The study enrolled participants who requested telemedicine consultation and medication at rural sanitary stations connected to the Department of Guangdong Online Hospital, Guangdong Second Provincial General Hospital, from June 2015 to May 2016. Each participant was informed of what telemedicine was and of the nature of the research and voluntarily signed a consent form before consultation. The participants consulted the remote medicine appliance system and registered with their demographic data including name, sex, age, telephone number, identity card number, historical medical record, and allergic history. The triage staff at the Department of Guangdong Online Hospital referred them to a relevant doctor after assessing and recording their vital signs at the rural sanitary stations. A diagnosis was provided by the doctor, and medical care was delivered to the sanitary station. The doctors prescribed medicine to the participants (medication prescription group), gave professional advice (medical advice group), or suggested that they have a face-to-face consultation with the doctors at a downtown hospital (face-to-face consultation group) depending on the participants’ diseases or syndromes. Prescribed medicines included Western medicines (Western medicine prescription group) and Chinese herbs (herb prescription group). For instance, a patient with a cough consulted with the Online Hospital at a sanitary station. The doctor diagnosed him with chronic bronchitis through inquiry, history medical record, and checking of his vital signs. The doctor prescribed medicine if he were confident of the diagnosis and considered the medicine necessary. The doctor gave professional suggestions such as the patient quit smoking and avoid allergens if he thought it was unnecessary for the patient to take medicine. However, if the doctor was unsure about the diagnosis or thought that the professional advice or medicine prescribed would not alleviate cough, he advised the patient to have a face-to-face consultation with a doctor at a downtown hospital. The communication was mainly conducted in Mandarin and Cantonese; some illiterate patients were assisted by staff at the rural sanitary stations. Satisfaction surveys were conducted immediately after the consultation, and telephone surveys on patient satisfaction, self-reported therapeutic effects, patients’ desire to revisit the Department of Guangdong Online Hospital, patients’ compliance with doctors’ advice, and self-reported difficulties with their telemedicine experience were conducted 2 to 4 weeks after the consultation (Figure 1). Two staff members from the department underwent advanced training to conduct telephone surveys. A full ethics review of the research protocol was conducted by the Institutional Review Board at the Guangdong Second Provincial General Hospital.

This study was launched by the Department of Guangdong Online Hospital, Guangdong Second Provincial General Hospital [13] the first telemedicine institution authorized by the Chinese government. The Department of Guangdong Online Hospital consisting of 24 clinics worked simultaneously with doctors from internal medicine, pediatrics, traditional Chinese medicine, dermatology, rehabilitation, and gynecology departments at the hospital. A medical technology company supported the Web-based consultation platform services including visual telephone, Web-based prescription services, electronic anatomic diagrams, triage, blood pressure and blood glucose measurement, Web-based auscultation, and geographic maps of the patients’ locations. The telemedicine network covered approximately 300 rural sanitary stations in the rural areas of Maoming, Jieyang, Zhaoqing, Huizhou, Shantou, Zhanjiang, Zhongshan, Jiangmen, Meizhou, Yunfu, Heyuan, Yangjiang, Shaoguan, Chaozhou, and Shanwei (Figure 2 and Table 1).

The survey instruments used in this study consisted of 3 evaluation charts. The charts were formulated according to the following 3 categories of service received by participants: medication prescriptions (Textbox 1), medical advice (Textbox 2), and referral to a doctor at a downtown hospital (Textbox 3). Each participant was interviewed and evaluated voluntarily according to the medical service received.

The questionnaires contained the basic information of the participants. Each chart contained 5 to 6 questions focusing on opinions and attitudes about telemedicine, including effectiveness of treatment, willingness to revisit, acceptance of medical expenses, and difficulties with the telemedicine experience.

Five quantitative and qualitative variables were categorized and calculated according to data collected from the 15 rural regions shown in Figure 1. The demographic characteristic and top 10 diseases and syndrome were collected from annual surveys, whereas patient satisfaction, prescription amount (the number of times patients received prescription orders), consultation amount (the number of times they received consultations without prescriptions), and the average prescription expense were analyzed monthly. The questionnaire items about medication effectiveness, acceptance of prescription expense, attitudes toward remote medicine, and difficulties with the telemedicine experience were also investigated. The surveys were conducted by telephone. Data including patients’ demographic features, patient satisfaction, medicine effect, patients’ compliance with doctors’ advices, patients’ acceptance of prescription expense, patients’ desire to revisit the Department of Guangdong Online Hospital, the top 10 diseases and self-reported difficulties in telemedicine experience that were described in terms of frequency and percentages (n, %). The monthly average prescription expense was described using a line chart. Monthly consultation and prescription amount, as well as monthly prescriptions of Western medicine and herbs, were described using a bar chart. The age distribution of the consultation population was described using a pie chart. Statistical analysis was performed with SPSS Version 22.0 statistic software package.

From June 2015 to May 2016, approximately 67,740 participants had consultations at the Department of Guangdong Online Hospital, Guangdong Second Provincial General Hospital. Approximately 22,740 of these participants were interviewed voluntarily. The number of participants in the medical prescription group was much greater than that in the medical and face-to-face consultation groups. Women comprised majority (45,386/67,740, 67.00%) of the participants and men comprised the minority (22,354/67,740, 33.00%, Table 2). Participants between 20 and 30 years old were more inclined to use telemedicine (24,269/67,740, 35.83%) compared with the others (Table 3).

Data obtained in previous studies indicated that telemedicine could significantly improve patient satisfaction, save costs and time compared with conventional means, and increase access to health care resources for rural patients [9,14]. The results of our study were almost consistent with the findings of previous research but presented more problem-oriented and detailed results. In this study, we found that telemedicine has a wide disease spectrum, similar to ordinary medicine in China. It saves costs, has high patient satisfaction and price acceptability, and can relieve disease and syndromes. However, challenges such as poor computer skills, transportation inconvenience, language barriers, unstable internet connection, and medication and hardware shortage at sanitary stations need to be resolved.

We noted some demographic characteristics concerning the inclination to use telemedicine. Participants between 20 and 40 years old accounted for more than half of the consultation, and women were more inclined than men to use the internet to obtain medical services, which was not reported previously. These findings indicated that people in this age spectrum have more open attitudes toward new ways of receiving health care. They have better computer skills and language abilities than seniors and the young, which might be the reasons for the inclination. The rural migrant workers account for most of the migrant population in China. The percentages of rural female and male migrant workers were 47% and 53%, respectively [15]. This means that more female farmers stay at home compared with men. Women were the main users of telemedicine because their spouses were working in the cities which is a characteristic pattern in China.

The maldistribution of medicine and hygiene resources between rural and urban regions has been evident despite several stages of medical reforms initiated in 1985. The rural population accounted for a large portion of the population but had fewer medical resources of both medical institutions and staffs than people in cities. The statistics reveal that the total number of people diagnosed and treated in medical and hygiene institutions in China was 64.2 billion, an increase of 2%, and the number of people in hospitals was 26.3 billion, an increase of 5%, but in grass-root medical institutes, the number was 35.6 billion, a decrease of 1% compared with the same period in 2016 [29]. This implies that a large number of rural people would seek health care from urban hospitals but not in their places of residential areas. As a result, the Chinese government launched official documents requiring and advocating telemedicine as an important approach for solving medical resource inequality between urban and rural regions and facilitate the ability of rural people to obtain medical services in their areas through local medicine and hygiene administration departments to resolve difficulties in access to better and sufficient medical services for rural residents [6]. The Department of Guangdong Online Hospital, Guangdong Second Provincial General Hospital, the first remote medical institution authorized by the National Health and Family Planning Commission, has endeavored to deliver health care to rural regions through telemedicine practice on which our research was based, indicating that adding telemedicine to rural sanitary stations was a feasible way to solve difficulties in access to high-quality medical services in tertiary hospitals for rural residents.

The results of this study could guide further promotion and advocacy of telemedicine for delivering better medical services from larger cities to remote and rural regions in China and other developing countries. However, some limitations are worth noting. Some of the participants could not be contacted for follow-up telephone interviews because of wrong telephone numbers or their refusal to answer questions.

Telemedicine has a wide disease spectrum similar to that addressed by ordinary medicine in China. It could save costs, provide high patient satisfaction, popularity and price acceptance, and help cure or relieve diseases and syndromes. However, problems remain that must be resolved, including poor computer skills, transportation inconvenience, language communication barriers, unstable internet connection, and medicine and hardware shortage at sanitary stations. Telemedicine could serve as a feasible approach to addressing the maldistribution of health care resources in rural China. The results could guide further promotion and advocacy of telemedicine practice in rural regions of China and other developing countries. Future research should focus on providing a smooth and stable telemedicine network, resolving transportation inconvenience, improving patient compliance and helping the elderly obtain telemedicine services in rural regions.