title: Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability.
abstract: With the escalating costs of health care, issues with recruitment and retention of health practitioners in rural areas, and poor economies of scale, the question of delivering people to services or services to people is a dilemma for health authorities around the world. People living in rural areas have poorer health outcomes compared to their urban counterparts, and the problem of how to provide health care and deliver services in rural locations is an ongoing challenge. Telehealth services can efficiently and effectively improve access to healthcare for people living in rural and remote areas of Australia. However, telehealth services are not mainstream or routinely available in many rural and remote locations. The barriers to integration of telehealth into mainstream practice have been well described, but not the factors that may influence the success and sustainability of a service. Our aim was to collate, review and synthesise the available literature regarding telehealth services in rural and remote locations of Australia, and to identify the factors associated with their sustained success.
  
  
  
  A systematic literature review of peer-reviewed and grey literature was undertaken. Electronic databases were searched for potentially relevant articles. Reference lists of retrieved articles and the grey literature were also searched. Searches identified 970 potentially eligible articles published between 1988 and 2015. Studies and manuscripts of any type were included if they described telehealth services (store-and-forward or real-time videoconferencing) to provide clinical service or education and training related to health care in rural or remote locations of Australia. Data were extracted according to pre-defined criteria and checked for completeness and accuracy by a second reviewer. Any disagreements were resolved with discussion with a third researcher. All articles were appraised for quality and levels of evidence. Data were collated and grouped into categories including clinical speciality, disciplines involved, geographical location and the role of the service. Data relating to the success or sustainability of services were grouped thematically.
  
  
  
  Inclusion criteria were met by 116 articles that described 72 discrete telehealth services. Telehealth services in rural and remote Australia are described and we have identified six key factors associated with the success and sustainability of services: vision, ownership, adaptability, economics, efficiency and equipment.
  
  
  
  Telehealth has the potential to address many of the key challenges to providing health in Australia, with its substantial land area and widely dispersed population. This review collates information regarding the telehealth services in Australia and describes models of care and characteristics of successful and sustainable services. We identified a wide variety of telehealth services being provided in rural and remote areas of Australia. There is great potential to increase this number by scaling up and replicating successful services. This review provides information for policy makers, governments and public and private health services that wish to integrate telehealth into routine practice and for telehealth providers to enhance the sustainability of their service.
authors.affiliation: The University of Queensland, Centre for Online Health, Princess Alexandra Hospital, Telehealth Centre, Woollongabba, Queensland, Australia. n.bradford@uq.edu.au.
authors.forename: Natalie K
authors.initials: NK
authors.lastname: Bradford
authors.affiliation: The University of Queensland, Centre for Online Health, Princess Alexandra Hospital, Telehealth Centre, Woollongabba, Queensland, Australia. l.caffery@uq.edu.au.
authors.forename: Liam J
authors.initials: LJ
authors.lastname: Caffery
authors.affiliation: The University of Queensland, Centre for Online Health, Princess Alexandra Hospital, Telehealth Centre, Woollongabba, Queensland, Australia. asmith@uq.edu.au.
authors.forename: Anthony C
authors.initials: AC
authors.lastname: Smith
mesh_terms: D001315:Australia; D017598:Efficiency, Organizational; D055317:Evidence-Based Practice; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D011320:Primary Health Care / Q000458:organization & administration*; D012423:Rural Health; D012424:Rural Population / Q000706:statistics & numerical data*; D017216:Telemedicine / Q000706:statistics & numerical data*
keywords: Administrator; Australia/Pacific; Continuing Professional Education; Health Scientist; Health Service reform; Management/Administration; Public Health; Researcher; Workforce