Abstract
Objective
Telemedicine is expected to be useful in rural areas owing to its advantages in improving patient access to medical care. In Japan, rural clinics and core hospitals are assigned to provide rural medical care according to the medical plans formulated for each prefecture. However, the relationship between telemedicine use in such medical facilities and the role of local governments remains unclear. Therefore, their relationship was investigated in this study.
Materials and Methods
A nationwide survey was conducted in 2022. Questionnaires were sent to rural clinics (n=1,006) and core hospitals (n=334) via mail.
Results
The response rates for rural clinics and core hospitals were 51.2% and 50.6%, respectively. Telemedicine was used in 24.9% of the clinics and 24.9% of the core hospitals. Local government collaboration was significantly more prevalent in the telemedicine (+) group than in the telemedicine (–) group in rural clinics (44.5% vs. 5.2%, P<0.01) and core hospitals (35.7% vs. 19.4%, P<0.05). In the telemedicine (–) group, the first-ranked barrier to telemedicine use was hardware preparation (clinics, 34.0%; core hospitals, 26.4%), followed by financial issues (clinics, 22.4%; core hospitals, 22.0%). In the telemedicine (+) group in rural clinics, both doctor-to-patient (45.6% vs. 22.5%, P<0.01) and doctor-to-patient with nurse models (52.6% vs. 7.0%, P<0.01) were significantly more prevalent in collaboration with local governments.
Conclusion
The relationship between rural medical care facilities and local government collaborations may contribute to the development of rural telemedicine in Japan.
Keywords: core hospital, government support, remote medicine, rural clinic, rural medicine
Introduction
Telemedicine is defined as the use of telecommunications and information technologies to deliver healthcare from a distance1). Particularly in rural areas, telemedicine is useful in providing medical care owing to its advantages, such as improving patients’ accessibility to the healthcare system, ensuring continuity of treatment, and enhancing the quality of care2, 3). Therefore, the adoption of telemedicine is increasing globally1).
In Japan, telemedicine has been adopted for medical care activities utilizing information and communication technology (ICT)4). It can be divided into two categories: “telemedicine between medical professionals” and “telemedicine between medical professionals and patients”4, 5). The former includes the doctor-to-doctor (D-to-D; professional doctors remotely support doctors) and doctor-to-nurse (D-to-N; doctors remotely support and guide nurses) models. The latter includes the doctor-to-patient (D-to-P; doctors remotely provide medical care to patients), doctor-to-patient with nurses (D-to-P with N; doctors remotely provide medical care while nurses attend to and support patients), and doctor-to-patient with doctors (D-to-P with D; professional doctors remotely consult care physicians treating patients) models4, 5).
As part of a policy to provide medical care in rural areas in Japan, each prefecture formulates a medical plan tailored to local conditions6, 7). According to these plans, rural clinics (hekichi-shinryosho in Japanese) provide medical care in rural areas with the aid of core hospitals (hekichi-iryo-kyoten-byoin in Japanese) that support the clinics6, 7). In Japan, rural clinics are established in areas where no other medical facilities exist within a four-kilometer radius; they serve a population of 1,000 or more and are located more than 30 minutes away from the nearest medical institute by transportation6). Core hospitals are assigned to aid rural clinics by providing mobile medical care and dispatching doctors to rural clinics. Moreover, telemedicine to assist rural clinics has recently been considered in core hospitals6, 8, 9).
Recently, some rural clinics have integrated telemedicine into their daily practices, and core hospitals have collaborated with rural clinics through telemedicine10). In Japan, rural clinics serve as the frontlines of medical care and often work closely with local governments to provide community services. Thus, telemedicine use in rural clinics may be related to local government action11). For example, a study in the United States showed that adoption of telemedicine depends on state policies12). The relationship between telemedicine use in rural clinics and core hospitals, and the role of local governments in Japan should be explored. Therefore, this study aims to investigate this relationship using a nationwide survey in Japan. We hypothesized that there would be a positive relationship between rural medical care facilities and local government collaboration in telemedicine use. We also investigated potential barriers to telemedicine adoption and collaboration between telemedicine models and local governments.
Materials and Methods
Study design
This cross-sectional survey was conducted in February 2022, and targeted rural clinics and core hospitals in Japan. Questionnaires were mailed to all the rural clinics (n=1,006) and core hospitals (n=334).
We asked whether telemedicine was being used or not (telemedicine (+) and (–)), followed by whether the local government, under whose jurisdiction the clinics or core hospitals were located, had implemented any collaboration for telemedicine use. If applicable, respondents were asked to select multiple options from the following measures for collaborative support: 1) improving the internet communication environment, 2) hardware preparation, 3) financial support, 4) operational and maintenance support, 5) provision of telemedicine-related information, 6) establishment of a telemedicine consultation desk, 7) holding training sessions, 8) dispatching ICT personnel, and 9) others.
Subsequently, the telemedicine (–) group was asked about future plans for implementation. Primary barriers to adoption were selected from the following seven options: 1) securing human resources for telemedicine implementation; 2) operations; 3) hardware preparation; 4) financial issues; 5) lack of information on the advantages or disadvantages of telemedicine; 6) lack of training opportunities for ICT use; and 7) lack of support systems. Finally, the telemedicine (+) group was asked about the telemedicine models used: 1) D-to-D (including teleconsultation, teleradiology, and telepathology), 2) D-to-P, 3) D-to-P with N (asked only for rural clinics), and 4) D-to-N.
Outcomes and statistics
The status of local government collaboration between the telemedicine (+) and (–) groups was compared. In the telemedicine (–) group, we assessed the relationship between future plans for telemedicine implementation and local government collaboration. We also tabulated the top-ranked barriers to telemedicine use in the telemedicine (–) group. In the telemedicine (+) group, we assessed the relationship between telemedicine use models and local government collaboration.
Nominal variables were expressed as proportions and analyzed using the χ2 test or Fisher’s exact test with residual analyses. Statistical analysis was conducted using the IBM SPSS software version 28.0 (IBM Corp., Tokyo, Japan), with the significance level set at 5% for all tests. The Jichi Medical University Ethics Committee for Medical Research approved this study (number: 24-212).
Results
The response rates were 51.2% for the rural clinics and 50.6% for the core hospitals. Telemedicine was used (telemedicine (+) group) in 24.9% of the clinics (128 clinics) and 24.9% of the core hospitals (42 hospitals) (Table 1).
Table 1. Local government collaboration for telemedicine use in rural clinics or core hospital.
| Rural clinics | Core hospitals | |||||||
|---|---|---|---|---|---|---|---|---|
| Overalln=515 | Tele-medicine (+) n=128 | Tele-medicine (−) n=387 | P-value | Overalln=169 | Tele-medicine (+) n=42 | Tele-medicine (−) n=127 | P-value | |
| Local government collaboration, n (%)a, b | 77 (15.0) | 57 (44.5) | 20 (5.2) | <0.01 | 39 (23.5) | 15 (35.7) | 24 (19.4) | <0.05 |
| Improvement of internet communication environment | 50 (64.9) | 38 (66.7) | 12 (60.0) | 0.59 | 14 (35.9) | 7 (46.7) | 7 (29.2) | 0.27 |
| Hardware preparation | 46 (59.7) | 40 (70.2) | 6 (30.0) | <0.01 | 15 (38.5) | 7 (46.7) | 8 (33.3) | 0.51 |
| Financial support | 39 (50.6) | 30 (52.6) | 9 (45.0) | 0.56 | 12 (30.8) | 6 (40.0) | 6 (25.0) | 0.48 |
| System operation and maintenance | 19 (24.7) | 18 (31.6) | 1 (5.0) | <0.05 | 6 (15.4) | 2 (13.3) | 4 (16.7) | 1.00 |
| Provision of information on telemedicine | 12 (15.6) | 11 (19.3) | 1 (5.0) | 0.17 | 9 (23.1) | 4 (26.7) | 5 (20.8) | 0.71 |
| Establishment of consultation desk forusing telemedicine | 10 (13.0) | 8 (14.0) | 2 (10.0) | 1.00 | 5 (12.8) | 2 (13.3) | 3 (12.5) | 1.00 |
| Holding training sessions | 9 (11.7) | 4 (7.0) | 5 (25.0) | <0.05 | 3 (7.7) | 2 (13.3) | 1 (4.2) | 0.55 |
| Dispatch of personnel related to ICTequipment operation | 6 (7.8) | 5 (8.8) | 1 (5.0) | 1.00 | 5 (12.8) | 2 (13.3) | 3 (12.5) | 1.00 |
| Others | 2 (2.6) | 2 (3.5) | 0 (0) | 1.00 | 7 (17.9) | 0 (0) | 7 (29.2) | <0.05 |
aMultiple answers. bThe denominator of the percentage is the number of respondents. ICT: information and communication technology.
Local government collaboration for telemedicine use was available in 15.0% (77/515) of the rural clinics and 23.5% (39/169) of the core hospitals (Table 1). Local government collaboration was significantly more prevalent in the telemedicine (+) group than in the telemedicine (–) group (rural clinics: 44.5% vs. 5.2%, P<0.01; core hospitals: 35.7% vs. 19.4%, P<0.05). In the rural clinics, support for hardware preparation (70.2% vs. 30.0%, P<0.01) and system operation or maintenance (31.6% vs. 5.0%, P<0.05) was significantly more common in the telemedicine (+) group. In contrast, in the core hospitals, no specific collaboration measures showed significant differences between the groups.
In both facilities in the telemedicine (–) group, the presence of future plans to introduce telemedicine was significantly associated with collaboration (rural clinics: 20.0% vs. 4.5%, P<0.01; core hospitals: 12.5% vs. 2.1%, P=0.02) (Table 2). Conversely, the absence of future plans was significantly associated with lack of collaboration (Table 2). The top-ranked barriers to telemedicine introduction in the telemedicine (–) group at both facilities included hardware preparation (34.0% for rural clinics and 26.4% for core hospitals), followed by financial issues (22.4% for rural clinics and 22.0% for core hospitals) (Table 3).
Table 2. Plans for future use of telemedicine in the telemedicine (−) group.
| Rural clinics | Core hospitals | |||||||
|---|---|---|---|---|---|---|---|---|
| Overall n=375 | Collabora-tion (+) n=20 | Collabora-tion (−) n=355 | P-value | Overalln=113 | Collaboration (+) n=16 | Collaboration (−) n=97 | P-value | |
| Planned, n (%) | 20 (5.3) | 4 (20.0) | 16 (4.5) | <0.01 | 4 (3.5) | 2 (12.5) | 2 (2.1) | 0.02 |
| No plan, n (%) | 276 (73.6) | 7 (35.0) | 269 (75.8) | 79 (69.9) | 7 (43.8) | 72 (74.2) | ||
| Under-consideration, n (%) | 79 (21.1) | 9 (45.0) | 70 (19.7) | 30 (26.5) | 7 (43.8) | 23 (23.7) | ||
Table 3. Barriers to telemedicine use in the telemedicine (−) group.
| Rural clinicsn=326 | Core hospitalsn=91 | |
|---|---|---|
| Hardware preparation, n (%) | 111 (34.0) | 24 (26.4) |
| Financial issues, n (%) | 73 (22.4) | 20 (22.0) |
| Securing human resources to introduce telemedicine, n (%) | 58 (17.8) | 15 (16.5) |
| Securing human resources for telemedicine operations, n (%) | 33 (10.1) | 19 (20.9) |
| Lack of information on the advantages or disadvantages of telemedicine, n (%) | 26 (8.0) | 6 (6.6) |
| Lack of support system, n (%) | 20 (6.1) | 7 (7.7) |
| Lack of training opportunities for using ICT equipment, n (%) | 5 (1.5) | 0 (0) |
Table 4 shows the association between telemedicine models and local government collaboration in the telemedicine (+) group. In rural clinics, telemedicine “between medical professionals” (71.1%) was more common than “between medical professional and patients” (47.7%). In the latter, both the D-to-P (45.6% vs. 22.5%, P<0.01) and D-to-P with N (52.6% vs. 7.0%, P<0.01) models were significantly more prevalent when collaborating with local governments. Conversely, in the telemedicine “between medical professionals,” D-to-D was the most common (56.3%) but was significantly less prevalent when collaborating with local governments (36.8% vs. 71.8%, P<0.01), including for teleradiology use (22.8% vs. 53.5%, P<0.01).
Table 4. Telemedicine models in the telemedicine (+) group.
| Rural clinics | Core hospitals | |||||||
|---|---|---|---|---|---|---|---|---|
| Overalln=128 | Collabora-tion (+) n=57 | Collabora-tion (−) n=71 | P-value | Overalln=42 | Collabora-tion (+) n=15 | Collabora-tion (−) n=27 | P-value | |
| Telemedicine between medical professionals and patients, n (%) | 61 (47.7) | 42 (73.7) | 19 (26.8) | <0.01 | 12 (28.6) | 4 (26.7) | 8 (29.6) | 1.00 |
| D-to-P | 42 (32.8) | 26 (45.6) | 16 (22.5) | <0.01 | 12 (28.6) | 4 (26.7) | 8 (29.6) | 1.00 |
| D-to-P with Na | 35 (27.3) | 30 (52.6) | 5 (7.0) | <0.01 | - | - | - | - |
| Telemedicine between medical professionals, n (%) | 91 (71.1) | 33 (57.9) | 58 (81.7) | <0.01 | 36 (85.7) | 15 (100) | 21 (77.8) | <0.05 |
| D-to-D | 72 (56.3) | 21 (36.8) | 51 (71.8) | <0.01 | 32 (76.2) | 13 (86.7) | 19 (70.4) | 0.29 |
| Teleradiology | 51 (39.8) | 13 (22.8) | 38 (53.5) | <0.01 | 19 (45.2) | 9 (60.0) | 10 (37.0) | 0.15 |
| Telepathology | 8 (6.3) | 3 (5.3) | 5 (7.0) | 0.73 | 2 (4.8) | 1 (6.7) | 1 (3.7) | 1.00 |
| Teleconsultation | 36 (28.1) | 15 (26.3) | 21 (29.6) | 0.68 | 20 (47.6) | 10 (66.7) | 10 (37.0) | 0.07 |
| D-to-N | 29 (22.7) | 38 (66.7) | 61 (85.9) | 0.01 | 6 (14.3) | 3 (20.0) | 3 (11.1) | 0.65 |
All response numbers in the table were multiple choice. a We asked only rural clinics about D-to-P with N. D-to-D: doctor to doctor; D-to-P: doctor to patient; D-to-P with N: doctor to patient with nurse; D-to-N: doctor to nurse.
Similarly, in the core hospitals, “telemedicine between medical professionals” was common (85.7%), particularly in the D-to-D model (76.2%), with teleconsultation (47.6%) being the most frequent subtype (Table 4). However, no significant relationship was found between telemedicine models and local government collaboration.
Discussion
This nationwide survey found a significant positive relationship between telemedicine use in rural medical care facilities and local government collaboration in Japan. We identified several barriers to the introduction of telemedicine in the telemedicine (–) group. In addition, we found a relationship between telemedicine models and local government collaboration in the telemedicine (+) group.
In Japan, rural facilities generally serve as essential infrastructure for providing medical care in the surrounding rural communities, with a close relationship to local governments. This may partially explain the positive relationship between rural medical care facilities and local governments. In the telemedicine (+) group of rural clinics, the hardware was most commonly provided by the government. This was also the top-ranked barrier in the telemedicine (–) group. Studies have highlighted the importance of addressing ICT-related equipment needs in promoting telemedicine adoption13,14,15,16). The smooth introduction of telemedicine into rural medical care facilities can be achieved through the provision of equipment by local governments.
Financial support is a critical factor for introducing telemedicine13). In this study, financial issues were the second top-ranked barrier. Because initial investments pose a substantial economic burden on remote medical institutions17, 18), financial support from local governments is essential14). Even after implementation, the sustainability of telemedicine may be challenged by increased operational costs19). In some European countries, financial support from local governments for initial and ongoing operational costs has been recognized as a factor in successful telemedicine implementation20). In the present study, “system operation and maintenance” was significantly more frequent in the telemedicine (+) group of rural clinics. Based on these findings, local governments should provide financial support to promote telemedicine.
Interestingly, telemedicine models in rural clinics are related to local government collaboration. Telemedicine “between medical professionals and patients” in rural clinics was significantly more common when collaborating with local governments, with the D-to-P with N model being prominent. This model can be recommended in rural clinics, where doctors often engage in solo practice and deal with older adults21,22,23,24). Nurses working in rural clinics typically provide care that is adapted to rural needs25). Nurses can help patients by communicating in a way that is specific to their situation and can assist doctors with shared tasks in telemedicine. We speculate that mutual agreement between doctors and nurses is a major premise for telemedicine use in rural clinics, and that the D-to-P with N model can be supported by local government collaboration. More information on each rural clinic adopting the D-to-P with N model, such as the number of nurses and their responsibilities, would have enabled us to refine our hypotheses.
For telemedicine “between medical professionals”, the D-to-D model was more common in both medical facilities. Notably, teleradiology was less common in rural clinics that collaborate with local governments. However, the mechanisms underlying teleradiology remain unclear. We suggest that the backgrounds of the introduction of teleradiology and telemedicine differ. For instance, teleradiology requires specific equipment and specialists. This can be achieved in specific situations beyond the efforts of local governments. In core hospitals, teleconsultation was most common, regardless of local government collaboration, possibly indicating their function as support hubs for rural clinics8). This was a connection between distant facilities that were not concerned with the local government.
This study has several limitations. First, the responses were self-reported, which may not completely reflect actual conditions. Second, the response rate was relatively low, and we should take care clinics that had an interest in telemedicine might have responded more to the survey, potentially causing a selection bias. Third, this is a cross-sectional study. A study that considers the implementation period of telemedicine is required to clarify the causal relationship between local government collaboration and the introduction of telemedicine in medical facilities. Additionally, more data on government collaboration, such as budget size, equipment preparation, and barriers to the introduction of telemedicine (e.g., telemedicine-related techniques and fear of security), should be collected to understand the results of the study. Multifaceted outcomes such as patient satisfaction, access to care, and cost-effectiveness should be evaluated to complement the study. Addressing these issues would be useful for formulating healthcare policies for rural practices.
Conclusion
The nationwide survey performed in this study revealed a significant positive relationship between telemedicine use in rural medical care facilities and local government collaboration. Hardware preparation and financial support were most commonly provided by the government and emerged as the most prominent barriers in the telemedicine (–) group, suggesting that these may represent priority areas for telemedicine use. The D-to-P with N model can be introduced in rural clinics with the help of local government collaboration. These findings offer insights into rural telemedicine strategies in Japan.
Conflict of interest
The authors declare no conflicts of interest associated with this manuscript.
Funding information
This study was supported by a Health and Labour Sciences Research Grant (21IA1004) in collaboration with the Japanese Rural-Urban Medicine Interest Study Group.
Ethics approval
The Jichi Medical University Ethics Committee for Medical Research approved this study (approval number: 24-212).
Consent for publication
All authors approved the publication of the article.
Author contributions
All authors contributed to the study conception and design as well as data collection, analysis, and interpretation. DM and HT wrote the draft of the manuscript, and KK critically revised it. All authors read and approved the final manuscript.
Data availability statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.