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Telemedicine has been used widely in China and has benefited a large number of patients, but little is known about the overall development of telemedicine.
The aim of this study was to perform a national survey to identify the overall implementation and application of telemedicine in Chinese tertiary hospitals and provide a scientific basis for the successful expansion of telemedicine in the future.
The method of probability proportionate to size sampling was adopted to collect data from 161 tertiary hospitals in 29 provinces, autonomous regions, and municipalities. Charts and statistical tests were applied to compare the development of telemedicine, including management, network, data storage, software and hardware equipment, and application of telemedicine. Ordinal logistic regression was used to analyze the relationship between these factors and telemedicine service effect.
Approximately 93.8% (151/161) of the tertiary hospitals carried out telemedicine services in business-to-business mode. The most widely used type of telemedicine network was the virtual private network with a usage rate of 55.3% (89/161). Only a few tertiary hospitals did not establish data security and cybersecurity measures. Of the 161 hospitals that took part in the survey, 100 (62.1%) conducted remote videoconferencing supported by hardware instead of software. The top 5 telemedicine services implemented in the hospitals were teleconsultation, remote education, telediagnosis of medical images, tele-electrocardiography, and telepathology, with coverage rates of 86.3% (139/161), 57.1% (92/161), 49.7% (80/161), 37.9% (61/161), and 33.5% (54/161), respectively. The average annual service volume of teleconsultation reached 714 cases per hospital. Teleconsultation and telediagnosis were the core charging services. Multivariate analysis indicated that the adoption of direct-to-consumer mode (
A variety of telemedicine services have been implemented in tertiary hospitals in China with a promising prospect, but the sustainability and further standardization of telemedicine in China are still far from accomplished.
Telemedicine refers to the remote delivery of health care services with the use of modern communication technology, electronic technology, and multimedia computer technology to realize the remote collection, transmission, processing, storage, and inquiry of medical information and to further provide the examination, surveillance and diagnosis of disease, remote education, and information management [
Medical care is an important issue related to the national economy and people's livelihood in China. However, there is a serious imbalance of distribution in medical resources, and patients in rural and remote areas do not have easy access to high-quality medical services [
The development of telemedicine in China began in the 1980s. In 1986, the Guangzhou Ocean Shipping Company conducted a cross-sea consultation for the emergency patients on the ocean-going freighter through telegraph, which was considered to be the earliest telemedicine activity in China. In 1997, the Jinwei Medical Network in China was officially opened to provide remote, off-site, real-time, and dynamic live television consultations for patients with severe illness [
Many scholars have carried out research on telemedicine, as telemedicine has been implemented in full swing in China. Several studies have analyzed the application of telemedicine in the treatment of different diseases such as diabetes and burns [
The Chinese hospitals are divided into 3 levels: tertiary hospitals, secondary hospitals, and primary hospitals. The tertiary hospitals are the main providers of telemedicine services. Therefore, investigation of the implementation and application of telemedicine in tertiary hospitals can help in understanding the development of telemedicine in China. A web-based questionnaire survey (
Distribution of the survey coverage areas in China.
The preliminary questionnaire was developed based on a literature review [
n = Zα/22p (1-p)/δ2, nc = n/(1+n/N)
where Zα/2 is 1.96 at the significance level of α=.05, and p is assumed to be 0.5 with the principle of maximum population variance, indicating a more conservative sample size. δ is 0.1, representing that the margin of error is within 10%. N is 2060, denoting the total number of Chinese tertiary public hospitals in 2016. nc is the number of the samples. According to the value above, we obtained nc to be 92, and the final sample size was 103 with the waste rate being 10%. Second, on the basis of the number of tertiary hospitals in the eastern, central, and western regions of China in 2016, we distributed the sample sizes in different regions proportionally, that is, 49 hospitals in the eastern region, 27 hospitals in the central region, and 28 hospitals in the western region. At the same time, we identified the person in charge of the survey in each region and organized the questionnaire survey by using snowball sampling.
The total number of tertiary hospitals investigated was 185. However, the questionnaires from 24 hospitals were incomplete with high percentages of missing data, and only 161 questionnaires were valid, with an effective rate of 87.0%. The number of hospitals located in the eastern, central, and western region was 59, 54, and 48, respectively, accounting for 36.7%, 33.5%, and 29.8%, respectively, of the total number of the tertiary hospitals investigated in this study. Among the 161 hospitals, 137 hospitals provided telemedicine services and 111 hospitals obtained telemedicine services from other hospitals. The results of some items were invalid or missing. Thus, in the analysis of the corresponding content, the unqualified answers were processed as missing values. The quantitative data were described by mean values, while the qualitative data were described by count and percentages. The column chart, bar chart, pie chart, and radar chart were adopted to analyze the implementation and application of telemedicine using the Excel software (Microsoft Corp). Furthermore, the study applied the methods of chi-square test, two-sided
The number of telemedicine staff in 75.8% (122/161) of the tertiary hospitals ranged from 1 to 6 (
Distribution of the telemedicine staff in tertiary hospitals of China.
Educational background of the telemedicine staff in the tertiary hospitals of different regions in China (person per hospital).
Educational background | Total (n) | Eastern region (n) | Central region (n) | Western region (n) |
Computer science and communication | 1.8 | 1.4 | 1.6 | 2.5 |
Medicine | 2.7 | 4.1 | 1.9 | 1.7 |
Management | 1.3 | 1.3 | 0.9 | 1.6 |
The sources of funding for telemedicine implementation mainly include government financial support, hospital self-raising, research funding, and corporate sponsorship. According to the survey results, 83.2% (134/161) of the tertiary hospitals implemented telemedicine by self-fundraising. By comparison, only 8.1% (13/161) of the hospitals received financial support through research funding. In terms of capital investment, the proportion of tertiary hospitals with an investment of less than 500,000 RMB (approximately US $71,218) was the highest at 64.6% (104/161). Approximately 19.3% (31/161) of the hospitals invested more than 1 million RMB (approximately US $142,500) into telemedicine implementation (
Source and investment amount of telemedicine implementation in tertiary hospitals in different regions of China (N=161).
Funds | Total, N=161, n (%) | Eastern region, n=59, n (%) | Central region, n=54, n (%) | Western region, n=48, n (%) | ||||
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Government finance | 47 (29.2) | 12 (20) | 18 (33) | 17 (35) | |||
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Hospital self-raising | 134 (83.2) | 51 (86) | 44 (82) | 39 (81) | |||
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Research funding | 13 (8.1) | 7 (12) | 3 (6) | 3 (6) | |||
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Corporate sponsorship | 14 (8.7) | 7 (12) | 5 (9) | 2 (4) | |||
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<100,000 | 59 (36.7) | 21 (36) | 21 (39) | 17 (35) | |||
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100,000-500,000 | 45 (28.0) | 17 (29) | 17 (32) | 11 (23) | |||
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500,000-1 million | 26 (16.2) | 10 (17) | 6 (11) | 10 (21) | |||
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1-5 million | 21 (13.0) | 6 (10) | 7 (13) | 8 (17) | |||
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>5 million | 10 (6.2) | 5 (9) | 3 (6) | 2 (4) |
a1 RMB=US $0.14.
As shown in
Telemedicine service modes include business-to-business (B2B), direct-to-consumer (DTC), and business-to-business-to-customer (B2B2C). B2B is a mode in which a medical institution provides telemedicine services to doctors in another medical institution. DTC means that medical institutions provide remote services directly to patients, while B2B2C refers to medical institutions providing telemedicine services to patients through other intermediaries such as telemedicine companies. The results suggested that 93.8% (151/161) of the tertiary hospitals carried out telemedicine services in B2B mode, which indicated the dominance of B2B mode in China. The proportion of the DTC mode (28/161, 17.4%) was closely matched to that of the B2B2C mode (32/161, 19.9%).
Telemedicine management and service mode of tertiary hospitals in different regions of China (N=161).
Mode | Total, N=161, n (%) | Eastern region, n=59, n (%) | Central region, n=54, n (%) | Western region, n=48, n (%) | |
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Self-management mode | 95 (59.1) | 40 (68) | 29 (54) | 26 (54) |
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Partial entrustment mode | 51 (31.7) | 16 (27) | 22 (41) | 13 (27) |
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Complete entrustment mode | 13 (8.1) | 3 (5) | 3 (6) | 7 (15) |
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Other | 2 (1.2) | 0 (0) | 0 (0) | 2 (4) |
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Established | 110 (68.3) | 48 (81) | 28 (52) | 34 (71) |
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Being established | 22 (13.7) | 5 (9) | 10 (19) | 7 (15) |
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Not established | 29 (18.0) | 6 (10) | 16 (30) | 7 (15) |
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B2Ba mode | 151 (93.8) | 58 (98) | 50 (93) | 43 (90) |
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DTCb mode | 28 (17.4) | 13 (22) | 6 (11) | 9 (19) |
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B2B2Cc mode | 32 (19.9) | 14 (24) | 12 (22) | 6 (13) |
aB2B: business-to-business.
bDTC: direct-to-consumer.
cB2B2C: business-to-business-to-customer.
Overall, the most widely used type of telemedicine network was virtual private network (VPN, a special telemedicine network constructed in China based on wired network) in 55.3% (89/161) of the hospitals, followed by internet (excluding VPN and wireless networks) in 43.5% (70/161) of the hospitals; both these networks are far ahead of 3G/4G (2/161, 1.2%) in the hospitals. In terms of regions, VPN and internet constituted the same percentage of the telemedicine networks in the central and eastern regions. Most of the hospitals (33/48, 69%) in the western region adopted VPN. With regard to the security of the telemedicine networks, overall, 97.5% (157/161) of the tertiary hospitals developed different cybersecurity measures. The proportion of the hospitals that utilized firewall equipment to ensure network security was the highest at 90.1% (145/161). The other 2 popular network security measures for telemedicine were the formulation of security management systems and the implementation of network isolation.
Telemedicine network security measures of tertiary hospitals in different regions of China.
Telemedicine data storage methods of tertiary hospitals in different regions of China (N=161).
Data storage methods | Total, N=161, n (%) | Eastern region, n=59, n (%) | Central region, n=54, n (%) | Western region, n=48, n (%) |
Independent storage | 58 (36.0) | 18 (31) | 23 (43) | 17 (35) |
Sharing with other departments | 45 (28.0) | 19 (32) | 14 (26) | 12 (25) |
Sharing with other hospitals | 13 (8.1) | 6 (10) | 4 (7) | 3 (6) |
No storage | 31 (19.3) | 10 (17) | 11 (20) | 10 (21) |
Other | 14 (8.7) | 6 (10) | 2 (4) | 6 (13) |
Telemedicine data security measures for tertiary hospitals in different regions of China.
Of the 161 hospitals in the survey, 100 (62.1%) conducted remote videoconferencing supported by hardware for telemedicine, while other hospitals chose remote videoconferencing supported by software. The high-definition audio and video terminals were the most critical devices for teleconsultation with hardware videoconferencing, which were classified into 4 categories, that is, audio-video terminals type A, type B, type C, and type D, according to the Technical Guide for the Construction of Telemedicine Information System (2014 edition) [
Seventy-seven hospitals built remote education systems and were equipped with related hardware and software devices. The results showed that all of these hospitals were equipped with high-definition audio and videoconference terminals. Video walls and doctor workstations were also favored by many hospitals, which were present in 66% (51/77) and 51% (39/77) of the hospitals, respectively (
Hardware and software equipment for telemedicine services in the tertiary hospitals of China. A. Types of high-definition (HD) audio and video terminals for teleconsultation in tertiary hospitals; B. Hardware and software device configuration for remote education in tertiary hospitals; C. Hardware device configuration for remote surgery teaching in tertiary hospitals; D. Hardware device configuration for remote ward rounds in tertiary hospitals.
Different types of telemedicine services have been more or less implemented nationwide. The top 5 service types are teleconsultation, remote education, telediagnosis of medical images, tele-electrocardiography, and telepathology, with coverage rates of 86.3% (139/161), 57.1% (92/161), 49.7% (80/161), 37.9% (61/161), and 33.5% (54/161), respectively. Other telemedicine services such as remote intensive care unit care (18/161, 11.2%), remote nursing (13/161, 8.1%), and remote emergency care (16/161, 9.9%) were implemented relatively rarely.
Development of various telemedicine services in the tertiary hospitals in different regions of China.
Business volume of the major telemedicine services in tertiary hospitals (cases per hospital) in different regions of China.
Telemedicine service | Total (n) | Eastern region (n) | Central region (n) | Western region (n) |
Teleconsultation | 714 | 604 | 532 | 1045 |
Remote education | 44 | 27 | 35 | 76 |
Telepathology | 139 | 48 | 266 | 107 |
Tele-electrocardiography | 3342 | 2645 | 4123 | 3292 |
Telediagnosis of medical images | 1107 | 593 | 405 | 2443 |
Proportion of hospitals charging for different telemedicine services.
Teleconsultation, as the core service of telemedicine, needs to be explored in depth.
Teleconsultation status in tertiary hospitals: A. Levels of teleconsultation specialists; B. Ways to apply for teleconsultation; C. Average waiting time for teleconsultation; D. Average duration of teleconsultation cases.
Standard formulation was the most crucial factor, as 68.3% (110/161) of the tertiary hospitals believed that the lack of uniform standards hindered the promotion of telemedicine in hospitals. The other influencing factors of the development of telemedicine in tertiary hospitals are listed in
As shown in
Similarly, the adoption of the DTC mode, the provision of research funding, and the charging for service had a positive impact on remote education by improving the medical service level. However, regional differences had no impact on the effect of remote education. Compared with hospitals that did not establish professional management departments, the remote education effects of hospitals that were establishing departments or with already established departments were better, with
For this study, the Checklist for Reporting Results of Internet e-Surveys has been uploaded in
Key factors affecting the development of telemedicine in tertiary hospitals of China.
Ordinal logistic regression results of the influencing factors of the consultation effect.
Variable | Regression coefficient | Standard error | Wald statistic | |||
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Computer science and communication professionals | –0.31 | 0.19 | 2.63 | .11 | |
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Medical professionals | 0.09 | 0.04 | 4.09 | .04 | |
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Management professionals | –0.27 | 0.14 | 3.87 | .049 | |
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Yes | 1.25 | 2.45 | 0.26 | .61 |
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Nob | N/Ac | N/A | N/A | N/A |
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Yes | 3.54 | 1.20 | 8.68 | .003 |
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No | N/A | N/A | N/A | N/A |
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Yes | –0.57 | 1.15 | 0.25 | .62 |
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No | N/A | N/A | N/A | N/A |
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>5 million | –1.26 | 1.57 | 0.65 | .42 | |
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1-5 million | 0.01 | 1.04 | 0.00 | .99 | |
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500,000-1 million | –3.26 | 1.25 | 6.79 | .01 | |
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100,000-500,000 | –0.61 | 0.85 | 0.52 | .47 | |
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Yes | –0.70 | 0.92 | 0.58 | .45 |
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No | N/A | N/A | N/A | N/A |
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Yes | –1.47 | 1.17 | 1.57 | .21 |
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No | N/A | N/A | N/A | N/A |
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Yes | 3.72 | 1.51 | 6.09 | .01 |
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No | N/A | N/A | N/A | N/A |
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Yes | –0.18 | 1.34 | 0.02 | .89 |
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No | N/A | N/A | N/A | N/A |
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Virtual private network | 4.55 | 2.02 | 5.08 | .02 | |
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Internet | 4.75 | 2.00 | 5.67 | .02 | |
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Independent storage | 1.41 | 1.22 | 1.34 | .25 | |
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Sharing with other departments | –0.16 | 1.29 | 0.02 | .90 | |
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Sharing with other hospitals | 3.66 | 1.79 | 4.19 | .04 | |
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No storage | –2.43 | 1.32 | 3.40 | .07 | |
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Chief physician and above | 5.29 | 2.37 | 4.99 | .03 | |
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Associate chief physician and above | 1.01 | 0.82 | 1.51 | .22 | |
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60 min | –11.10 | 3.50 | 10.06 | .002 | |
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40-60 min | –5.50 | 2.96 | 3.45 | .06 | |
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30-40 min | –7.83 | 3.05 | 6.61 | .01 | |
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20-30 min | –6.08 | 2.89 | 4.42 | .04 | |
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10-20 min | –3.37 | 2.66 | 1.61 | .21 | |
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Yes | 4.26 | 1.02 | 17.30 | <.001 | |
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No | N/A | N/A | N/A | N/A |
aB2B: business-to-business.
bReference.
cN/A: not applicable.
dDTC: direct-to-consumer.
eB2B2C: business-to-business-to-customer.
f1 RMB=US $0.14.
Ordinal logistic regression results of the influencing factors of the remote education effect.
Variable | Regression coefficient | Standard error | Wald statistic | |||||||
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East | –1.04 | 1.10 | 0.90 | .34 | |||||
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West | –1.66 | 1.16 | 2.03 | .15 | |||||
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Yes | 5.70 | 4.68 | 1.48 | .22 | ||||
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Nob | N/Ac | N/A | N/A | N/A | ||||
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Yes | 4.01 | 1.59 | 6.39 | .01 | ||||
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No | N/A | N/A | N/A | N/A | ||||
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Yes | –2.57 | 1.47 | 3.05 | .08 | ||||
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No | N/A | N/A | N/A | N/A | ||||
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Established | 1.45 | 1.27 | 1.31 | .25 | |||||
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Being established | 3.67 | 1.78 | 4.28 | .04 | |||||
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>5 million | 0.60 | 2.26 | 0.07 | .79 | |||||
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1-5 million | 0.19 | 1.48 | 0.02 | .90 | |||||
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500,000-1 million | –2.22 | 1.82 | 1.48 | .22 | |||||
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100,000-500,000 | 0.39 | 1.12 | 0.12 | .73 | |||||
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Yes | –2.22 | 1.22 | 3.31 | .07 | ||||
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No | N/A | N/A | N/A | N/A | ||||
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Yes | –2.18 | 1.53 | 2.03 | .15 | ||||
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No | N/A | N/A | N/A | N/A | ||||
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Yes | 4.69 | 1.83 | 6.61 | .01 | ||||
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No | N/A | N/A | N/A | N/A | ||||
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Yes | –1.77 | 1.65 | 1.15 | .28 | ||||
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No | N/A | N/A | N/A | N/A | ||||
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15 instances and above per month | 5.95 | 2.11 | 7.94 | .01 | |||||
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11-14 instances per month | –3.64 | 6.51 | 0.31 | .58 | |||||
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7-10 instances per month | 2.99 | 1.69 | 3.13 | .08 | |||||
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4-6 instances per month | 0.14 | 1.11 | 0.02 | .90 | |||||
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Yes | 4.30 | 1.53 | 7.97 | .01 | |||||
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No | N/A | N/A | N/A | N/A |
aB2B: business-to-business.
bReference.
cN/A: not applicable.
dDTC: direct-to-consumer.
eB2B2C: business-to-business-to-customer.
f1 RMB=US $0.14.
Based on a national survey, this study analyzed the development of telemedicine in Chinese hospitals from multiple aspects, including implementation, application, and the key factors influencing telemedicine service effects. We found that telemedicine services were mainly carried out in the form of hardware videoconferences in B2B mode through VPN in Chinese tertiary hospitals, with various service types and a large service quantity, which were considered to have positive effects on the improvement of medical treatment in primary hospitals. Despite the rapid development of telemedicine in China, there are still problems such as the lack of uniform standards and laws, which reminds us that a lot of work is needed to improve the standardization of telemedicine services and establish legal protection for telemedicine services.
In terms of human resource and management, 31.7% (51/161) of the tertiary hospitals had no specific management departments, and some tertiary hospitals did not even have full-time staff. Further, the number of telemedicine staff with majors in computer science and communication and management was relatively small. As a burgeoning, cutting-edge, and multidisciplinary technology, telemedicine is in high need of a compound talent team that integrates the knowledge structure of science, engineering, and medicine. According to the technical guide of telemedicine in China, a tertiary hospital should set up an independent telemedicine department with medical, information technology, and management professionals and technical personnel [
Through the investigation, we found that B2B was the main telemedicine service mode in China. Historically, as the original intention of telemedicine is that experts in tertiary hospitals assist doctors in secondary or primary hospitals at different locations to provide solutions to the management of complicated diseases by videoconferencing, telemedicine services are still mainly limited to the B2B mode, and the DTC mode remains to be improved [
According to the results of the network construction, VPN was the main type of network used for telemedicine. With the advantages of high security, flexible access, and low latency [
The survey results showed that 62.1% (100/161) of the hospitals conducted hardware videoconferences instead of software videoconferences for teleconsultation. Despite the availability of low-cost videoconferencing software, due to the high requirements for information transmission and video quality, many hospitals have adopted high-performance hardware videoconferencing owing to the advantages of high definition, security, stability, and interoperability [
Studies have revealed that the lack of uniform standards and laws was an essential factor hindering the development of telemedicine, which might lead to repeated and chaotic implementation of telemedicine [
This study shows that most hospitals believe that telemedicine is effective and could improve the medical service level of the hospitals, which was consistent with the results of many studies that positively evaluated telemedicine [
Although previous studies have analyzed the utilization of telemedicine in a certain region, the overall development of telemedicine in China has not yet been studied, especially in terms of network construction, security measures, and hardware and software facilities. This study investigated the implementation and application of telemedicine from a national perspective, which will provide people with a comprehensive, multilevel, and multifaceted understanding of telemedicine development in China. Moreover, to our knowledge, this is the first study to use ordinal regression models to deeply analyze the factors influencing the effectiveness of telemedicine in multiple dimensions, including human resources, funding, management and service modes, networks, and charging, which will supply a reference for telemedicine planning.
Although our findings provide a deep insight into the development of telemedicine in China, this study has several limitations. As the first nationwide survey on telemedicine in China, our sample is nationally representative and covers most areas of China. However, the sample size is still insufficient, as some areas with few tertiary hospitals were not included, such as Tibet; therefore, the scope of the research needs to be further expanded. Besides, we have only considered tertiary hospitals as the survey object; however, patients’ attitude toward telemedicine is also important for the development of telemedicine, which will be the focus of the next study.
We conducted a quantitative analysis of the overall implementation and application of telemedicine in China with the data from 161 tertiary hospitals in 29 provinces, autonomous regions, and municipalities. Our findings revealed that telemedicine services were carried out in most parts of China, and most tertiary hospitals provided telemedicine services in B2B mode through the hardware videoconferencing. VPN was the most widely used type of telemedicine network, and audio-video terminals with large screens was the mainstream hardware. Teleconsultation, remote education, and telediagnosis were the main types of telemedicine service. Service modes, financial sources, network types, service charges, and medical experts are the main factors influencing the effect of teleconsultation and remote education. The management, uniform standards, and legislation still need to be improved for the sustainability of telemedicine in China. To plan the development of telemedicine further, our research provides a reference for policymakers to promote the implementation of DTC mode of telemedicine, expand the coverage of VPN, develop innovative service patterns such as remote nursing and remote care in intensive care units, and formulate complete telemedicine laws and regulations.
Web-based questionnaire survey (translated version).
Estimation results of ordinal regression analyzing the influencing factors of teleconsultation.
Estimation results of ordinal regression analyzing the influencing factors of remote education.
Data reporting guidelines and checklist for reporting results of internet e-surveys (CHERRIES).
business-to-business
business-to-business-to-customer
direct-to-consumer
Telemedicine Information Professional Committee of China
virtual private network
This research was supported by grants from the National Key Research and Development Program of China (Grant No. 2017YFC0909900), the National Natural Science Foundation of China (Grant No. 71673254), and the Innovation Research Team of Higher Education in Henan Province (Grant No. 20IRTSTHN028). Special thanks to the Telemedicine Information Professional Committee of China for providing a platform to conduct the telemedicine survey.
None declared.