Rural health

Village elders participate in a training for rural health care workers in Ethiopia.

In medicine, rural health or rural medicine is the interdisciplinary study of health and health care delivery in rural environments. The concept of rural health incorporates many fields, including geography, midwifery, nursing, sociology, economics, and telehealth or telemedicine.

Research shows that the healthcare needs of individuals living in rural areas are different from those in urban areas, and rural areas often suffer from a lack of access to healthcare. These differences are the result of geographic, demographic, socioeconomic, workplace, and personal health factors. For example, many rural communities have a large proportion of elderly people and children. With relatively few people of working age (20–50 years of age), such communities have a high dependency ratio. People living in rural areas also tend to have poorer socioeconomic conditions, less education, higher rates of tobacco and alcohol use, and higher mortality rates when compared to their urban counterparts.[1] There are also high rates of poverty amongst rural dwellers in many parts of the world, and poverty is one of the biggest social determinants of health.

Many countries have made it a priority to increase funding for research on rural health.[2][3] These efforts have led to the development of several research institutes with rural health mandates, including the Centre for Rural and Northern Health Research in Canada, Countryside Agency in the United Kingdom, the Institute of Rural Health in Australia, and the New Zealand Institute of Rural Health. These research efforts are designed to help identify the healthcare needs of rural communities and provide policy solutions to ensure those needs are met. The concept of incorporating the needs of rural communities into government services is sometimes referred to as rural proofing.

Definitions

There is no international standard for defining rural areas, and standards may vary even within an individual country.[4][5] The most commonly used methodologies fall into two main camps: population-based factors and geography-based factors. The methodologies used for identifying rural areas include population size, population density, distance from an urban centre, settlement patterns, labor market influences, and postal codes.[6]

The reported number of individuals living in rural areas can vary greatly depending on which set of standards is applied. Canada’s rural population can be identified as anywhere from 22% to 38%,[7] of the population. In the United States the variation is greater; between 17% and 63% of the population may be identified as living in rural areas.[8] The lack of consensus makes it difficult to identify the number of individuals who are in need of rural healthcare services.

Life expectancy

Studies show that in many parts of the world life expectancy rates are higher in urban areas than in rural areas.[1] There is some evidence to suggest that the gap may be widening in these countries as economic conditions and health education has improved in urban areas.[9]

In Canada, life expectancy in men ranged from 74 years in the most remote areas to 76.8 years in its urban centers. For women, life expectancy was also lowest in rural areas, with an average of 81.3 years. Those living in rural areas adjacent to urban centers also experience higher life expectancies (with men at 77.4 years and women at 81.5 years). Australian life expectancies ranged from 78 years in major cities to 72 years in remote locations.[10] In China, the life expectancy of females is 73.59 years in urban areas and 72.46 in rural areas. Male life expectancy varies from 69.73 years in urban areas and 58.99 in rural areas.[11]

However, there are countries such as the United Kingdom, where life expectancy in rural areas exceeds that of urban areas. Life expectancy there is two years greater for men and one-and-a-half years greater for women in rural areas when compared to urban areas. This may be due, in part, to smaller economic disparities in rural areas as well as an increasing number of well-educated and wealthy individuals moving to rural areas in retirement.[12] This is a significant departure to the rural poverty found in many countries.

Health determinants

Access to healthcare

Telemedicine consult: Dr. Juan Manuel Romero, a cardiologist in Sonora, Mexico, engages in a pre-op consultation with Alma Guadalupe Xoletxilva, who is 640 km (400 mi) away in La Paz, Baja California. Telemedicine helps deliver care to patients in rural and remote areas.

People in rural areas generally have less access to healthcare than their urban counterparts. Fewer medical practitioners, mental health programs and healthcare facilities in these areas often mean less preventative care and longer response times in emergencies. The lack of healthcare workers has resulted in unconventional ways of delivering healthcare to rural dwellers, including medical consultations by phone or internet as well as mobile preventative care and treatment programs. There have been increased efforts to attract health professionals to isolated locations, such as increasing the number of medical students from rural areas and improving financial incentives for rural practices.[13]

Canadians living in rural areas and small towns have access to half as many physicians (1 per 1000 residents) as their urban counterparts. On average, these individuals have to travel five times the distance (an average of 10 km [6.2 mi])to access these services.[14] They also have fewer specialized health care services such as dentists, dental surgeons, and social workers. One study found ambulance service was available in only 40% of the selected sites, blood and Urine testing services in one third of the sites, and only one of the 19 sites had neonatal services. Nursing service had reduced from 26.3% in 1998 to 21.1% in 2005.[15]

The gap in services is due, in part, to the focus of funding on higher-population areas. In China only 10% of the rural population had medical insurance in 1993, compared with 50% of urban residents.[16] In the 1990s, only 20% of the government's public health spending went to the rural health system, which served 70% of the Chinese population.[16] In the United States, between 1990 and 2000, 228 rural hospitals closed, leading to a reduction of 8,228 hospital beds.[17] In 2009, patients living in rural areas of the United States were transferred to other facilities for care at a rate three times higher than that of patients in large central metropolitan areas.[18]

Rural areas, especially in Africa, have greater difficulties in recruiting and retaining qualified and skilled professionals in the healthcare field.[19] In Sub-Saharan Africa, urban and more prosperous areas have disproportionately more of the countries’ skilled health care workers.[19] For example, urban Zambia has 20 times more doctors and over five times more nurses and midwives than the rural areas. In Malawi, 87% of its population lives in rural areas, but 96.6% of doctors are found in urban health facilities. Burkina Faso has one midwife per 8,000 inhabitants in richer zones, and one per nearly 430,000 inhabitants in the poorest zone.[19] In South Africa alone, half of their population lives in rural areas, but only 12% of doctors actually practice there.[20] One solution has been to develop programs designed to train women to perform home-based health care for patients in Rural Africa. One such program is African Solutions to African Problems (ASAP).[21]

Working conditions

Rural areas often have fewer job opportunities and higher unemployment rates than urban areas. The professions that are available are often physical in nature, including farming, forestry, fishing, manufacturing, and mining.[22][23] These occupations are often accompanied by greater health and safety hazards due to the use of complex machinery, exposure to chemicals, working hours, noise pollution, harsher climates, and physical labor. Rural work forces thus report higher rates of life-threatening injuries.[24][25]

Personal health

Lifestyle and personal health choices also affect the health and expected longevity of individuals in rural areas. Persons from rural areas report higher rates of smoking, exposure to second-hand smoke, and obesity than those in urban areas. Additionally, rural areas often have low rates of fruits and vegetable consumption even where farming is prevalent.[1]

While homicide rates are lower in rural areas, death by injury, suicide and poisoning are significantly more prevalent.[26][27] The Australian Institute of Health and Welfare also reports higher rates of interpersonal violence in rural communities.[10]

Physical environment

In many countries a lack of critical infrastructure and development in rural areas can impair rural health. Insufficient wastewater treatment, lack of paved roads, and exposure to agricultural chemicals have been identified as additional environmental concerns for those living in rural locations.[28] The Australian Institute of Health and Welfare reports lower water quality and increased crowding of households as factors affecting disease control in rural and remote locations.[10]

Efforts to increase health

Since the mid-1980s, there has been increased attention on the discrepancies between healthcare outcomes between individuals in rural areas and those in urban areas. Since that time there has been increased funding by governments and non-governmental organizations to research rural health, provide needed medical services, and incorporate the needs of rural areas into governmental healthcare policy.[29][30] Some countries have started rural proofing programs to ensure that the needs of rural communities, including rural health, are incorporated into national policies.[31][32]

Research centers (such as the Center for Rural and Northern Health Research at Laurentian University, the Center for Rural Health at the University of North Dakota, and the RUPRI Center) and rural health advocacy groups (such as the National Rural Health Association, National Organization of State Offices of Rural Health, National Rural Health Alliance) have been developed in several nations to inform and combat rural health issues.[33]

Rural health projects worldwide

In Canada, many provinces have started to decentralize primary care and move towards a more regional approach. The [Local Health Integration Network] was established in Ontario in 2007 order to address the needs of the many Ontarians living in rural, northern, and remote areas.[34] In China, a US $50 million pilot project was approved in 2008 to improve public health in rural areas.[35] China is also planning to introduce a national health care system.

In the United States, the Health Resources and Services Administration funds the Rural Hospital Performance Improvement Project to improve the quality of care for hospitals with fewer than 200 beds.[36] Eula Hall founded the Mud Creek Clinic in Grethel, Kentucky to provide free and reduced-priced healthcare to residents of Appalachia. In Indiana, St. Vincent Health implemented the Rural and Urban Access to Health to enhance access to care for under-served populations, including Hispanic migrant workers. As of December 2012, the program had facilitated more than 78,000 referrals to care and enabled the distribution of US $43.7 million worth of free or reduced-cost prescription drugs.[37] Owing to the challenges of providing rural healthcare services worldwide, the non-profit group [Remote Area Medical] began as an effort to provide care in third-world nations but now provide services primarily in the US.

Telemedicine and rural health

For residents of rural areas, the lengthy travel time and distance to larger, more developed urban and metropolitan health centers present significant restrictions on access to essential health care services. Telemedicine has been suggested as a way of overcoming transportation barriers for patients and health care providers in rural and geographically isolated areas. According to the Health Resources Services Administration, telemedicine may be defined as the use of electronic information and telecommunication technologies to support long-distance healthcare and clinical relationships.[38][39] Relevant literature notes that telemedicine provides clinical, education, and administrative benefits for rural areas.[40][41][42] First, telemedicine eases the burden of clinical services by the utilization of electronic technology in the direct interaction between health care providers, such as primary and specialist health providers, nurses, and technologists and patients in the diagnosis, treatment, and management of diseases and illnesses.[43] Secondly, the advantage of telemedicine on educational services includes the delivery of healthcare related lectures and workshops through video and tele-conferencing, practical simulations, and web casting. In rural communities, medical professionals may utilize pre-recorded lectures for medical or health care students at remote sites.[41][42] Also, healthcare practitioners in urban and metropolitan areas may utilize teleconferences and diagnostic simulations to assist understaffed healthcare centers in rural communities diagnose and treat patients from a distance.[43] In a study of rural Queensland health systems, more developed urban health centers used video-conferencing to educate rural physicians on treatment and diagnostic advancements for breast and prostate cancer, as well as various skin disorders, such as eczema and chronic irritations.[43] Thirdly, telemedicine may pose significant administrative benefits to rural areas.[41] Not only does telemedicine aid in the collaboration among health providers with regard to the utilization of electronic medical records, but telemedicine may pose benefits for interviewing medical professionals in remote areas for position vacancies and the transmission of necessary operation-related information between rural health systems and larger, more developed healthcare systems.[42][43]

Application of Telemedicine in rural areas

There are two primary methods of telemedicine, which are real-time and store and forward.[43]

Real-Time Telemedicine

In real-time telemedicine, electronic telecommunication allows providers and patients to send and receive health-related information instantly or with limited delay.[39] The most predominate method of real-time telemedicine is videoconferencing.[39] The primary advantage of real-time telemedicine is that it significantly reduces wait time rural patients incur when seeking more specialized health services, and information is shared at an increasing speed.[41][43] Although the costs of videoconferencing equipment may pose strain on the limited financial resources of rural areas, the availability of more advanced and cheaper communication channels, direct two-way audio, and electronic video streaming between rural and more developed urban and metropolitan health centers through computers have led to more economical options.[41][43]

Application of Real-Time Telemedicine

Telepediatrics

It was noted in a study conducted by the University of Queensland that the use of telemedicine within pediatrics provided convenient access to specialist and pediatric services for rural areas lacking on-site pediatricians.[41][43] Telepediatrics involves a wide range of telecommunication options.[41] The most utilized methods are email, telephone correspondence, and videoconferences.[41][43] Approximately 85 percent of all correspondences result in consultations by videoconference. Physicians are able to provide treatment counseling and diagnostic follow-ups by remote satellite conferences. In the study of telemedicine in remote Australian locations conducted by the University of Queensland, it was noted the benefit of telepediatrics spread to more than 35 different pediatric sub-specialties, including cardiology, nephrology, neurology, dermatology, oncology, and psychiatry.[44] For example, remote teledermatology consultations have become commonplace at many medical centers.[43] Many diagnostic dermatology evaluations for young children can be performed by using high-quality still images. Although standard video cameras used in teleconferencing systems may not provide enough detail to make a dermatologic diagnosis, special peripheral cameras termed dermatoscopes have proven adequate.[43]

Additionally, the estimated savings garner by telepediatrics is approximately $1.1 million per year for rural health districts, with regard to travel time and costs.[44] Nevertheless, within rural areas, the effectiveness of telepediatric services hinders on patient-provider coordination, establishment of videoconferencing facilities, and the ability of the rural health centers to garner financial support.[39][41][43][44]

Home Telemedicine

According to the World Health Organization, home health may be defined as the “provision of health services by formal and informal caregivers in the home in order to promote, restore, and maintain an individual’s maximum level of comfort, function, and health …” [43] In 2005, approximately 7.5 million of the 50 million people living in rural American localities were over the age of 65.[45] The rural elderly are more likely to have limited transportation options when compared to their urban counterparts, as rural areas generally lack public transportation and nearby healthcare facilities.[43][45] Nonetheless, home-telemedicine provides options, with regard to the provision of services for asthma, cardiac disease, and smoking cessation.[45] For many of these health services, the primary mode of service delivery is the telephone service, as telephones are the cheapest and most readily available source of communication in rural areas.[43][45] Healthcare providers may discuss treatment options with patients, review diagnostic information, and complete exit counseling over the phone.[43] Additionally, home telephone lines may provide the necessary bandwidth for the electronic transmission of clinical information, such as blood pressure, blood glucose levels, and weight measurements, through NetMeeting software and web cameras.[45]

Store and Forward Telemedicine

While there are primary advantages of real-time telemedicine, the service may not be appropriate in all situations, particularly when it is not possible to gather patients and health care providers at the same time.[43] This method of telemedicine does not require all consulting parties to partake in the exchange of information at the same time, but rather the information may be reviewed at the participants’ convenience.[43] Emails, fax, and post mailings are the primary methods of delivering store and forward telemedicine.[41][43]

Application of Store and Forward Telemedicine

Teleradiology

According to the World Health Organization , teleradiology may be utilized to increase treatment and management options for specialists serving rural areas remotely.[43] Teleradiology greatly improves the quality of services delivered to rural citizens by increasing access to radiologists without traveling to distant locations for service.[46] The benefits are especially noted when service delivery requires the consultation of sub-specialists, such as neuroradiologists and pediatric radiologists, as these healthcare providers are generally located in larger urban research hospitals.[46] In teleradiology, a healthcare provider transmits radiological images, including X-ray computed tomography and Magnetic Resonance Imaging (MRI), to other health providers in remote locations.[39][46] Teleradiology uses standardized network technologies such as the internet, telephone lines, broadband, and local area networks. Specialized software is used to transmit the images and enable the radiologist to effectively analyze the information transmitted by the rural provider.[39][43] The providers to not need to simultaneously conduct virtual meetings online or mobile telephone conferences, but rather may send and review information at any time, 24 hours a day.[39][46] Health providers have the option of reviewing the materials during the consultation with the patient, prior to the meeting, or at any other time.[46]

Telepsychiatry

Access to mental health services have also been increased through the use of telemedicine. Telepsychiatry through video conferencing sessions allows individuals in remote areas to have one-on-one sessions with a mental health professional.[47] In the United States, several programs have been established that use telemedicine to provide mental health services to rural patients. Between 2007 and 2012, the University of Virginia Health System implemented a videoconferencing project that allowed child psychiatry fellows to host approximately 12,000 sessions with children and adolescents living in rural parts of the state.[48] In 2009, the South Carolina Department of Mental Health established a partnership with the University of South Carolina School of Medicine and the South Carolina Hospital Association to form a statewide telepsychiatry program that provides access to psychiatrists to treat patients with mental health issues who present at emergency departments in the network.[49] Videoconferencing has also been used to diagnose child abuse in remote emergency departments and clinics.[50]

See also

References

  1. 1 2 3 How healthy are Rural Canadians? An Assessment of Their Health Status and Health Determinants (PDF). Ottawa: Canadian Institute for Health Information. 2006. ISBN 978-1-55392-881-2. Archived from the original (PDF) on 2010-03-08.
  2. ↑ "Healthy Horizons- Outlook 2003-2007: A Framework for Improving the Health of Rural, Regional, and Remote Australians" (PDF). Australian Health Ministries’ Advisory Council’s National Rural Health Policy Sub-committee and the National Rural Health Alliance for the Australian Health Minister’s Conference. National Rural Health Alliance. 2003. ISBN 07308 56844.
  3. ↑ Ministerial Advisory Council on Rural Health (2002). "Rural Health in Rural Hands: Strategic Directions for Rural, Remote, Northern and Aboriginal Communities" (PDF). Ottawa: Health Canada.
  4. ↑ "Population density and urbanization". United Nations Statistics Division. Retrieved 8 March 2014.
  5. ↑ Pong, R. W.; Pitbaldo, R, J (2001). "Don't take "geography" for granted! Some methodological issues in measuring geographic distribution of physicians". Canadian Journal of Rural Medicine. 6: 105.
  6. ↑ Pitblado, JR (March 2005). "So, what do we mean by "rural," "remote" and "northern"?". The Canadian Journal of Nursing Research. 37 (1): 163–8. PMID 15887771.
  7. ↑ du Plessis, V.; Beshiri, R.; Bollman, R.; Clemenson, H. (2001). "Definitions of Rural" (PDF). Rural and Small Town Canada Analysis Bulletin. 3 (3).
  8. ↑ "Rural Definitions: Data Documentation and Methods". United-States Department of Agriculture. 2007. Retrieved January 31, 2008.
  9. ↑ Stephens, Stephanie. "Gap in Life Expectancy Between Rural and Urban Residents Is Growing". Center for Advancing Health. Retrieved 9 March 2014.
  10. 1 2 3 "Rural, regional, and remote health: Indicators of health". Australian Institute of Health and Welfare. 2005. ISBN 9781740244671. Retrieved February 19, 2008.
  11. ↑ Shen, J (February 1993). "Analysis of urban-rural population dynamics of China: a multiregional life table approach". Environment & Planning. 25 (2): 245–53. doi:10.1068/a250245. PMID 12286564.
  12. ↑ Ramesh, Randeep (25 May 2010). "Country dwellers live longer, report on 'rural idyll' shows". The Guardian. Retrieved 9 March 2014.
  13. ↑ Rourke, J. (2008). "Increasing the number of rural physicians". Canadian Medical Association Journal. 178: 322–325. doi:10.1503/cmaj.070293. PMC 2211345Freely accessible. PMID 18227453.
  14. ↑ Ng, E.; Wilkins, R.; Pole, J.; Adams, O. (1999). "How far to the nearest physician". Rural and Small Town Analysis Bulletin. 1: 1–7.
  15. ↑ Halseth, G.; Ryser, L. (2006). "Trends in service delivery: Examples from rural and small town Canada, 1998 to 2005". Journal of Rural and Community Development. 1: 69–90.
  16. 1 2 Brant, S.; Garris, M.; Okeke, E.; Rosenfeld, J. (2006). "Access to Care in Rural China: a Policy Discussion" (PDF). The Gerald R. Ford School of Public Policy, University of Michigan: 1–19. Retrieved February 27, 2009.
  17. ↑ "Trends in rural hospital closure 1990–2000" (PDF). U.S Department of Health and Human Services. 2003. Retrieved February 19, 2008.
  18. ↑ Kindermann, D; Mutter, R; Pines, JM (February 2006). "Emergency Department Transfers to Acute Care Facilities, 2009: Statistical Brief #155". PMID 24006549.
  19. 1 2 3 "Health Workers Needed: Poor Left Without Care in Africa's Rural Areas". The World Bank. 2008. Retrieved February 27, 2009.
  20. ↑ "Bring Health Care Services to Rural Africa". The Atlantic Philanthropies. 2012. Retrieved Dec 13, 2013.
  21. ↑ "Health". African Solutions to African Problems. 2013. Retrieved December 2, 2013.
  22. ↑ Bollman, Ray D. (13 Nov 2008). "An Overview of Rural and Small Town Canada". Canadian Journal of Agricultural Economics. 39 (4): 805–817. doi:10.1111/j.1744-7976.1991.tb03642.x.
  23. ↑ U.S Congress, 1991
  24. ↑ Gerberich S.G.; Gibson, R.W.; French, L.R.; Lee, T.Y.; Carr, W.P.; Kochevar, L.; Renier, C.M.; Shutske, J. (1998). "Machinery-related injuries: Regional Rural Injury Study-I (RRIS-I)". Accident Analysis and Prevention. 30 (6): 93–804. PMID 9805522.
  25. ↑ Pickett, W.; Hartling, L.; Brison, R. J.; Guernsey, J. R.; Program (1999). "Fatal work-related farm injuries in Canada, 1991-1995". Canadian Medical Association Journal. 160 (13): 1843–1848. PMC 1230438Freely accessible. PMID 10405669.
  26. ↑ Walsh, Bryan (23 July 2013). "In Town vs. Country, It Turns Out That Cities Are the Safest Places to Live". Time. Retrieved 9 March 2014.
  27. ↑ Butterfield, Fox (13 February 2005). "Social Isolation, Guns and a 'Culture of Suicide'". The New York Times. Retrieved 9 March 2014.
  28. ↑ Aday, L. A.; Quill, B. E.; Reyes-Gibby, C. C. (2001). "Equity in rural health and health care". In Loue, Sana; Quill, B.E. Handbook of Rural Health. New York City: Kluwer Academic-Penum Publishers. pp. 45–72. ISBN 9780306464799.
  29. ↑ "A New Era of Responsibility" (PDF). United States Office of Management and Budget.
  30. ↑ Humphreys, J; Hegney, D; Lipscombe, J; Gregory, G; Chater, B (February 2002). "Whither rural health? Reviewing a decade of progress in rural health.". The Australian Journal of Rural Health. 10 (1): 2–14. doi:10.1046/j.1440-1584.2002.00435.x. PMID 11952516.
  31. ↑ "Rural proofing guidance". Department for Environment, Food & Rural Affairs. Government of the United Kingdom. 16 May 2013. Retrieved 9 March 2014.
  32. ↑ "What makes rural New Zealand different". Ministry for Primary Industries. Government of New Zealand. 17 September 2010. Retrieved 9 March 2014.
  33. ↑ Ottawa Charter for Health Promotion (PDF). First International Conference on Health Promotion. World Health Organization. November 21, 1986. Archived from the original (PDF) on February 18, 2012. Retrieved February 15, 2009.
  34. ↑ "Population health profile: North East LHIN" (PDF). North Bay, Ontario: North East LHIN: North East Local Health Integration Network. 2006. Retrieved January 20, 2009.
  35. ↑ "China launches rural health project". China Daily. 2008. Retrieved March 2, 2009.
  36. ↑ "Challenges Facing Rural Health Care: A Conversation With Brock Slabach, Senior Vice President for Member Services at the National Rural Health Association". Agency for Healthcare Research and Quality. 2013-04-17. Retrieved 2013-09-29.
  37. ↑ "Field-Based Outreach Workers Facilitate Access to Health Care and Social Services for Underserved Individuals in Rural Areas". Agency for Healthcare Research and Quality. 2013-05-01. Retrieved 2013-05-13.
  38. ↑ Telehealth use in Rural Healthcare. Rural Assistance Center Web site. http://www.raconline.org/topics/telehealth Published October 2011. Updated August 5, 2014. Accessed November 1, 2014.
  39. 1 2 3 4 5 6 7 Rural Health. HealthIT.gov Website. http://www.healthit.gov/providers-professionals/frequently-asked-questions/487#id157 Accessed November 3, 2014.
  40. ↑ What is telemedicine?. Telemedicine ICUCARE website. https://www.icucare.com/PageFiles/Telemedicine.pdf. Accessed November 3, 2014.
  41. 1 2 3 4 5 6 7 8 9 10 Smith, A., Bensink, M., Armfield, N., Stillman, J.,& Caffery,L. Telemedicine and rural health care applications. Journal of Postgraduate Medicine. 2005; 51: 286-293.
  42. 1 2 3 McCrossin R. Successes and failures with grand rounds via videoconferencing at the Royal Children's Hospital in Brisbane. Journal of Telemedicine and Telecare.2001;7:25-8.
  43. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Hornsby D. Videoconference Usage Report: May 2000. Brisbane: Queensland Telemedicine Network (Queensland Health);2000
  44. 1 2 3 Finley, J., Sharratt, G., Nanton, M., Chen, R., Bryan, P., & Wolstenholme J. Paediatric echocardiography by telemedicine - nine years' experience. Journal of Telemedicine and Telecare. 1997;3:200-4.
  45. 1 2 3 4 5 Affordable Care Act provisions affecting the rural elderly. National Advisory Committee Rural Health and Human Services website. http://www.hrsa.gov/advisorycommittees/rural/publications/elderly.pdf Created December 2011. Accessed November 12, 2014.
  46. 1 2 3 4 5 Crowe BL, Hailey DM, de Silva M. Teleradiology at a children's hospital: a pilot study. Journal of Telemedicine and Telecare. 1996;2:210-6.
  47. ↑ Ana Maria Lopez, MD, MPH, FACP (2013-12-04). "Academic Telepsychiatry Programs Enhance Access for Rural Populations". Retrieved 2013-12-04.
  48. ↑ "Videoconferencing Enhances Access to Psychiatric Care for Children and Adults With Mental Illness in Rural Settings". Agency for Healthcare Research and Quality. 2013-12-04. Retrieved 2013-12-04.
  49. ↑ "Statewide Partnership Provides Mental Health Assessments via Telemedicine to Patients in Rural Emergency Departments, Reducing Wait Times, Hospitalizations, and Costs". Agency for Healthcare Research and Quality. 2013-12-04. Retrieved 2013-12-04.
  50. ↑ "Child Abuse Experts Provide Videoconference-Enabled Consultations to Providers in Remote Emergency Departments and Clinics, Leading to More Accurate Diagnosis". Agency for Healthcare Research and Quality. 2014-03-26. Retrieved 2014-03-26.

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