- Yes, as already mentioned, some ethnic groups (cultural or religious), though unlikely, might refuse such interference;
- In rare cases there is a risk of damaging the socially disadvantaged segments of the population, leading in turn to a prerequisite for social discrimination by making telemedicine a potential new form of access discrimination;
- In comorbid older patients, having more or slightly pronounced mental deficiency, handling smartphones would pose some difficulties due to the need of specific technical knowledge and skills. This technology may prove inaccessible to other groups, as well, particularly those with visual or auditory impairments.
From SOC Domain Team:
A lack of effect for the intervention could be the cohort of HF patients which is usually older and has a special experience with their nature of illness. These are not the baby boomers more experienced with technology and with more sophisticated means of monitoring their health as they age. [Schwarz 2008] In opposite to this the study of Lind  asked for the experiences in using the telemonitoring structure for daily reporting of the health status and patients answered that they quickly were able to manage it and felt empowered and increased their own participation. Fourteen patients (11 men, mean/median age 84/83 years at inclusion) diagnosed with HF, NYHA class II-IV, with a median of two previous hospital admissions during the last 12 months were included in the study. Authors analysis of the interviews allowed to focus on the fact that technology in general, including computers and mobile phones, was regarded at the beginning as “not interesting” and “a bit scaring” but digital illiterate patients expressed admitted that they were going to miss a lot of information this way. During the study the patients began using new daily routines for the reporting of assessments and measurements, and they thought that handling the equipment digital pen was an easy task. According to Lind et al. the HF patients in their study had no experiences of using the internet but quickly accepted and managed to handle the digital pen technology for daily reporting of their health status, making them more empowered and increased their own participation. The study shows that, „given that technologies are tailored to specific patient groups, even “the digital illiterate” may use“ them. [Lind 2014].
In thier qualitative study Lynga et al. did a typology of the patients and linked their habitual status to the telehealth results. There were different ways in understanding the telemonitoring in a dominating or non-dominating way. The five women show a higher summary of points (1 or 2 crosses on table 1) in the habitual category than the 15 men (7/5 versus 12/15, respectively) leading to the assumption that they got the daily weight measure easily into daily routine.
The study of Seto  mentioned the young average age of their study participants and the possible bias by positive attitudes towardas telehealth, „however, the participation refusal rate was very low, which suggests that the bias was minimal. Finally, the mobile phone-based remote monitoring system that was proposed to the participants had functionality that was beyond what is available in current best practice“. [Seto 2010]
Seto  also mentioned the lack of continuity for telemonitoring patients going on vacation without bringing the monitoring equipment with them. On average, every phone call was associated with an increase in perceived health, indicating that the overall process was responsible for the improvement of participants’ health states. Considering the fact that there were significantly more contacts for participants with poorer initial perceived health, it was suspected that there is an effect of severity (NYHA stage) on the outcome variables. However, there wasn’t any evidence for a negative impact of NYHA status on participants’ development over the course of counseling. [Boehme 2012]. The study participants in the study of Brandon 2009 all (100%) had annual income levels < 20.000 $ (median income in this county = 30.952 $), were mainly (7/10 in the intervention group, 8/10 in the control group) high school (with or without degree) or lower level, only 30% of the participants had some college or postgraduate study. In the intervention group 70% were female. There was also an option for cardiac rehabilitation education after discharge from hospital only for those patients who had access to transportation. [Brandon 2009]