Conducting a Global Quadruple Aim Thematic Analysis of Telemedicine Performance in Rural Indigenous Populations and Evidence-based Recommendations for Improvement

Hussain Ali Naqvi

Affiliations: Student, University of Waterloo, Waterloo, Canada

Keywords: health policy, indigenous, quadruple aim, rural health, telehealth, telemedicine

Section: Narrative/Systematic Reviews/Meta-Analysis

Citation: Telehealth and Medicine Today 2022, 7: 301 - https://doi.org/10.30953/tmt.v7.301

Copyright: © 2022 The Authors. This is an open access article distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, adapt, and enhance this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See http://creativecommons.org/licenses/by-nc/4.0.

Received: September 28, 2021; Revised: October 13, 2021; Accepted: November 03, 2021; Published: January 31, 2022

Funding Statement: I wish to confirm that there has no financial support or funding for this research paper that could have influenced its outcome. This research did not receive any specific grant or funding from funding agencies in the public, commercial, or not-for-profit sectors.

Financial and non-Financial Relationship and Activities: I wish to confirm that there are no known conflicts of interest associated with this research.

Corresponding Author: Hussain Ali Naqvi, Email: hussainalinaqvi@hotmail.com

Abstract: The literature on electronic information and telecommunication technologies reveals that telehealth houses many elements of support, benefit, and care delivery into rural indigenous communities. As per the Canada Health Act (1984), healthcare must be equally accessible for all groups without significant accessibility costs, and that healthcare must incorporate all “medically necessary” healthcare services that a population requires. This article uses the quadruple aim to present a thematic analysis regarding patient experience, the health of populations, provider experience, and the cost per capita of telehealth into rural indigenous communities.

Ever since the Canada Health Act was passed as legislation in 1984 with the objective of protecting, promoting, and restoring the physical and mental well-being of Canadians, as well as facilitating reasonable access to health services without barriers, all provinces and governments have been obligated to meet the five key principles.¹ These principles are: public administration, accessibility, comprehensiveness, universality, and portability.¹ While arguments can be made regarding how well these principles have been followed throughout the last three decades, there is a consensus among policy experts about the utter denial and failure of the federal government in being consistent with the principles of accessibility and comprehensiveness when delivering care to first nations on reserves in rural communities.² As per the Canada Health Act, accessibility and comprehensiveness represent the concept that healthcare must be equally accessible for all groups without significant accessibility costs, and that healthcare must incorporate all “medically necessary” healthcare services that a population requires.² In fact, over 50% of first nations community members report not having access to relevant medical services.³

Through telehealth, patients and providers can see each other virtually to conduct remote medical consultations, and with the implementations of robotic diagnostic devices, the provider can maneuver this technology to adequately assess a patient at their local community/testing center.⁴ This technology has enabled a diversity of providers to consult with rural patients, increasing the accessibility to care for many of these populations.⁴

Despite the implementation of telehealth, many concerns remain, and new one’s continued to arise.⁴ Issues such as clinical care quality, sustainable implementation, provider ease, and costs continue to rise to the forefront in clinical practice and literature.⁴ These issues are consistent with the themes of the Quadruple Aim.⁴ The quadruple aim is an extension of the Triple Aim developed by the Institute for Healthcare Improvement which comprises four key principles⁴:

Patient Experience
Health of Populations
Per Capita Cost
Provider Experience

As such, this paper seeks to conduct a quadruple aim thematic analysis in a review format to decipher concerns regarding patient experience, the health of populations, provider experience, and the cost per capita of telehealth delivery in rural first nations communities.

METHODS

The research for this paper was conducted through the Medline database. All searches were conducted in September 2021.

To conduct a review-based search of the literature on the four concepts embedded within the quadruple aim, the following terms were used in variation: “telemedicine,” “telehealth,” “first nations,” “aboriginals,” “indigenous,” “patient,” “population,” “population health,” “cost,” “finance,” “economics,” “healthcare providers,” and “providers.”

A detailed breakdown of the terms and extracted papers can be observed in Table 1.

*Table 1*. *Variations of the search terms used to identify relevant research articles as part of this study*
Search Terms	Article(s) Yielded	Month/Year of Search
telehealth OR telemedicine AND aboriginal AND patient	Outcomes of using telehealth for the provision of healthcare to Aboriginal and Torres Strait Islander people: a systematic review	Sep-21
	A cost-consequence analysis comparing patient travel, outreach, and telehealth clinic models for a specialist diabetes service to Indigenous people in Queensland	Sep-21
	Enablers and barriers in providing telediabetes services for Indigenous communities: A systematic review	Sep-21
	An evaluation of the telehealth facilitation of diabetes and cardiovascular care in remote Australian Indigenous communities: - protocol for the telehealth eye and associated medical services network [TEAMSnet] project, a pre-post study design	Sep-21
	Validation of the Kimberley Indigenous Cognitive Assessment short form (KICA-screen) for telehealth	Sep-21
	Uptake of telehealth services funded by Medicare in Australia	Sep-21
	Barriers to Telehealth Uptake in Rural, Regional, Remote Australia: What Can Be Done to Expand Telehealth Access in Remote Areas?	Sep-21
	A mobile telemedicine-enabled ear screening service for Indigenous children in Queensland: activity and outcomes in the first three years	Sep-21
	The Cedar Project - Mobile Phone Use and Acceptability of Mobile Health Among Young Indigenous People Who Have Used Drugs in British Columbia, Canada: Mixed Methods Exploratory Study	Sep-21
	The use of remote presence for health care delivery in a northern Inuit community: a feasibility study	Sep-21
	The use of remote presence for health care delivery in a northern Inuit community: a feasibility study	Sep-21
	Positive Clinical Outcomes Are Synergistic With Positive Educational Outcomes When Using Telehealth Consulting in General Practice: A Mixed-Methods Study	Sep-21
	Increasing the impact of teleophthalmology in Australia: Analysis of structural and economic drivers in a state service	Sep-21
	Videoconferencing could reduce the number of mental health patients transferred from outlying facilities to a regional mental health unit	Sep-21
telehealth OR telemedicine AND first nation AND population health telehealth OR telemedicine AND indigenous AND population health	Telehealth and indigenous populations around the world: a systematic review on current modalities for physical and mental health	Sep-21
	Specialist cancer care through telehealth models	Sep-21
	An economic cost analysis of an expanding, multi-state behavioural telehealth intervention	Sep-21
	Patient and practitioner satisfaction with tele-dermatology including Australia’s indigenous population: A systematic review of the literature	Sep-21
	Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities	Sep-21
	A cost comparison of travel models and behavioural telemedicine for rural, Native American populations in New Mexico	Sep-21
telemedicine AND cost AND aboriginal		Sep-21
telemedicine OR telehealth AND cost AND indigenous	The socio-economic impact of telehealth: a systematic review	Sep-21
telemedicine OR telehealth AND finance AND indigenous		-
telemedicine OR telehealth AND economics AND indigenous		-
telemedicine OR telehealth AND healthcare providers OR providers AND indigenous		-

An inclusion and exclusion criteria were also developed as presented in Table 2.

*Table 2*. *The inclusion and exclusion for literature as part of this study*.
Inclusion Criteria	Exclusion Criteria
Country of study, or health system of study must be a part of an Organisation for Economic Co-operation and Development (OECD) country	Country of study or health system in study is not part of an OECD country
Literature must be in English	Literature is not in English
Literature must be published in 2010 or be published later	Literature is published before 2010
Literature must be in line with one of the themes of the quadruple aim: Patient Experience Health of Populations Per Capita Cost Provider Experience	Literature does not fit atleast one of the themes of the quadruple aim

Papers were short-listed based on the relevance of their title and abstract to the contents of this paper. Selected papers were then categorized into the respective domains of the quadruple aim they would fall into (i.e., patient experience, population health, per capita cost, and provider experience). Often, one paper would fall into more than one domain; duplicate citations were managed through a sequential order. A summary and key data were then extracted from the papers and can be observed in Table 3.

DISCUSSION & RECOMMENDATIONS

Patient experience

Access to care

There has been a consistent presence of the increased accessibility components that telehealth offers to remote populations, particularly the ease of access presented through the avoidance of long travel times.^5,6,7 Generally, patients mentioned travelling into large regional facilities to receive basic healthcare screening, diagnosis, and care.^5,6,7 Travelling to these facilities was accompanied with long road-trip times, averaging more than 2 to 3 hours.^5,6,7 In fact, when it came to specialist care, patients mentioned that often they would travel to the point where they would have to spend the night at another facility.^5,6,7 As a result, patients would often avoid accessing specialist care, leading to a significant increase in chronic disease.⁷ For example, in a remote Australian community, the implementation of an ear-screening service with a specialist improved screening rates in children in Australia from 35% to 80%.⁸ Consequently, specialist waiting time was reduced to an average of 29 days from 64 days.⁸ Problems, however, did arise for many other specialties where consultations would be taking place from home.^7,8 As a result of poor telecommunications network in aboriginal care, many patients cited that appointments would be re-scheduled, or video quality would be poor when conducting diagnostic assessments and consultations.^6,8 It’s recommended to policy makers, therefore, based on the national survey for the Broadband for the Bush Alliance (B4BA) to make significant investments into telecommunications technology to be implemented in rural regions.⁸ When providers and patients can use this technology at an affordable subscription-based price, it can offer telecommunications providers the opportunity to make staunch revenues.^8,9

Patient perceptions

Throughout literature, the response that indigenous groups have had towards telehealth has been positive and effective.⁹ In fact, in a cognitive assessment telehealth clinic, patients rated telehealth services higher than in-person services; 4.86 out of 5.0 versus 4.5 out of 5.0, respectively.⁹ Patient perceptions, however, were hindered in the realms of diagnosis, quite significantly, where 20% of patients found telehealth to be ineffective and inaccurate as compared to in-person testing.⁷ In the instance of tele-dermatology, patients feared that telehealth technology would miss critical diagnostic data that a doctor would not.⁷ Many of these concerns are motivated by a strong fear linked to physical presentability in dermatology, but similar results were observed in cardiology, endocrinology, and mental health diagnosis.^7,8,9 In particular, diagnosis that require a physical examination from the provider are regularly questioned by rural and indigenous patients, many of whom are not familiar with clinical technology and do not trust it.^7,8,9 To add to that, patients who regularly require diagnosis that requires physical touching, are far more likely to pursue conventional treatment over telemedicine.⁵ As garnered by a systematic review, changing patient perceptions on telemedicine and its diagnostic accuracy requires a thorough intervention from local community health centers through community leaders who can explain to populations about the convenience, safety, and accessibility with telehealth diagnosis; past strategies have even increased telehealth acceptance from 30% to 70%.⁷

Care quality

According to clinicians, and even in accordance with patient perceptions, the efficacy of telehealth in delivering safe and quality healthcare was found to be the same as conventional treatment methods.⁵ Ironically, in some indigenous groups, telehealth resulted in more desirable outcomes such as lower blood pressure for patients with hypertension and better glucose levels for those with diabetes.^5,9 This is because, patients who didn’t have to leave their communities to receive care (i.e., through telehealth) were more likely to feel comfortable and avoid the feelings of alienation, anxiety, and distress associated with a regional center that feels “foreign” to them.^5,7,8 Despite bolstered clinical outcomes, issues did arise.⁵ For geriatric care, and in particular, patients with technological accessibility concerns such as older adults and those with hearing difficulties, telehealth utilization could not be performed individually.⁷ For many of these medically marginalized groups having difficulty accessing healthcare, literature mentions the growing need to have clinicians delivering home care or community-level care during telehealth administration with specialists at regional facilities to uphold patient equity.^6,7 Furthermore, in the delivery of care itself, evidence-based interventions were seldom followed.⁶ In fact, in an international systematic review of telehealth studies worldwide, only 40% of telehealth care services in rural indigenous populations integrated cultural and community values.⁶ As a result of this, and as per the health-belief model, patients failed to resonate and engage with providers as well as they could have.^6,7,9 Additionally, this also had the effect of shortening the delivery of care from a recommended 8 to 12 weeks for rural indigenous populations, to an average of 2 weeks.^6,7 Not only are these patterns strong supporters of higher cholesterol levels, higher hypertension rates, and worse mental health, but they also distance providers from rural patients.⁶ Literature urges for increased funding and resources to be supplemented into more thoroughly understanding and implementing aboriginal values, training physicians in regional facilities, and embedding community-based care as part of telehealth delivery.^6,7,8,9

Health of populations

Patient education and awareness

Among the benefits of telehealth are patient education and patient engagement strategies, particularly when patients are keen to bring their families and caregivers with them, further improving the health literacy of a patient’s mesosystem.^5,10 This enhanced health awareness has had the effect of increasing in-patient attendance to community-wide health education programs from 20% to over 85%, on average, in indigenous regions around the world.¹¹ Subsequently, heightened community programming, and patient engagement in telehealth related health promotion endeavors has had the effect of improved screening rates and has bolstered openness about receiving medical treatment.^10,11, ¹² For instance, with a disease as stigmatized and taboo as HIV, over 60% of rural indigenous folks after receiving care services through telehealth, reported being open to receiving treatment and publicly attending engagement and awareness events.¹⁰ While telehealth was initiated to deliver care, it also delivers education to marginalized communities, empowers them to seek care, and even encourages them to be proud of it.¹³

Lowering emergency department visits, waiting times, and patient transfers

In rural indigenous communities, regional center are often over-burdened with patients in the emergency department (ED), and for specialist appointments.^6,7,8 With the incorporation of telehealth, and the vast growth of preliminary screening, ED visits in regional facilities have been reduced by up to a third.^6,7,8 This has also had the effect of freeing up specialists in the hospital who now have more time to conduct care consultations with patients based off appointments.^6,8,9 In fact, waiting times for specialist consultations following the year-long implementation of telehealth have been reduced from 90 days to a range of 4 hours to 3 days in some states.⁸ While this is good for patients in terms of transportation efficiency, it does increase burden upon those sites.¹⁴ Literature encourages investments into software development and EMR (electronic medical record) competency for community members to consult with physicians from their phones through mobile applications.¹⁴ This is believed to reduce the burden and wait times on community health centers for telehealth consultations.¹⁴

Research opportunities

As research into indigenous healthcare, their needs, their preferences, and community-level care are often neglected, so are the biological underpinnings of many diseases such as cancer.¹⁵ There is a great lack of patient data, clinical data, and even behavioral data for aboriginal patients across a variety of chronic diseases including cardiovascular disease, diabetes, arthritis, etc.^10,12,15 This makes it difficult for practitioners to provide care for many indigenous populations and having this data available could advance much development.^10,12,15 Telehealth has been found to provide this patient data, and with enhanced electronic health record (EHR) communications, it can be shared to conduct more population-specific clinical research and analysis.¹⁵

Per capita costs

Up-front investments

Unlike in urban regions where the costs of technological implementation have started to become subsidized and more streamlined with existing telecommunications and technological infrastructure, the opposite is the case for rural indigenous communities.⁸ An investment into the average rural indigenous community is sought to accompany a capital infrastructure cost of $30,000 USD to care for about 1,000 patients.^8,16 Typically, these investments include the development of telecommunications infrastructure, staff training, procedural management, referral management, documentation, clinical standards implementation, billing, and other forms of structural management.¹⁶ Despite a relatively consistent set of fiscal requirements for telehealth implementation across regions, literature observes that most implementations of telehealth in rural indigenous communities don’t follow similar standards of clinical guidelines, financial regulations, or even cost structuring.^16,17,18 Therefore, it’s recommended for policy specialists to fund research and devise evidence-based procedures for incorporating telehealth practices into rural indigenous communities in a more systematic, consistent, and cost-effective manner.^8,16,17,18

Travel costs

Understandably, the most critical cost-savings in telehealth take place in the reduction of travel costs, for both patients and providers.^14,17 On average, travel costs provider into rural communities for consultations or procedure was found to be $85 USD more expensive, per patient, than using telehealth.^14,17 In fact, patient travel was found to be $174 USD more expensive, per patient, than using telehealth.^14,
17

Medical specialties

Surprisingly, while telehealth offers the opportunity of using many medical specialties, geriatric services and psychiatric services are mostly used.¹⁹ Interestingly, chronic diseases—which are mostly prevalent in most of the population—were less used.¹⁹ This includes diseases such as cardiovascular disease, diabetes, kidney disease etc.^12,14,19 As a result, most telehealth services offered, were those of a consultation-based nature, as opposed to a diagnostic or procedural one, even though the technological capabilities are present.^12,14,19 It is also these specialties that require greater clinical resource mobilization such as staff or specific imaging softwares.¹⁹ In consequence, the cost savings with respect to telehealth in literature must be taken with a grain of salt as they do not comprise largely of more costly medical specialties such as cardiology, endocrinology, oncology, neurology, and others.^7,19 In fact, literature has found that patients who had dermatology diagnosis and consultations were more likely to increase costs because they would be transferred to a hospital more frequently because of incorrect clinical analysis.^7,8,9 To account for the cost of these specialties, and to better measure their outcomes, more pilot programs with them must be run to develop a better sense of clinical cost.^7,
19

Preventative care cost reduction

While telehealth houses some complexities in calculating savings, certainly there are elements that can be simply computed.^7,19,20 For instance more thorough and active screening, as well as enhanced monitoring and case management following telehealth implementation have resulted in a 23% reduction in ED admissions at regional facilities from rural indigenous populations.²⁰ In fact, primary care prevention has been effective to the point where children screened for ear issues from a young age through telehealth, were 70% less likely than their counterparts to repetitively present ear problems to their physician.⁸ These populations were also less likely to contract ear disease and infections in communities of poor sanitation, where infections are common.^8,9,20 Furthermore, combining primary and specialist care through integrative rural health models was shown to further improve workflow, enhance patient outcomes, and reduce fiscal barriers.¹⁷ Therefore, the recommendation of rural health integration, fiscal accountability, resource sharing, and clinical-practice standardization is consistently re-emphasized to ensure all facilities in the region are equipped to service the population.²¹ With the implementation of Ontario Health Teams, this can definitely be facilitated with strong legislative support.

Provider experience

Perceptions

Overall, when it comes to telemedicine and telehealth delivery into rural populations, literature shows high favorability among clinicians, healthcare practitioners, and most notably, physicians.^5,21 On a rough aggregate, 84% of physicians enjoyed telehealth deployment in rural indigenous communities and found it to be more effective than traditional, in-person care.²² Because of an increased ease of access, “failed to attend” rates declined, providers noted to use more screening tools which resulted in fewer case complications, and more evidence-based care was being implemented.²² In fact, administrative work also became simpler for clinicians with the implementation of all-in-one EMR solutions.^21,22

Championing indigenous clinicians

While certainly the rates of provider experience through telemedicine have been beyond exceptional, literature does indicate that increasing indigenous healthcare worker participation is essential in facilitating more effective clinical outcomes.¹¹ In fact, the incorporation of indigenous clinicians was found to increase telehealth uptake in these communities from 46% to 75%.¹¹ This is because indigenous clinicians better understand local languages and cultures, and hence connect better with patients.¹¹ More importantly, literature suggests that indigenous clinician-specific training modules be developed by regional hospitals and rural health governing bodies to train indigenous clinicians in delivering healthcare.^21,22 Also, a new role that has emerged would be “clinician liaisons” in community health centers, who facilitate patients in the implementation of telehealth with specialists, through diagnostic examinations, translations, explanations, or technological support.^21,22 Certainly, medical curriculum development for indigenous clinicians in delivering telehealth care to indigenous communities is deemed to be helpful.¹¹

Clinician skillset

A barrier that’s often perceived by system experts against the implementation of telehealth especially into rural communities is often the component of staff, clinician, and physician training with the technology.²² This argument becomes more complex depending on the medical specialty and the increasing web of complications in diagnosis and treatment.²² However, contrary to popular belief, 80% of clinicians found telehealth technology to be easy to learn and understand.²² In fact, in a Northern indigenous study in Canada, a seemingly complex robot used for general diagnostic procedures by general physicians, dermatologists, cardiologists and others, required an hour worth of training to be clinically operated.^8,9,19 Physicians even found some of this technology to be easier and timelier than conducting in-person examinations, leading 84% of nurses to be content with the technology.¹³ Furthermore, with a greater array of information available through teleconferencing on the EMR system, up to 85% of general practitioners acknowledge learning more about other specialties, such as dermatology.⁷ In fact, this can be a great resource for medical students or practitioners in residencies, who can learn greatly about using new healthcare technologies for marginalized communities.¹³

CONCLUSIONS

As illustrated in literature, telehealth certainly houses many elements of support, benefit, and care delivery into rural indigenous communities, which are often deprived of access to quality healthcare. While the existing structures of telehealth bode decently well with conforming to the guidelines of the quadruple aim, there is substantial evidence indicating that investments into telecommunications software, clinical skillsets, population monitoring and awareness as well as integration will help it conform better.

Author’s contribution

As per the “Role of Authors and Contributors” outlined by ICMJE, Mr. Hussain Ali Naqvi meets all four parts mentioned below:

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND
Drafting the work or revising it critically for important intellectual content; AND
Final approval of the version to be published; AND
Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

References

Government of Canada. Canada’s Health Care System. Canada.ca; 2019. Available from: https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html [cited 17 September 2021].
Lavoie JG. Policy silences: Why Canada needs a National First Nations, Inuit and Métis health policy. Int J Circumpolar Health. 2013;72:22690. https://doi.org/10.3402/ijch.v72i0.22690
Ballard D, Cook C, Alix-Roussin A, Gray K. Towards equity in Aboriginal health: An overview of factors impacting the delivery of health services to Aboriginal peoples of Canada. InCongress on Circumpolar Health July 11–16, 2009 Yellowknife, Canada 2010 Jan 1 (No. 7, p. 388).
Muttitt S, Vigneault R, Loewen L. Integrating telehealth into Aboriginal healthcare: The Canadian experience. Int J Circumpolar Health. 2004;63(4):401–14. https://doi.org/10.3402/ijch.v63i4.17757
Caffery LJ, Bradford NK, Wickramasinghe SI, et al. Outcomes of using telehealth for the provision of healthcare to Aboriginal and Torres Strait Islander people: A systematic review. Aust N Z J Public Health. 2017;41:48–53. https://doi.org/10.1111/1753-6405.12600
Dawson AZ, Walker RJ, Campbell JA, et al. Telehealth and indigenous populations around the world: A systematic review on current modalities for physical and mental health. mHealth. 2020;6:30.
Kozera EK, Yang A, Murrell DF. Patient and practitioner satisfaction with tele-dermatology including Australia’s indigenous population: A systematic review of the literature. Int J Womens Dermatol. 2016;2:70–3. https://doi.org/10.1016/j.ijwd.2016.06.004
Smith AC, Armfield NR, Wu W-I, et al. A mobile telemedicine-enabled ear screening service for Indigenous children in Queensland: Activity and outcomes in the first three years. J Telemed Telecare. 2012;18:485–9.
Russell S, Quigley R, Strivens E, et al. Validation of the Kimberley Indigenous Cognitive Assessment short form (KICA-screen) for telehealth. J Telemed Telecare. 2021;27:54–8. https://doi.org/10.1177/1357633X19860309
St Clair, M., Murtagh, D. Barriers to telehealth uptake in rural, regional, remote Australia: What can be done to expand telehealth access in remote areas? Stud Health Technol Inform. 2019;266:174–82.
Wickramasinghe SI, Caffery LJ, Bradford NK, et al. Enablers and barriers in providing telediabetes services for Indigenous communities: A systematic review. J Telemed Telecare. 2016;22:465–71. https://doi.org/10.1177/1357633X16673267
Jongbloed K, Pearce ME, Thomas V, et al. The Cedar Project – Mobile phone use and acceptability of mobile health among young indigenous people who have used drugs in British Columbia, Canada: Mixed methods exploratory study. JMIR mHealth uHealth. 2020;8:e16783. https://doi.org/10.2196/16783
Knight P, Bonney A, Teuss G, et al. Positive clinical outcomes are synergistic with positive educational outcomes when using telehealth consulting in general practice: A mixed-methods study. J Med Int Res. 2016;18:e31. https://doi.org/10.2196/jmir.4510
Buckley D, Weisser S. Videoconferencing could reduce the number of mental health patients transferred from outlying facilities to a regional mental health unit. Aust N Z J Public Health. 2012;36:478–82. https://doi.org/10.1111/j.1753-6405.2012.00915.x
Sabesan S. Specialist cancer care through Telehealth models. Aust J Rural Health. 2015;23:19–23. https://doi.org/10.1111/ajr.12170
Snoswell CL, Caffery LJ, Haydon HM, et al. A cost-consequence analysis comparing patient travel, outreach, and telehealth clinic models for a specialist diabetes service to Indigenous people in Queensland. J Telemed Telecare. 2019;25:537–44. https://doi.org/10.1177/1357633X19873239
Yilmaz SK, Horn BP, Fore C, et al. An economic cost analysis of an expanding, multi-state behavioural telehealth intervention. J Telemed Telecare. 2019;25:353–64. https://doi.org/10.1177/1357633X18774181
Horn BP, Barragan GN, Fore C, et al. A cost comparison of travel models and behavioural telemedicine for rural, Native American populations in New Mexico. J Telemed Telecare. 2016;22:47–55. https://doi.org/10.1177/1357633X15587171
Wade V, Soar J, Gray L. Uptake of telehealth services funded by Medicare in Australia. Aust Health Rev. 2014;38:528. https://doi.org/10.1071/AH14090
Jennett PA, Hall LA, Hailey D, et al. The socio-economic impact of telehealth: A systematic review. J Telemed Telecare. 2003;9:311–20.
Razavi H, Copeland SP, Turner AW. Increasing the impact of teleophthalmology in Australia: Analysis of structural and economic drivers in a state service. Aust J Rural Health. 2017;25:45–52. https://doi.org/10.1111/ajr.12277
Mendez I, Jong M, Keays-White D, et al. The use of remote presence for health care delivery in a northern Inuit community: A feasibility study. Int J Circumpolar Health. 2013;72:21112. https://doi.org/10.3402/ijch.v72i0.21112

Copyright Ownership: This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, adapt, enhance this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0.