Use of telemedicine and e-health in disasters: a systematic review

)) OR ((""Telemedicine""[Majr:NoExp]) OR ""Telecommunications""[Majr:NoExp]))) AND ((((((((((((((((((((((""mass disaster""[Title/Abstract]) OR hazard[Title/Abstract]) OR hurricane[Title/Abstract]) OR tsunami[Title/Abstract]) OR disaster[Title/Abstract]) OR ""natural disaster""[Title/Abstract]) OR accidents[Title/Abstract]) OR ""mass casualty incidents""[Title/Abstract]) OR emergencies[Title/Abstract]) OR earthquake[Title/Abstract]) OR avalanche[Title/Abstract]) OR ""cyclonic storms""[Title/Abstract]) OR hurricane[Title/Abstract]) OR drought[Title/Abstract]) OR flood[Title/Abstract]) OR landslide[Title/Abstract]) OR ""tidal waves""[Title/Abstract]) OR tsunami[Title/Abstract]) OR tornado[Title/Abstract]) OR wildfire[Title/Abstract])) OR ((((((((""Disasters""[Majr:NoExp])) OR ""Natural Disasters""[Majr]) OR) OR ""Accidents""[Majr:NoExp]) OR ""Disaster Medicine""[Majr:NoExp]) OR ""Mass Casualty Incidents""[Majr:NoExp]) OR ""Emergencies""[Majr:NoExp]))" Embase #1 hazard:ti,ab,kw OR tsunami:ti,ab,kw OR disaster:ti,ab,kw OR 'natural disaster':ti,ab,kw OR accident:ti,ab,kw OR 'mass disaster':ti,ab,kw OR emergency:ti,ab,kw OR earthquake:ti,ab,kw OR avalanche:ti,ab,kw OR hurricane:ti,ab,kw OR 'cyclonic storms':ti,ab,kw OR drought:ti,ab,kw OR flood:ti,ab,kw OR landslide:ti,ab,kw OR 'tidal waves':ti,ab,kw OR tsunami:ti,ab,kw OR tornado:ti,ab,kw OR wildfire:ti,ab,kw #2 telemedicine:ti,ab,kw OR telehealth:ti,ab,kw OR mhealth:ti,ab,kw OR 'mobile health application':ti,ab,kw OR 'm health':ti,ab,kw OR 'e health':ti,ab,kw OR 'telecare medical information system':ti,ab,kw OR telecommunication:ti,ab,kw OR ehealth:ti,ab,kw OR telecare:ti,ab,kw

information is a critical issue that crisis managers face after catastrophic events. (8). If accurate and timely information is made available, unwanted morbidity and mortality may be prevented. Communications are essential requirements to establish contact with the outside world in a disaster management process (9).
It seems that by using IT in disaster management we can detect the risks of disasters and suggest practical solutions in order to save the lives of people and reduce damages (10).
Telemedicine is one of the latest developments in information technology and communications.
Telemedicine, with its unique features, can provide a quick response to essential needs in the event of a disaster (11). For example, in an infectious disease outbreak, remote tracking of care can be utilized quickly and readily through information technology (12) Army programs, space programs, and various government agencies have gradually developed telemedicine programs, testing them in real, simulated emergencies in the face of civilian disasters (13).
The first application of wireless telemedicine in the disaster was the National Air and Space (NASA) in the 1985 Mexico City earthquake, which destroyed all terrestrial communication infrastructures. The use of advanced communications satellite (ATS-3) voice transmission was the only possible option for international rescue organizations. Also, a space bridge was built during the earthquake in Armenia. The virtual bridge enabled global satellite communications between various countries, including Russia and the United States, in those times (8). Evidence shows that there has been a significant increase in the use of multiple cases of telemedicine successfully in the multinational disasters. With the COVID-19 pandemic of 2020, however, the application of telemedicine and its ability to provide safe, rapid, and high-quality care is apparent (14).
But any action in the use and development of telemedicine must be based on evidence. Its functions and quality of control measures should be evaluated and reported to identify strengths and weaknesses and be integrated into continuous use in critical and standard situations (14).
Therefore, the purpose of this systematic review was to gather information for future research and identify the use of telemedicine in disasters with the following research questions: 1.
In which phase of disasters, telemedicine services were used? 2. Which subtype of telemedicine system was used? 3. Which kind of telecommunication technology was employed?

Methods
This systematic review was undertaken to identify studies focusing on telemedicine and e-health systems in natural and man-made disasters.

Data sources
We searched PubMed, Web of sciences and, Scopus databases without time limitation for relevant papers in English until May 2020.

Search strategy
In searching these databases, two groups of key terms were used: (A) key terms denoting disaster concepts including mass disaster, hazard, hurricane, tsunami, disaster, natural disaster, accidents, mass casualty incidents, emergencies, earthquake, avalanche, cyclonic storms, drought, flood, landslide, tidal waves, tornado, and wildfire; (B) key terms denoting telemedicine concepts including telemedicine, telehealth, m-health, mobile health, e-health, telecommunication, and telecare.
To search databases, in advanced search part of each database, we used "OR" to combine terms in groups A and B separately, then, we combined results from two groups using "AND" operator to accumulate all the studies about the telemedicine in disasters (Table 1).

Inclusion and exclusion criteria
Once the titles and abstracts of the identified articles were obtained, two evaluators independently reviewed and assessed the retrieved publications against the following predefined inclusion and exclusion criteria. Special emphasis was given to articles developing telemedicine or e-health systems in different phases of disaster. Systematic reviews, letter to editor, non-English papers, and studies that did not use telemedicine system in a disaster were excluded from the study.

Data selection, extraction, and analysis
After searching databases, two reviewers independently selected the articles first by title and abstract and then by full-text review. Then, according to the predefined inclusion and exclusion criteria, relevant articles were selected. Disagreements were discussed between reviewers and in case of any disagreement, a third person was negotiated. Finally, two reviewers extracted relevant information for each article, and then analyzed data using descriptive statistics.

Summary of the selected literature
A total of 6300 articles were originally retrieved from the search strategies. A total of 1810 duplicates were removed, leaving 4490 articles to screen. Of these, 16 met our inclusion criteria and were finally analyzed. Publication dates ranged from 2005 to 2018, with the majority of literature published from 2006 to 2020. Important findings were grouped into three main categories: type of telemedicine system, type of telecommunication technology, and the phase of a disaster in which telemedicine was used ( Figure 1).

Geographical focus
Most of the studies were conducted in united states of america (50%) , and after that in asian countries (43%) (see Table 2 ). Two studies (11%) discussed telemedicine and e-health in disasters that happened in the continent of Australia (one in Australia and one in New Zealand). Also, one study addressed the telemedicine system in Africa, including three nations (Guinea, Liberia, and Sierra Leone).

Types of outbreaks
The use of telemedicine in a disaster was another common thread within this theme. The specific type of disaster addressed most frequently in the reviewed studies was hurricane with 6 citations out of the 16 (37.5%). Three articles (19%) specifically addressed war, two highlighted the development of telemedicine in the tsunami and two addressed earthquakes. Disasters including bushfire, debris flow, and terrorist attack were just addressed in one study (6%). Overall, most studies highlighted the use of telemedicine in natural disasters (75%), and only four discussed it in man-made disasters like war and terrorist attacks.

Type of telemedicine system and telecommunication technology
A focus on the type of telemedicine system was the most prominent theme identified in the literature. Six (37%) papers specifically addressed the telemedicine system used for assessment, diagnosis, and treatment of mental disorders, including depression, anxiety, and PTSD in the post-disaster phase. Six of them were related to the telemedicine system for a visit and triage patients with every symptom during and after a disaster. Tele-radiology, tele-ICU, tele-rehabilitation, and tele-monitoring were discussed accordingly. The results of the studies showed There was no intervention and use of telemedicine 67 articles excluded due to: • Full-text was not available • Used telemedicine system just in a simulated environment, not in the context of any disaster     that in 12 studies (75%), telecommunication technology was internet-based, telephone based technology (call back & SMS) discussed in two studies and the satellite was the technology used for communication in one study.

Phase of disaster
Of 16 articles, 13 articles (81%) focused on the use of telemedicine in post-disaster phase. two articles reported the use of telemedicine services in all three phase of disaster, and in one article, it was used just in during and response phase of disaster.

Discussion
In disasters, both short-term and long-term interventions are needed to reduce morbidity and mortality among affected populations. Modern Information and communication technologies could be incorporated in disaster preparedness, response and recovery operations and functions (31).
In this systematic review, we investigated the use of telemedicine and e-health systems in four phases of disaster management including reduction, preparedness, response, and recovery. According to our results, in majority of the studies, telemedicine was used in the postdisaster or recovery phase. A short time after the response phase, local governments try to recover residents and get them back to their normal life. For example, experiences of some natural disasters in 2018 show the importance of information systems in coordinating and managing of available resources after response phase (32).
Despite the great potential of telemedicine, it has not been used satisfactorily in all phases of disaster, especially during the disaster and response phases. In most studies, advances in technological communications and telemedicine and its subdomains were in the recovery phase, especially in the field of mental health. The study results show that most of the telemedicine services are related to tele-mental health. It seems that mental disorders are prevalent during or after a disaster. Evidence indicates that survivors of natural disasters may experience several effects on their mental health (33). Common post-traumatic stress responses include psychological distress, physical pain, hyper arousal, behavioral changes, and heightened anxiety (34). After a disaster, many problems can lead to mental disorders. These problems include economic issues, infrastructure damage, house breakdown, and loss of family. These problems have been significant secondary stressors over the subsequent years (35).
On the one hand, early action following a disaster that efficiently reduces such incidents may be of great benefit (33). On the other hand, interventions administered several weeks after the event appear to be related to improved short-term rehabilitation (36). So, tele-mental health can provide early mental health services and help people cope with their psychological problems during or after a disaster. Tele-mental has been used in different disasters, including earthquakes, terrorist attacks, tsunami, and hurricanes.
Telemedicine visits are other kinds of standard telemedicine services. Telemedicine visits can serve millions of patients and support those seeking emergency care through natural disasters (15). During or after a disaster, telemedicine visits may promote treatment that would otherwise be unavailable due to distance, impassable highways, emergency shutdowns, or increased demand for health services (37). Based on our results during two hurricanes, telemedicine visits were used to care for people impacted by this event.
Other telemedicine services have been used in different disasters. These services are tele-ICU, tele-rehabilitation, tele-radiology, tele-monitoring, and tele-health. All these services can be useful in providing diagnosis, treatment, and consultation to survivors of disasters in the early days.
Telemedicine services can be provided on different telecommunication technologies such as the Internet, telephone call, and short message service (SMS). Most telemedicine services are provided using the Internet. An Internet-based approach to telemedicine can offer a cost-effective way of delivering health services and provide a telecommunication technology for long-term care treatment that promotes contact, personalization, and education between patients and physicians (38). Moreover, the Internet can improve healthcare quality and decrease the cost of delivering healthcare (39). The growth of internet-based communication technologies, including email, the worldwide web, and social media telecommunication technologies such as Twitter, Facebook, and YouTube have facilitated telemedicine services (40). Other telecommunication technologies to deliver care are a phone call and SMS. However, these telecommunication technologies have limitations. For example, sending radiology images or medical reports is impossible.
The goal of this study was to discuss the usefulness of telemedicine technology and emphasize that the creation of a disaster preparedness plan that incorporates the available technologies will enhance disaster response efforts.
This study had some limitations due to its explorative nature. The selection of articles may have some reviewer biases. To overcome this limitation, we involved multiple reviewers for the selection and the subsequent analyses. Also, the interpretation of results must be with caution as studies with different methods were included in our investigation.

Conclusion
In this systematic review we investigated the use of telemedicine in disasters. Based on the obtained results, telemedicine technology was not used in all disaster phases equally. Therefore, efforts should be made to encourage the use of telemedicine for effective and quality care in all phases of a disaster, especially in the response and recovery phases. It is now time for policymakers, disaster preparedness teams, technology researchers, and the medical community to create effective disaster management plans to use cost-effective technologies for disaster preparedness, response, and recovery. We believe that the use of information technology such as telemedicine can strengthen disaster managers such as local authorities and policy makers before, during and after disasters.