLT.12.040512