This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Medical Informatics, is properly cited. The complete bibliographic information, a link to the original publication on http://medinform.jmir.org/, as well as this copyright and license information must be included.
Health care maldistribution is a long-term problem in China. Telemedicine is an efficient way to deliver medical resources to remote areas; however, there are few studies on the effectiveness and challenges in providing health care from rural to urban areas in China.
The objective was to describe the effectiveness and challenges of telemedicine for providing health care from Guangzhou to rural areas in Guangdong Province.
We designed surveys and conducted them immediately after the consultation and 2-4 weeks later. Data were collected from June 2015 to May 2016 including patients’ demographic features, patient satisfaction, medicine effect, patient compliance, acceptability of prescription expenses, patients’ desire to revisit the department, the top 10 diseases, and self-reported difficulties in telemedicine experience. The monthly average prescription expense was described using a line chart. The monthly consultation and prescription, as well as monthly prescriptions of Western medicines and herbs, were described using a bar chart.
Women comprised majority (45,386/67,740, 67.00%) of participants and men comprised the minority (22,354/67,740, 33.00%). The top 3 diseases were upper respiratory diseases (12,371/36,311, 34.07%), laryngopharyngitis (4938/36,311, 13.60%), and menstrual disorders (4669/36,311, 12.86%). The monthly prescription for Western medicine was much more than that for Chinese herbs. The annual average medicine expense per prescription was 62.9 ¥. The participants’ perception of expense was acceptable (8775/12,450, 70.48%), mostly acceptable (2497/12,450, 20.01%), accepted but somewhat expensive (980/12,450, 7.9%), and unacceptable because of high cost (198/12,450, 1.6%). The surveys on patient satisfaction demonstrated very satisfied (55,687/67,740, 82.21%), satisfied (5891/67,740, 8.70%), basic satisfaction (3561/67,740, 5.26%), dissatisfaction (1454/67,740, 2.15%), and no comment (1147/67,740, 1.69%). Participants reported their treatment outcome as follows: full recovery (5008/12,450, 40.22%), recovering (4873/12,450, 39.14%), no effect (2153/12,450, 17.29%), or worsening (416/12,450, 3.3%). Approximately 89.01% (20,240/22,740) of participants will revisit the department, whereas 10.99% (2500/22,740) will not. Most patients complied with the doctors’ advice completely (5430/10,290, 52.77%), whereas the rest reported partial compliance (3684/10,290, 35.80%) or no compliance at all (1176/10,290, 11.43%). The participants reported poor computer skills (4980/22,740, 21.90%), transportation inconvenience (4670/22,740, 20.50%), unstable internet connection (3820/22,740, 16.80%), language barriers (3708/22,740, 16.30%), medication and medical hardware shortage (2459/22,740, 10.82%), tiring commute (2068/22,740, 9.08%), family care burdens (679/22,740, 3.0%), and other unclassified difficulties (356/22,740, 1.6%) as difficulties in using telemedicine.
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, certain problems need to be resolved. Telemedicine could be a feasible approach to address the health care maldistribution in rural China. This study may provide useful information for policy making and guidance for further telemedicine practice in China and other developing countries.
China is regarded as a traditionally agricultural society comprised of urban and rural areas with populations of 6.6 billion and 6.7 billion, respectively [
Under these circumstances, the Chinese government proposed the development of telemedicine service as an approach to optimize and redistribute medical resources in remote places [
In this study, we present the practice of telemedicine in a tertiary hospital in Guangdong Province that provides high-quality medical services to rural areas. We will describe the application, effectiveness, and difficulties of telemedicine practice for providing health care resources from Guangzhou to rural areas of Guangdong Province.
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 (
This study was launched by the Department of Guangdong Online Hospital, Guangdong Second Provincial General Hospital [
Flowchart for telemedicine consultation with Department of Guangdong Online Hopsital, Guangdong Second Provincial General Hospital.
Guangdong administrative map.
Distance to Guangzhou and population of rural regions.
Rural regions | Distance to Guangzhou (km) | Population, n |
Mao ming | 340.5 | 5,817,753 |
Jie yang | 430.4 | 5,877,025 |
Zhao qing | 97.1 | 3,918,085 |
Hui zhou | 144.2 | 4,597,002 |
Shan tou | 439.3 | 5,391,028 |
Zhan jiang | 416.4 | 6,993,304 |
Zhong shan | 83.4 | 3,120,884 |
Jiang men | 91.3 | 4,448,871 |
Mei zhou | 390 | 4,240,139 |
Yun fu | 143.8 | 2,360,128 |
He yuan | 199.6 | 2,953,019 |
Yang jiang | 223.6 | 2,421,812 |
Shao guan | 222.4 | 2,826,612 |
Chao zhou | 498 | 2,669,844 |
Shan wei | 274.2 | 2,935,717 |
Name: Sex: Age:
Identity number: Telephone number:
Residence place: Public clinic:
Please check the option that fits for you.
1. What kind of medicine did you obtain from the doctors?
Western medicine ( ); Chinese herbs ( )
2. What was the curative effect of the drug prescribed by the doctor?
Cured ( ); got better ( ); no use ( ); got worse ( )
3. What is your acceptance of the medical expense?
Completely acceptable ( ); mostly acceptable ( ); acceptable but somewhat expensive ( ); unacceptable due to high cost ( )
4. Do you think telemedicine is useful?
Very useful ( ); somewhat useful ( ); not very useful ( ); no use ( )
5. Will you visit the online hospital again?
Yes ( ); no ( )
6. What difficulties you have had in your telemedicine experience?
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 (
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.
Name: Sex: Age:
Identity number: Telephone number:
Residence place: Public clinic:
Please check the option that fits for you.
1. Did you follow the doctor’s advice completely?
Completely ( ); partially ( ); just listened to the advice ( )
2. What are your opinions on the usefulness of the doctor’s advice?
Very useful ( ); useful ( ); no use ( ); got worse ( )
3. Do you think that telemedicine is useful?
Very useful ( ); useful ( ); not too useful ( ); no use ( )
4. Will you visit online hospital again?
Yes ( ); no ( )
5. What difficulties have you had in your telemedicine experience?
Name: Sex: Age:
Identity number: Telephone number:
Residence place: Public clinic:
Please tick the option that fit for you.
1. Did you follow the doctor’s advice to have a face-to-face consultation in a downtown hospital?
Yes ( ); no ( )
2. What was the doctors’ diagnosis?
3. What therapy did you receive at the downtown hospital?
Medicine ( ); surgery ( ); rehabilitation ( ); psychiatry ( ); others ( )
4. What was the outcome of the telemedicine?
Cured ( ); got better ( ); no curative effect ( ); got worse ( )
5. Do you think that telemedicine is useful?
Very useful ( ); useful ( ); no use ( ); got worse ( )
6. Would you visit the Department of Guangdong Online Hospital again?
Yes ( ); no ( )
Five quantitative and qualitative variables were categorized and calculated according to data collected from the 15 rural regions shown in
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%,
The top 10 diseases included respiratory ailments, gynecological conditions, sleep disorders, and pain syndrome. The top 3 diseases and syndromes of telemedicine consultation in rural areas were upper respiratory ailments (12,371/36,311, 34.07%), laryngopharyngitis (4938/36,311, 13.60%), and menstrual disorder (4669/36,311, 12.86%), as seen in
Demographic characteristics of telemedicine users (N=67,740).
Demographic characteristics | Medical prescription group (n=35,021) | Medical advice group (n=21,887) | Face-to-face consultation group (n=10,832) | Total |
Male, n (%) | 10,059 (28.72) | 8271 (37.79) | 4024 (37.15) | 22,354 (33.00) |
Female, n (%) | 24,962 (71.28) | 13,616 (62.21) | 6808 (62.85) | 45,386 (67.00) |
Age, mean (SD) | 34.05 (15.45) | 35.75 (20.40) | 36.81 (14.72) | 34.76 (17.06) |
Age distribution of consultation population (N=67,740).
Age (years) | n (%) |
<10 | 2618 (3.86) |
11-20 | 3657 (5.40) |
21-30 | 24,269 (35.83) |
31-40 | 14,060 (20.76) |
41-50 | 10,808 (15.95) |
51-60 | 7816 (11.54) |
61-70 | 3069 (4.53) |
>70 | 1443 (2.13) |
Top 10 diseases and syndromes in telemedicine consultations in rural regions (N=36,311).
Ranking | Disease or syndromes | n (%) |
1 | Upper respiratory infection | 12,371 (34.07) |
2 | Laryngopharyngitis | 4938 (13.60) |
3 | menstrual disorder | 4669 (12.86) |
4 | Cough | 3728 (10.27) |
5 | sleep disorder | 3132 (8.63) |
6 | Gastritis | 1969 (5.42) |
7 | Dyspepsia | 1812 (4.99) |
8 | Colpitis | 1400 (3.86) |
9 | Dysmenorrheal | 1258 (3.45) |
10 | Osphyalgia | 1034 (2.85) |
Monthly consultations and prescriptions.
The prescription amount (35,021) was lower than the total consultation amount (67,740) from June 2015 to May 2016, and the prescription amount was lower than the consultation amount every month (
The monthly average medicine expense per prescription was lowest in June 2015 (54.84 ¥) and highest in May 2016 (77.29 ¥) but did not change substantially within a year (
The surveys on patient satisfaction demonstrated that most patients were very satisfied (55,687/67,740, 82.20%), whereas few were satisfied (5891/67,740, 8.70%), basically satisfied (3561/67,740, 5.26%), dissatisfied (1454/67,740, 2.15%), or had no comment (1147/67,740, 1.69%). The percentages of those who were very satisfied, satisfied, and basic satisfied in the face-to-face consultation group (10,527/10,832, 97.10%) was higher than those in the medical prescription group (33,622/35,021, 96.00%) and the medical advice group (20,990/21,887, 95.90%), as seen in
Most participants perceived the telemedicine expense to be acceptable (8775/12,450, 70.50%) or mostly acceptable (2497/12,450, 20.01%) with fewer perceiving it to be acceptable but somewhat expensive (980/12,450, 7.9%) or unacceptably expensive (198/12,450, 1.6%). The percentages of those who found their expenses completely acceptable, mostly acceptable, or acceptable but somewhat expensive in the Western medicine prescription group (11,103/11,271, 98.5%) were higher than in the herbal prescription group (1149/1179, 97.46%), as seen in
A majority of participants reported positive treatment outcomes (full recovery: 5008/12,450, 40.22% and recovering: 4873/12,450, 39.14%); fewer reported no effect (2153/12,450, 17.29%) or worsening conditions (416/12,450, 3.3%). The percentages of full recovery and recovery in the Western medicine prescription group (8952/11,271, 79.43%) were the same as those in the herbal prescription group (929/1179, 78.80%), as seen in
Patients’ compliance with doctors’ advice included complete compliance (5430/10,290, 52.77%), partial compliance (3684/10,290, 35.80%) with doctor advice and no compliance at all (1176/10,290, 11.43%). Approximately half reported complete compliance in both the medical advice group and the face-to-face consultation group. Nearly half complied with the doctors’ advice partially and just listened to the advice without action in the medical advice group (3235/6907, 46.84%) and the face-to-face consultation group (1625/3383, 48.03%), as seen in
Approximately 89.00% (20,240/22,740) of the participants were willing to revisit the Online Hospital, whereas 10.99% (2500/22,740) would not. Most of the participants in the medical prescription group (11,078/12,450, 88.98%) would revisit it, as would those in the medical advice group (6182/6907, 89.50%) and face-to-face consultation group (2982/3383, 88.10%), however, the rest would not revisit it, as seen in
Monthly prescriptions for Western medicine and herbs.
Monthly average prescription expenditures.
Patient satisfaction rates in the 3 groups (N=67,740).
Patient satisfaction | Medical prescription group (n=35,021), n (%) | Medical advice group (n=21,887), n (%) | Face-to-face consultation group (n=10,832), n (%) | Total, n (%) |
Very satisfied | 28,718 (82.00) | 17,838 (81.50) | 9131 (84.30) | 55,687 (82.21) |
Satisfied | 3152 (9.00) | 1860 (8.50) | 879 (8.11) | 5891 (8.70) |
Basic satisfied | 1752 (5.00) | 1292 (5.90) | 517 (4.77) | 3561 (5.26) |
Unsatisfied | 701 (2.0) | 547 (2.5) | 206 (1.90) | 1454 (2.14) |
No comment | 698 (2.0) | 350 (1.6) | 99 (0.91) | 1147 (1.69) |
Annual expense acceptance (N=12,450).
Expense acceptance | Western medicine prescription group (n=11,271), n (%) | Herb prescription group (n=1179), n (%) | Total, n (%) |
Completely acceptable | 7956 (70.59) | 819 (69.47) | 8775 (70.48) |
Mostly acceptable | 2262 (20.07) | 235 (19.93) | 2497 (20.02) |
Acceptable but somewhat expensive | 885 (7.85) | 95 (8.06) | 980 (7.9) |
Unacceptable due to the high cost | 168 (1.49) | 30 (2.54) | 198 (1.6) |
Self-reported therapeutic effects (N=12,450).
Treatment outcome | Western medicine prescription group (n=11,271), n (%) | Herb prescription group (n=1179), n (%) | Total, n (%) |
Full recovery | 4528 (40.17) | 480 (40.71) | 5008 (40.22) |
Recovery | 4424 (39.25) | 449 (38.08) | 4873 (39.19) |
No effect | 1933 (17.15) | 220 (18.66) | 2153 (17.29) |
Worsening | 386 (3.42) | 30 (2.54) | 416 (3.3) |
Patient compliance with doctors’ advice (N=10,290).
Patient compliance | Medical advice group (n=6907), n (%) | Face-to-face consultation group (n=3383), n (%) | Total, n (%) |
Completely | 3672 (53.16) | 1758 (51.97) | 5430 (52.77) |
Partially | 2442 (35.36) | 1242 (36.71) | 3684 (35.80) |
Just listen to the advice | 793 (11.48) | 383 (11.32) | 1176 (11.43) |
Patients’ desire to revisit the Department of Guangdong Online Hospital (N=22,740).
Whether to revisit | Medical prescription group (n=12,450), n (%) | Medical advice group (n=6905), n (%) | Face-to-face consultation group (n=3385), n (%) | Total, n (%) |
Yes, I will revisit the online hospital | 11,078 (88.98) | 6180 (89.50) | 2982 (88.) | 20,240 (89.01) |
No, I will not revisit the online hospital | 1372 (11.02) | 725 (10.50) | 403 (11.90) | 2500 (10.99) |
Self-reported difficulties with the telemedicine experience (N=22,740).
Difficulties in telemedicine experience | n (%) |
Language barrier | 3708 (16.30) |
Tiring commute | 2068 (9.08) |
Transportation inconvenience | 4670 (20.50) |
Medication shortages | 1282 (5.64) |
Unstable internet connection | 3820 (16.80) |
Poor computer skills | 4980 (21.90) |
Family care burden | 679 (3.0) |
Medical hardware shortage | 1177 (5.18) |
Others unclassified difficulties | 356 (1.6) |
The top 3 self-reported difficulties by the participants included poor computer skills (4980/22,740, 21.90%), transportation inconvenience (4670/22,740, 20.50%), and an unstable internet connection (3820/22,740, 16.80%), whereas they also complained about medical hardware and medicine shortages, language barriers, and tiring commute (
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 [
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 [
Our research found that the top 3 diseases and syndromes treated by telemedicine were mainly upper respiratory diseases, Laryngopharyngitis and menstrual disorder, a pattern comparable with that reported in the health medical yearbook of China in 2009 [
Monthly consultation and prescription showed an abnormal distribution. The consultation services included prescriptions and advices. Some of the participants obtained prescriptions, whereas the others received professional advice from doctors. The number of prescriptions was lower than the number of visits every month. Both Western medicine and herbs were prescribed with the former prescribed much more than the latter, expanding the range of telemedicine treatment reported previously [
We calculated that the annual average prescription price was 62.9 ¥, which was much lower than the average outpatient prescription expenditure of 291.3 ¥ in tertiary public hospitals and 189.5 ¥ in secondary public hospitals according to the latest data from January 2016 to October 2016 from the website of the National Health and Family Planning Commission of the People’s Republic of China [
Telemedicine had a high patient satisfaction rate. A survey of patient satisfaction was conducted immediately after the consultations. Approximately vast majority (55,687/67,740, 82.21%) of the participants were very satisfied with their telemedicine experience, whereas minority (1454/67,740, 2.14%) was not satisfied. The results of this research were comparable with those of a previous study that found a good patient satisfaction rate with telemedicine in rural regions [
We also assessed the difficulties associated with the telemedicine experience. Opinions from 22,740 participants on the problems they encountered and included poor patient computer skills, transportation problems, an unstable internet connection, and language communication barriers. The percentage of the peasants who were illiterate and had less than a middle school education was 91.7% [
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 [
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.
traditional Chinese medicine
We thank the Department of Guangdong Online Hospital, Guangdong Second Provincial General Hospital for their support of this research.
None declared.