Background and context: Distance spanning solutions and environmental sustainability

There is no consensus on the definition of sustainable health care and care despite increasing global interest in them (Pereno & Eriksson, 2020; see endnote 1). Any attempts to define them are complicated by the diversity of services and patient/client groups, technologies and systems, programmes and infrastructure, and the fact that services are offered and used in different ways and in different circumstances and environments, ranging from homes to various institutional settings. However, the Nordic countries form a relatively homogeneous region in this regard. According to Nordic Innovation (2019), sustainable healthcare covers 

Knowledge is also needed on what sustainable digital healthcare and care services, such as distance spanning solutions, are like and how they are defined (e.g. Faggini et al., 2019). There are both challenges and opportunities in the way in which digital technologies are integrated into existing healthcare and care services and systems – or how new services are initiated. Contextual factors such as funding, organisational support and people’s individual abilities, capacity and education affect integration (e.g. Jungwirth & Haluza, 2019; Stanford et al., 2023). 

The digitalisation of health care and care-related processes and improved cooperation between, for example, hospitals and product suppliers can help to reduce the carbon footprint. Improved availability of data may make decision-making in hospitals and healthcare centres more effective. There must also be focus on the sustainability of materials used in buildings and materials of the technology to be utilised, which emphasises the need for procurement expertise. (Nordic Innovation, 2019) However, sustainable healthcare and care should not only be seen in the context of situations in which a person has already become ill and is a care receiver; the early introduction of proactive digital services in home environments could make it possible to benefit more from the positive potential of digitalisation (Melkas et al., 2020).

In recent years, there have been several studies on the topic of the carbon footprint of telemedicine (e.g. Thiel et al., 2023). The increase in the use of such solutions during the COVID-19 pandemic has affected this recent research (e.g. Ohannessian, Duong & Odone, 2020; Greenhalgh, Koh & Car, 2020). The studies have concerned very different kinds of systems. The researchers have typically focused on benefits, such as avoided patient transfer. Schmitz-Grosz et al. (2023), for example, found that overall, a physician-operated telemedicine centre with a high patient volume showed a negative CO₂ balance with saved CO₂e emissions. 

In a systematic review of whether telemedicine reduces the carbon footprint of health care, Purohit, Smith and Hibble (2021) noted the extensive research into the effectiveness, cost and perceptions of telemedicine, while only few studies have assessed the environmental impacts (apart from stating a reduction in travel time). Purohit and colleagues divided the publications into three categories for analysis: telephone synchronous, video synchronous and asynchronous. They compared travel distance saved (average travel saving ranged from about one kilometre to 901 kilometres) with the carbon footprint reduction per telemedicine consultation. Some of the studies also accounted for the carbon footprint of the telemedicine equipment. Purohit et al. (2021) concluded that the reported benefits were primarily travel-associated savings that greatly outweighed the carbon footprint of the telemedicine equipment (see endnote 2). Most of the studies did not include the carbon footprint of the telemedicine service, and Purohit and colleagues also listed several other limitations.

Health care and care are increasingly affected by so-called emerging technologies, such as robotics, artificial intelligence and automated systems. While opportunities have been recognised in healthcare and care services, the use of robots, for instance, is still relatively rare (Pekkarinen & Melkas, 2019; Pekkarinen et al., 2019). The Finnish Ministry of Transport and Communications has assessed that with the help of new solutions implemented using these technologies, such as robotics and their support technologies (e.g. cloud services), the negative environmental impacts of health care and care, and other sectors, could be decreased (LVM, 2020). However, thus far, there have been few impact assessments and it has been noted that the use of AI requires various resources that have negative environmental impacts (OECD, 2022), while recent literature focuses on and emphasises the benefits of AI in climate change adaptation (e.g. Filho et al., 2022).

Distance spanning solutions can reduce the workload of home care visits even in situations in which the number of clients increases. In Finland, the development of distance spanning solutions is related to the policies of the Ministry of Social Affairs and Health and ongoing legislative reforms. In 2022, approximately 194,000 clients were receiving home care in Finland. Of the home care clients, 59% of them used home care services regularly and 46% used them often and were clients of the so-called intensive home care. 

The need for regular home care increases with age. Of the population in the age group 75–84 years, 8% received regular home care services; in the age group 85–94 years, 30% received regular home care services and in the age group over 95 years, 57% received regular home care services. The share of clients receiving regular home care services varied across wellbeing services counties. In the age group 85–94 years, the share was smallest in the Päijät-Häme wellbeing services county (22%; the context of this study), whereas in some counties, the share was as much as 40%. Over half (59%) of the clients in regular home care received at least one home visit per day, and 17% received three or more home visits per day. (THL, 2023)

One third of staff in elderly care services work in home care (THL, 2021). Almost all (96%) home care contacts in 2022 were visits by a professional caregiver at the client’s home. 4% of the contacts were conducted remotely, and most of these were real-time connections using distance spanning solutions (THL, 2023). Medicine robot services are one example of distance spanning solutions used in home care in Finland, the other Nordic countries, and elsewhere.

Medication is an important part of healthcare and care systems. Medicine robot services have been developed to assist patients and clients in homes and hospitals or other healthcare and care settings. With the help of a medicine robot, home care clients, for example, receive their regular medication in a timely manner, packed into unit doses.

Typically, an alert sounds when it is time for the client to take their medication, and if they miss a dose during the set period due to forgetfulness, a message stating that they did not take their medication is sent to the relevant persons, such as the client’s professional or informal caregivers. 

Several commercial products are available, as well as preliminary or working prototypes (Gargioni, Fogli & Baroni, 2024) and the related services are organised in different ways in different national healthcare and care systems (e.g. Iqbal et al., 2021). The management of older people’s medication can be particularly challenging due to an increased prevalence of multimorbidity, changes in pharmacokinetics and pharmacodynamics, and clients or patients experiencing problems handling their medication due to a physical disability and/or cognitive impairment (Iqbal et al., 2021). The aim of medicine robot services is to improve medication safety and adherence but also to assist professional caregivers by reducing their workload (e.g. Turjamaa, Kapanen & Kangasniemi, 2020). They can also improve the self-management and independent living of older persons (Tian et al., 2024).

In recent years, medicine robots have gained increasing attention among researchers in different countries, partly because of the special circumstances resulting from the COVID-19 pandemic (e.g. Krishna et al., 2021). Gargioni et al. (2024) recently conducted a systematic review of (what they term) pill and medication dispensers from a human-centred perspective. They concluded that research is often focused on hardware and/or software technology. Human-centred perspectives are overlooked, such as the impacts on the various stakeholders (patients, caregivers, medical doctors, etc.), which they note is crucial to achieve technology acceptance and relevant benefits. They called for comprehensive socio-technical healthcare solutions that involve the use of medicine robots, and showed that several gaps exist in the design, development and deployment of such solutions. 

According to Gargioni et al. (2024), the most important open issues and challenges are solution scalability, system integration, authentication and security, dependability and safety, user experience and personalisation. They limited their research to the period from 2013 to 2023, as well as research on Scopus. They did not discuss sustainability or environmental or climate impacts (see also Turjamaa et al., 2020), and a review of the literature suggests that, to date, those have not been the focus of previous research. 

Home care-related studies were recently conducted by Suzuki, Takahashi and Tofukuji (2024), and Iqbal et al. (2021). In an experiment conducted in Japan with one older patient with diabetes living in a residential home, Suzuki et al. (2024) found that the medicine robot was effective in facilitating medication adherence. A qualitative case study by Iqbal et al. (2021) adopted a systems thinking approach and explored the implementation and deployment of a robotic system for medication management for municipal home care services in Sweden. They emphasised the need for holistic medication management that requires communication, coordination and effective information sharing among network actors and across different settings, as well as the role of the care personnel and key stakeholders involved in these processes. 

Iqbal et al. (2021) also noted that it is challenging for service providers, such as municipalities, to develop and adopt medication management solutions, since additional work procedures need to be in place for care personnel, who also need to adjust to a different type of telepresence relationship with clients or patients. In addition, management and maintenance issues regarding the system and its interface with support services need to be addressed. Another Nordic study on Finnish home care reported the safety profile and usability of medicine robot services and their acceptability to patients and nurses (Rantanen et al., 2017). Turjamaa et al. (2023) also focused on the experiences of Finnish professional caregivers. 

In their study on sustainable healthcare systems, Iqbal et al. (2021) referred to the environmental perspective by noting that home visits by nurses to administer medication only should be reduced, as fewer visits to patients’ homes would involve less use of vehicles, which is environmentally friendly, sustainable and cost-effective in terms of work/life balance and overall impact on society. Their approach to sustainability was to link medication management robotic systems to the UN’s SDGs, of which they had selected 3, 4 and 9 (for other SDG-related perspectives, see Carson et al., 2021).