This document discusses the experience with telemedicine programs in rural Catalonia. It summarizes that since 2010, several successful telemedicine programs have been implemented, including teledermatology and teleaudiometries. These programs allow primary care physicians to take photos of lesions or injuries and send them via electronic medical records to specialists, who provide treatment plans. This has reduced dermatology waiting times from 30 to 16 days on average. A cost analysis found telemedicine saved over €780,000 from 2011-2019, providing an average €15 savings per visit primarily benefiting patients. Telemedicine referral rates were higher for rural versus urban centers. During the COVID-19 pandemic, non-face-to-face visits increased greatly,

1. All Party Parliamentary Inquiry
into Rural Health and Care
TELEMEDICINE
Josep Vidal-Alaball. MD, PhD, MPH
Gerència territorial de la Catalunya Central
Institut Català de la Salut

2. Biography
2
Berga
Pre-Pyrenees
Barcelona

3. Biography (1998-2006)
3
Huddersfield
Devon
Wales

4. Biography (2007- )
4
• Rural GP
• Primary Care regional manager
• PhD. Telemedicine
• Rural GP + Head of the Central Catalonia Innovation
and Research Primary Care Unit

5. Our telemedicine experience
5
Population: 407,606 habitants
Extension: 4,940.69 km²
Cities:
• Manresa: 77,714 hab.
• Vic: 46,214 hab.
• Igualada: 39,967 hab.
• Berga: 16,494 hab.

6. Our telemedicine experience
6

7. Our telemedicine experience
7
• Since 2010 we developed several telemedicine programs.
• Among the programs, the most successful is teledermatology
and the most innovative are teleulcers and teleaudiometries
• All telemedicine programs work in the same way; the primary
care physician or nurse take a photograph of the lesion or the
injury and attaches it to the electronic medical records of the
patient along with an explanation of the injury.
• The use of electronic medical records guaranties confidentiality
of images, since it avoids potentially insecure electronic storage
and e-mail.

8. Our telemedicine experience
8
• The specialists of the hospital access the electronic medical
records, review the images and propose a treatment or action
plan.
• The primary care physician or nurse review these instructions
and makes a telephone call to the patient to explain the results
of the consultation
• All of this can usually be done in less than 5-7 working days

9. Evaluation
9
This program has had considerable success in reducing
dermatology waiting lists, from a mean of 30 days (95% CI: 29-32)
to a mean of 16 days (95% CI: 15-17) after its implementation.

10. Evaluation
10
Cost-Minimization Analysis
• For the period between 2011 and 2019, a total of 52,198 visits
were recorded. Telemedicine saved € 780,397.
• A differential cost favorable to telemedicine of about € 15 per
visit was observed, with the patient being the largest
beneficiary of this saving (by 85%) in terms of shorter waiting
times and travel costs (RURAL).
• In social terms and in our semi-rural context, telemedicine is
more efficient than usual care.

11. Evaluation
11
In the two years analysed, referral rates to the teledermatology service
per thousand inhabitants from rural centres was statistically much higher
than that of urban centres

12. Evaluation
12
• Both in the urban environment and in rural areas there is an
increase in referrals to the teledermatology service in 2016
compared to the previous year.
• The teledermatology consultation rate per thousand
inhabitants assigned was greater in rural teams than in the
urban ones.
• However, the number of referrals to the face-to-face
dermatology service after a teledermatology consultation
also decreased significantly and this effect was more
pronounced in RURAL centers.

13. COVID-19
13
Rural health centers CLOSED
Huge increase in non-face-to-face visits
• Telephone calls (triage, COVID-19
follow up)
• Virtual visits (tasks): repeat
prescriptions, sick notes…
• eConsultations (access for all)
• Video Consultations (new)

14. COVID-19
14

15. eConsultations
15
• eConsulta is an asynchronous teleconsulting service between
GPs and nurses and members of the public connected to the
electronic medical records of public primary care.
• The service was introduced in 2015 and was gradually phased
in until 2017, when it became established as a service available
to all primary care teams.
• Before the COVID-19 pandemic, eConsulta was already
growing at a rate of 24,000 conversations, 44,000 messages,
5500 new users, and 140 new professionals per month. With
COVID-19 these rates have increased exponentially from
March 15, 2020 to the present day.

16. eConsultations
16

17. eConsultations
17
COVID-19Pre
COVID-19

18. VideoConsultations
18
• New service. Initial enthusiasm.
• Not very useful. Can’t offer more
than a telephone call…
• Technically difficult for patients
• Not linked to electronic medical
notes
• Need fast broadband (?rural)

19. Future for rural telemedicine
19
• Remote monitoring. Devices that collect (Wearables),
transform and evaluate patient health data such as
blood pressure, oxygen level and respiratory rate, and
report them to the care team – chronic patients
• Chatbots: for recommendations, FAQs, and
connecting at-risk patients to a doctor.

20. Risks with telemedicine
20
• Can induce consultations for banal reasons, which could be
almost 30% of eConsultatios and could increase as easier
access is provided (through a mobile application, for example).
• Can cause inequalities in the use of the service, with access
differences for specific groups of patients according to their
resources or digital skills (elderly). These inequalities could
also occur among professionals less familiar with technological
environments (out of the loop).
• Telemedicine seen as a cheap alternative by governments.

21. Rural justice
21

22. Conclusions
22
• Telemedicine has shown great potential to help improve patient care,
specially in rural settings.
• Telemedicine is a medical act, and as such, must be accepted by the
patient. Patients need to be involved.
• Telemedicine must guarantee the patient's right to autonomy, professional
secrecy, protection of personal data, privacy and confidentiality.
• Telemedicine is not a replacement to face-to-face visits, it is an adjunct
• The professional and the patient should decide which model of visit is
appropriate in each case (face-to-face, telephone, telemedicine, house
visit) and how to reverse a face-to-face visit to a telemedicine one and vice
versa depending on its suitability.
• Telemedicine should not be an excuse for inferior health care and should
not be used to cut health care services, specially in rural areas.

23. ics.gencat.cat
Josep Vidal-Alaball
jvidal.cc.ics@gencat.cat
@jvalaball