Utilization Barriers and Medical Outcomes Commensurate With the Use of Telehealth Among Older Adults: Systematic Review

Background: Rising telehealth capabilities and improving access to older adults can aid in improving health outcomes and quality of life indicators. Telehealth is not being used ubiquitously at present. Objective: This review aimed to identify the barriers that prevent ubiquitous use of telehealth and the ways in which telehealth improves health outcomes and quality of life indicators for older adults. Methods: This systematic review was conducted and reported in accordance with the Kruse protocol and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Reviewers queried the following four research databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed (MEDLINE), Web of Science, and Embase (Science Direct). Reviewers analyzed 57 articles, performed a narrative analysis to identify themes, and identified barriers and reports of health outcomes and quality of life indicators found in the literature. Results: Reviewers analyzed 57 studies across the following five interventions of telehealth: eHealth, mobile health (mHealth), telemonitoring, telecare (phone), and telehealth video calls, with a Cohen κ of 0.75. Reviewers identified 14 themes for barriers. The most common of which were technical literacy (25/144 occurrences, 17%), lack of desire (19/144 occurrences, 13%), and cost (11/144 occurrences, 8%). Reviewers identified 13 medical outcomes associated with telehealth interventions. The most common of which were decrease in psychological stress (21/118 occurrences, 18%), increase in autonomy (18/118 occurrences, 15%), and increase in cognitive ability (11/118 occurrences, 9%). Some articles did not report medical outcomes (18/57, 32%) and some did not report barriers (19/57, 33%). Conclusions: The literature suggests that the elimination of barriers could increase the prevalence of telehealth use by older adults. By increasing use of telehealth, proximity to care is no longer an issue for access, and thereby care can reach populations with chronic conditions and mobility restrictions. Future research should be conducted on methods for personalizing telehealth in older adults before implementation. T r i a l R e g i s t r a t i o n : P R O S P E R O C R D 4 2 0 2 0 1 8 2 1 6 2 ; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020182162. International Registered Report Identifier (IRRID): RR2-10.2196/15490 (JMIR Med Inform 2020;8(8):e20359) doi: 10.2196/20359


Introduction Background
A demographic shift has been evident globally since 2015. Specifically, the aging population has been growing at a rapid rate and has been predicted to reach 22% by the year 2050 [1]. In fact, the World Health Organization (WHO) estimates that during 2020, adults aged 60 years or older will outnumber children aged 5 years or younger [1]. The United States Census Bureau published a graphic on March 13, 2018, depicting the population pyramid from 1960 and comparing it with the 2060 prediction [2]. The graphic demonstrated the gradual change of the US population pyramid to a pillar shape [2]. This graphic is key to understanding the demands on the health care system in the area of geriatric, long-term, and end-of-life care, because it highlights the larger number of older adults living longer lives. By 2030, 60 million people in the "baby boomer" generation (born between 1946 and 1964) will have reached 65 years of age or older and will be eligible for age-related state entitlements in most countries [3,4]. This demographic shift is an impending issue facing health care, as geriatric, long-term, and end-of-life care will experience a surge in demand. Health care organizations and their providers must find ways to effectively allocate resources and provide the right care at the right time and at the right place [5].
Telemedicine has the potential to increase access among elderly people and relieve the stress regarding care for the unusually large number of elderly people. The WHO defines telemedicine as "healing from a distance." More specifically, it is healing through the use of information and communication technologies "to improve patient outcomes by increasing access to care and medical information" [6]. The WHO also does not differentiate between the terms telemedicine and telehealth.
There has not been much work on the use of telehealth based on age; however, we know that a technology gap or digital divide exists. It is established by tiers of race, age, and economic disparities [7]. In the United States, for instance, the elder-care entitlement Medicare imposes restrictions on the use of telehealth for the primary population [8]. The Coronavirus Aid, Relieve, and Economic (CARES) Act provides a regulatory waiver to extend reimbursements to telemedicine, but this is only a relief act and not permanent legislation [9]. Previous reviews have investigated facilitators and barriers to the adoption of telehealth, the use of eHealth and mobile health (mHealth) tools in health promotion and primary prevention among older adults, and patient satisfaction with telehealth interventions [10][11][12]. A narrative analysis on mHealth solutions for the aging population used a generational analysis that included culture and trust of other people and a distrust of technology [13]. This work noted an increase in the use of technology for health purposes and an increase in the use of the internet for health purposes. It also noted concerns of security and privacy and technical troubleshooting. A review from 6 years ago spanned 10 years, analyzed 14 articles, and focused on older adults over 65 years old [10]. The most recent review on a topic most like this work was published 5 years ago, spanned 10 years, analyzed 45 articles, and focused on older adults aged over 50 years [11].
With an aging population, telehealth services are becoming more common to aid in independent living and health management [14]. An example of telehealth is virtual home health care, where health care providers provide guidance in specific procedures while the patients are in the comfort of their home. Telehealth programs can improve access to health care and have a positive effect on patients' medical outcomes, especially for the treatment of chronic illnesses in vulnerable populations, such as elderly people [15]. Utilizing age-friendly technology could improve the care providers give to older adults through telehealth services and improve the usability of telehealth for older adults [16]. It is essential to first understand the barriers that affect the usability of telehealth services among older adults in order to find opportunities for improving health outcomes. Barriers to using telehealth can affect the accessibility of health services to older adults. When it comes to technology, older adults are often stereotyped as laggards in technology adoption [7]. However, owing to rising telehealth capabilities, improvement of access, especially to older adults, can aid in improving health outcomes [15]. Understanding the perspectives of older adults is important when evaluating telehealth barriers because older adults generally develop different perspectives compared with those of other age demographics [16]. Other studies on this topic have focused on conditions like depression, heart failure, and falls [17][18][19]. However, no review has looked at medical outcomes, including indicators of quality of life, that come as a benefit of using telehealth and the barriers that exist to the use of telehealth internationally. This review intends to examine these issues and what has changed in telehealth for older adults in the last 5 years.

Objectives
The purpose of this systematic review was to evaluate the current literature to help identify and understand health-related quality of life enhancers and general health outcomes that are commensurate with and barriers to the use of telehealth services by older adults. Health outcomes, including quality of life enhancers, provide the "so what" to the use of telehealth modalities. Recognizing barriers can help develop solutions for broadening the use of telehealth services in older adults. During the COVID-19 crisis, providers and patients alike were thrust into the world of telehealth. An overview of the benefits and barriers would be helpful to those deciding whether to continue the use of telehealth modalities.

Protocol and Registration
This review used the Kruse protocol published in 2019 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [20,21]. The review was registered with PROSPERO on May 2, 2020 (ID: CRD42020182162). In accordance with the rules at PROSPERO, the registration was completed before analysis began.

Eligibility Criteria
Studies were eligible for this review if participants were older adults (older than 50 years), if the intervention was some form of telehealth (including mHealth, eHealth, and all forms of telehealth), if the authors reported either barriers to the use of telehealth or health outcomes, and if the article was published in a research journal in the English language in the last 5 years. Adults older than 50 years were chosen out of trial and error. When we initially wrote the methods for this study, we chose a more universal definition of older adults as those over 65 years of age. Once we started filtering articles for analysis, we noticed a large number of articles that were being eliminated, despite the high level of quality of these studies. If we had stuck with age over 65 years as our screening criteria, we would have eliminated more than half of the group of articles for analysis. As a result, we chose age over 50 years, which is supported by other reviews in this field [11]. This is a limitation we list later.

Information Sources
The following four databases were queried: Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed (MEDLINE), Web of Science (WoS), and Embase (Science Direct). Additionally, a specific journal search was conducted in the journal of choice for publication (Journal of Medical Internet Research). Databases were filtered for the last 5 years. Database searches occurred between February 2 and 14, 2020. A period of 5 years was chosen because it has been that long since the last review was published on a similar topic. We expect to find advances in technology and advances in adoption by elderly people because younger people who use technology regularly have advanced into the observation group of over 50 years old. We hope to find fewer barriers.

Search
Reviewers carefully analyzed the MEDLINE Medical Subject Headings (MeSH) for key terms related to telehealth and elderly people. Based on the established hierarchy of indexed terms at MeSH and a series of experimental searches, the final search terms were "Telehealth AND 'older adults.'" This combination of terms yielded the maximum number of results in all four databases. Reviewers used available filters to eliminate other reviews and focus on academic or peer-reviewed journals over the last 5 years.

Study Selection
Reviewers followed the Kruse protocol, which entails a series of three consensus meetings. The results of the first consensus meeting identified the studies for analysis. After filtering the results of the four databases to meet the eligibility criteria, all reviewers screened the abstracts of the results to ensure that articles were germane to the topic, they were actually studies (not protocols), and they contained tangible results to enable analysis toward the review's objectives. The first consensus meeting discussed whether to keep articles for analysis. The reasons for rejection included opinion article (not a study), protocol (no results), concept or design paper (no results), review, no use of telehealth, and no reporting of either outcomes or barriers. A kappa statistic was calculated from the results of this meeting [20]. Before consensus meeting number two, the group leader assigned workload to ensure that each article was analyzed by at least two reviewers. Reviewers independently analyzed articles using a piloted form. Reviewers collected several standard items used for summary, such as PICOS (Participants, Intervention, Comparison [to the control group], Outcome, Study design), and analysis, such as forms of telehealth interventions, barriers to the use of telehealth by older adults, and the medical outcomes observed in older adults using telehealth solutions [20]. After making a list of observations, reviewers attempted to make sense of the observations using a narrative analysis [22].

Data Collection Process
The group leader divided analysis workload to ensure all articles were reviewed by at least two reviewers. Reviewers independently analyzed articles using a standardized Excel spreadsheet as a piloted form for data extraction.

Data Items
The piloted form collected data, including participants, intervention, study design, results compared to a control group (where applicable), medical outcomes, sample size, bias within studies, effect size, country of origin, statistics used, barriers to the use of telehealth, and quality assessment from the John Hopkins Nursing Evidence-Based Practice (JHNEBP) rating scale, as well as general observations about the article that would help in interpretation of the results [23]. These data items were independently collected and discussed in the second consensus meeting.

Risk of Bias Within and Across Studies
General observations of bias were made about each study, such as selection bias. These observations were independently collected and discussed in the second consensus meeting. The JHNEBP rating scale was used to assess the risk and quality of each study analyzed. Within the JHNEBP rating scale, level I indicates experimental studies, randomized controlled trials (RCTs), or meta analyses of RCTs; level II indicates quasiexperimental studies; level III indicates nonexperimental studies, qualitative studies, or meta-syntheses; level IV indicates opinions of nationally recognized experts based on research evidence or expert consensus panels (systematic reviews or clinical practice guidelines); and level V indicates opinions of individual experts based on nonresearch evidence. There are three levels of quality of evidence, which are listed as A (high quality), B (good quality), and C (low quality or major flaws). Each of these levels define the following four thresholds: research, summative reviews, organizational opinion, and expert opinion. For instance, in level A, studies have consistent results with sufficient sample size, adequate control, and definitive conclusions. In level C, studies have little evidence with inconsistent results and insufficient sample size, and conclusions cannot be drawn. To limit the inherent bias and limitations commensurate with low-quality studies, the ratings from the JHNEBP rating scale serve as screening criteria. Articles with evidence ratings below level IV were not accepted. Quality of evidence ratings below level B were highly suspect.

Summary Measures and Additional Analysis
The review analyzed both qualitative and quantitative methods, so the summary measures sought were not consistent. The preferred summary statistic was the risk ratio, but other summary statistics were also sufficient. The summary statistics were independently collected and discussed in the second consensus meeting.

Pretest eHealth
Participants were matched into geographically based small groups with an assigned health coach, and they began the program at the same time. Group members were connected to each other through a private online social forum where they could post comments and questions, engage in health coach-moderated discussions, and provide social support to one another.
Using internet-enabled devices (laptop, tablet, or smartphone), program participants were able to asynchronously complete weekly interactive curriculum lessons, reflections, and goalsetting activities in relation to the weekly topic.

Risk of Bias Within Studies
At the study level, reviewers recorded observations of bias. The most frequently observed form of bias was selection bias (asking for volunteers for a research study involving technology will result in volunteers who already gravitate toward technology), which occurred in 7 out of 57 (13%) articles analyzed [15,26,[30][31][32]37,39]. There were six instances of convenience samples from a local population [34,[49][50][51][52]64]. Both examples of bias limit the external validity of the results.

Results of Individual Studies
Themes that resulted from the narrative analysis are listed in Table 2. Repetition can be observed in a frame of a theme owing to multiple observations from the same article for that theme. Translations from observations to themes for interventions, medical outcomes, and barriers are listed in Multimedia Appendix 1, Multimedia Appendix 2, and Multimedia Appendix 3, respectively. These appendices illustrate the logical inference reviewers made for each theme. For instance, one article listed remote patient monitoring for blood pressure, pulse oximeter, and body weight scales. These were categorized under telemonitoring [26]. The same article listed a decrease in hospital visits and a decrease in readmissions. These were categorized under an increase in hospital metrics. Additional data collected (bias, statistics, country of origin, and quality assessments) are displayed in Multimedia Appendix 4. In consensus meeting number two, we identified general observations, as depicted in the tables [20].  Table 3 summarizes the quality indicators identified by the JHNEBP tool [15]. The most frequent strength rating was III, followed by I, II, and IV. The most frequent evidence rating was A, followed by B and C. No strengths below IV were encountered. A full list of quality assessments is presented in Multimedia Appendix 4. Articles that did not meet the minimum standards of quality were not included in the analysis. This decision was made to limit the bias inherent to nondata-driven opinions or conclusions that do not logically follow the data.

Additional Analysis
The results of consensus meeting three identified the themes that corresponded with telehealth interventions, barriers to the use of telehealth, and medical outcomes. These are summarized in Tables 4-6.

Interventions of Telehealth
Five themes for interventions were identified. Two studies used multiple telehealth interventions. Table 4 lists the interventions with the associated references, number of occurrences, and probability of occurrence in the review. The most common intervention was eHealth (computer driven), followed by mHealth (smart device driven), telemonitoring (remote sensors), telecare (phone), and telehealth video call.
We also analyzed the interactions between interventions and medical outcomes. eHealth interventions were associated with an increase in cognitive ability. This interaction occurred seven times in the literature [28,31,41,50,51,54,69].

Results Summary
This review identified 13 themes and one lone observation of medical outcomes incident with the adoption of five types of telehealth approaches. This review also identified 14 themes and one observation of barriers to the adoption of telehealth.

Common Barriers to Telehealth
In this review, we were able to identify the common barriers associated with older adults utilizing telehealth. The most frequent barriers were lack of desire, cost, lack of technical support, visual acuity, social implications of use, ownership of technology, privacy and security, medical literacy, trust of the internet, mental acuity, hand-eye coordination, auditory acuity, and computer anxiety. Each of these barrier areas could present hurdles for elderly people dealing with telehealth and reasons to not use it. Lack of technical literacy is a large area of concern, as many elderly people have issues using computers to check email or smartphones to make telephone calls [13]. Because this is new to this population, they are also being held back from acceptance by a simple lack of wanting to do it [28,34,[37][38][39]57,58,60,63,64,67,74,76]. It seems to be an easy thing to add to one's daily tasks, but when one has lived largely without the use of these technologies, it can become an arduous task to "sell" the benefits of the sudden use of new technology and learning how to use new technology. They have the attitude "as it was not needed before, why bother to learn it now?" This can prove to be an uphill battle for providers who are attempting to utilize new technologies in different ways.
The cost of technology is also quite prohibitive, as computers, smartphones, and other devices cost hundreds to thousands of dollars. Those living on fixed incomes are cash strapped and may not be able to afford to purchase or use such new technologies. Not owning such technologies presents its own concerns for the provision of care. Besides cost, there are concerns in this population regarding the ability to actually utilize the modality of telehealth efficiently. Issues with visual acuity [4,27,29,37,59,61,73], mental acuity [27,29,38,59,63,73], hand-eye coordination [37,58,59,73], and auditory acuity [4,50,61] are all relevant concerns for elderly people. Many people, as they become older, experience decreases in the efficiencies of the operations of many body systems, including their senses. Many develop disease processes that can affect their mental status, vision, and hearing, and any or all of these could easily lead to problems with being able to use technology, let alone having a clear understanding of what they need to be doing with the device or even how to interact with it.
The elderly population also has relevant concerns with trust and technology, as they are one of the prime targets for abuse from their use of technology according to popular media [13,78]. This is where lack of technical support for the use of technology can become a very relevant area of concern. There is no affordable and adequate source of "technical support" to simply learn how to use devices [14,28,59,73]. This lack of knowledge and available education can be a very problematic barrier for the use of the modality of telehealth. Furthermore, problems surrounding trust of the internet [5,[14][15][16]30,58], concerns of privacy and security [5,19,28,34,38,58,76], and even computer anxiety [65] can figure into the use of technology. As there are concerns with privacy and security, telehealth could easily cause patients to succumb to some level of anxiety. Not understanding the modality of telehealth or how to use it can add to the level of this anxiety at an exponential rate.
Another consideration with the use of telehealth is that it requires a certain level of user knowledge. The utilization of medical applications requires the user to have some knowledge of medical terms, procedures, etc [5,14,15,35,38,49,56,73]. This is often not the case, as this population was raised without the internet or medical knowledge. Medical knowledge came from physicians during their younger years, and only recently, the approach has changed to the utilization of internet web searches to garner knowledge about symptoms and diagnoses. This is an entirely new world for the elderly population and a relevant barrier to the use of these applications overall. Overcoming this knowledge gap could prove to be an insurmountable task or one that requires any telehealth use to be kept to an absolute minimum for knowledge or know-how on the part of the user.

Common Outcomes Associated With Telehealth Interventions
The research supports strong medical outcomes incident to the use of telehealth as follows: decreased psychological distress [32,42,46,51,60,68,70,71,76], increased autonomy [29,34,35,46,48,[52][53][54]56,62,67,75,76], increased cognitive ability [27,28,31,41,50,51,54,69], and many others. This review supports an increased quality of life for those who adopt telehealth [29,32,44,53,67,69]. The use of telehealth can lead to less psychological distress, as users know that they have a way of communicating their medical concerns to their providers in a much easier and faster way. This could eventually enable better health due to better management, thus allowing for fewer associated medical conditions for those patients who use telehealth for assistance in the management of their care.
The observation of greater documentation for providers demonstrated that the use of telehealth is not all about the patient. It is just as much about practitioners providing care. The use of telehealth allows for much faster accessibility to documentation to provide care or even real-time information about the patient to allow for immediate diagnosis or intervention, based on information being gathered by the used technology. This can make the provision of care easier and much more efficient for the field, which is already seeing more patients than it can comfortably manage.

Interactions Among Outcomes, Barriers, and Types of Interventions
eHealth interventions were the most frequently observed interventions in the literature, and these interventions were most frequently associated with the barriers of technical literacy and lack of technical support. This observation is interesting because general technical support, whether from friends, neighbors, family, or caregivers, or professionally acquired technical support is a control for the barrier of technical literacy. The interaction between eHealth and technical literacy is interesting as well. This could signal that older adults are more adept at mobile technology than computer technology for application of telehealth. This supposition is supported by the literature because many older adults are turning to mobile technology to communicate with children and grandchildren [13]. The interaction between mHealth and lack of desire is noteworthy. This seems to indicate that older adults are willing to interact with mobile technology to communicate with children and grandchildren, but they are not as willing to use it for telehealth interventions.

Study Quality and Literature Bias
The assessment of the quality of the articles studied is worthy of discussion. The majority (27/57, 49%) of the articles analyzed were level III (nonexperimental, qualitative, or meta-synthesis studies). The reviewers would have preferred to analyze only the highest level (level I) (experimental study or RCT), but only 10 (17%) such studies were available. Fortunately, 98% (56/57) of the articles were rated as quality level A (high quality) or B (good quality). The importance of this rating cannot be understated. If the findings from this review were from low-quality articles, the results would not be as strong. By analyzing high-quality articles with strong levels of evidence, readers can be more assured of the results. Research articles with strong study designs and sufficiently large samples are generally accepted in the scientific field for their veracity.

Limitations
The authors identified the low number of articles analyzed as a limitation of this systematic review. If the authors conduct another systematic review on the same topic, they would like to have a larger analysis pool. This could be achieved by broadening the years of study in the selection or by reducing the threshold of quality. However, the additional years of study would only repeat the results from previously published reviews of a similar topic, and lowering the threshold of quality would introduce articles with dubious results.
Although not intentional, the authors realized that selection bias may be present in this article. To combat selection bias, the authors worked to minimize its effects by ensuring each article was reviewed by at least two authors. The authors held consensus meetings after each screening to provide feedback and reach total agreement on the inclusion and exclusion of articles for the analysis.
Another source of bias that could have affected this article is publication bias. To control for publication bias, the authors searched the Boolean search string in Google Scholar. This action was intended to identify articles from lesser-known journals that may not have appeared in MEDLINE or CINAHL.
Another limitation is our inclusion of people aged 50 years or above in the study of older adults. Most studies categorize older adults as those aged 65 years or above. The elderly population currently spans baby boomers and the silent generation. The youngest members of the former group are still working and are most likely using technology fluently. It is possible that our generalizations do not apply to all members of the elderly demographic.

Future Research
Health care systems can utilize knowledge of these barriers to develop solutions for broadening the use of telehealth among older adults. A multidisciplinary approach and culture of collaboration between administrative leadership and providers may be the most effective and immediate manner of implementing solutions to breach these barriers and strengthen the reach of health care services. However, some barriers may be out of the scope of impact, and policy makers should consider supporting the efforts. Future research should be conducted on methods for personalizing telehealth in older adults before implementation.

Conclusion
Providing sufficient health care access to the rapidly growing aging population has been an imminent issue, and telehealth is a useful tool that can provide a solution. While health care systems increase their telehealth efforts to improve access to health care services among vulnerable populations, such as older adults, some health care organizations do not consider the technological, educational, financial, and behavioral barriers before implementing telehealth solutions. It is imperative that health care systems use a multidisciplinary approach and collaborate with health care providers, community partners, and policy makers to address these barriers of utilizing telehealth among older adults and to successfully implement telehealth solutions. This systematic review provides some understanding of older adults' perspectives and experiences with the barriers of implementing telehealth services.