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Aust. J. Rural Health (2015) 23, 19–23
Special Issue – Rural Cancer Original Research Specialist cancer care through Telehealth models Sabe Sabesan, BMBS(Flinders), FRACP Tropical Centre for Telehealth Practice and Research, Townsville Cancer Centre, Townsville Hospital, and School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
Abstract Objective: Disparities in outcomes are experienced between people who live in rural and remote areas and those who live in larger cities. This paper explores the ability to deliver specialist cancer care through the use of telehealth models. Design: Review of telehealth models for cancer care. Setting, participants and intervention: Cancer patients in rural, remote and Indigenous communities who receive their care through telehealth. Outcome measures and results: Telehealth models seem to be applicable to all fields of oncology and all health professionals. These models not only facilitate the provision of specialist services closer to home in an acceptable, safe and cost-effective manner, but also help expand the rural scope of practice and enhance service capabilities at rural centres. Conclusion: New models of telehealth are another avenue to help further decrease the disparity of access and survival outcomes between rural and urban patients. Implementation of these models requires health system wide approach for development key performance indicators and allocation of resources. KEY WORDS: cancer, rural, telehealth, telemedicine.
Introduction
overall work force shortages. These three factors create and perpetuate a vicious cycle (Fig. 1), with the end result of lack of availability of specialist services closer to home and the need for often costly long distance travel. In this vicious cycle, lack of availability of specialists or specialist visits may be due to true shortage of specialist workforce, or low patient numbers, which does not justify the time and cost of specialist travel to many rural centres.3 Telehealth is an example of one solution to break this vicious cycle by increasing the rural access to specialists from tertiary or larger regional centres. It appears that there is a role for teleoncology (telehealth in oncology) models in almost all the subspecialties in cancer care including medical and radiation oncology, haematology and bone marrow transplantation, palliative care, nursing and allied health. Table 1 summarises the nature of services provided by various subspecialties. In addition, teleoncology models are increasingly used for providing clinicians from smaller centres access to multidisciplinary team meetings at larger cancer centres.13
Outcomes of teleoncology models Several evaluation studies have reported positive findings with telehealth and teleoncology. These findings include:
Limited and/or lack of access to specialist cancer services is a well-known health and societal problem faced by patients from rural and remote areas in Australia and other countries with large travel distances.1–3 These access problems are partly due to lack of specialist visits or availability of specialists locally, narrow scope of practice for rural health professionals and
High rates of satisfaction of telehealth models among patients and rural health professionals,14–16 • Safety of chemotherapy supervision remotely,17 • Cost savings to the health systems.18,19 However, literature on true savings to the patients and their carers and survival outcomes is limited. These outcomes are summarised in Table 2.
Correspondence: A/Prof Sabe Sabesan, Tropical Centre for Telehealth Practice and Research, Townsville Cancer Centre, Townsville Hospital, 100 Angus Smith Drive, Townsville, Queensland, 4814, Australia. Email: sabe.sabesan@health .qld.gov.au
Requirements for teleoncology services
Accepted for publication 4 December 2014. © 2015 National Rural Health Alliance Inc.
•
Various colleges and professional associations have developed guidelines to assist with the effective doi: 10.1111/ajr.12170
20
S. SABESAN
What is already known on this subject: • There are disparities in outcomes between people who live in metropolitan and rural/ remote Australia. These disparities are complex and are not simply related to differentials in access. • New models of care allow a number of therapies to be provided safely closer to home and some ongoing assessment that otherwise would require travel.
TABLE 1: Examples of telehealth services provided by oncology sub-specialities Subspecialty
Examples of services
Radiation oncology4,5 Medical oncology6,7
Radiotherapy treatment planning Patient consultations Patient consultations Remote supervision of chemotherapy Acute care management Patient consultation and home management Patient consultations
Palliative care8,9 Haematology/ Bone marrow Transplantation Nursing10
Allied health11,12
FIGURE 1:
Patient education Supervision of oral and intravenous chemotherapy administration Swallow assessment, lymphoedema management psychosocial counselling
What this study adds: • This paper is a worked example of telehealth in the real world, delivering care in the Australian context. • It provides a framework for models that can deliver systems change. • It is a successful demonstration project of the use telehealth, significantly improving specialist access over a large geographic region within existing funding mechanisms.
implementation of telehealth models. Although these guidelines are not specific to oncology, the requirements and principles of establishing such models are same for all specialities. One such example is the Royal Australasian College of Physicians (RACP) Guidelines and Practical Tips for Telehealth accessible via http:// www.racptelehealth.com.au/guidelines/. Another useful resource is the practical aspects of Telehealth series of articles produced by the RACP Telehealth Working Group. Essentially, all these guidelines assist the clinicians and health managers in several requirements of telehealth including issues such as technology, funding and resources, training, governance and other aspects of health care. Specific to oncology, more guidance is needed in relation to breaking bad news and discussing prognosis on technology-based consultations.
Enhancing rural capabilities through telehealth Telehealth models can improve the access to specialists closer to home.6 Providing telehealth consultations will
The vicious cycle of issues related to rural specialist services. © 2015 National Rural Health Alliance Inc.
21
CANCER CARE THROUGH TELEHEALTH MODELS
TABLE 2:
Summary of reported outcomes on telehealth models
Outcome
Results
Comments
Patient satisfaction
High levels of satisfaction among patients including Indigenous patients High levels of acceptance of telehealth models
Benefits include reduction in travel, reduced cost of travel, less disruption to family and work routine Major benefits for continuity of care, ability to network with tertiary colleagues and to receive support This is based on a single centre study.
Perspectives of health professionals Safety of chemotherapy supervision Cost
Dose intensity and safety profile was similar to reports in the literature Telehealth models can save money to the health system
FIGURE 2: A Townsville teleoncology network model of rural specialist service.
Townsville Cancer Centre Medical oncology Staff specialists
When the number of consultations increases, savings also increase. Limited studies on cost savings to patients.
Mt Isa Cancer Care Unit Telemedicine
Staff Allied health, local senior and junior medical officers, nursing Services Specialist clinics-new, routine and on demand, ward consults, urgent reviews, most cancer types, all chemotherapy regimens, in patient admissions
reduce the need for unnecessary travel to major centres. If specialist treatment is not provided as part of the model, it is unlikely that the scope of practice and workforce will improve at rural centres. The following case study illustrates how rural service capability can be improved by shifting specialist services closer to home.
Townsville-Mt Isa case study Prior to the establishment of the Townsville teleoncology network (TTN)6, all patients had to travel to Townsville for specialist consultations and most types of chemotherapy regimens. Because the establishment of the TTN, by shifting specialist medical oncology services to Mt Isa gradually over 6 years, the scope of practice has expanded and the number of health professionals increased to accommodate the new services and scope of practice. As a result, Mt Isa has become a stand-alone rural cancer care unit as depicted in Figure 2. This case study illustrates how telehealth models have the potential to break the rural viscous cycle depicted in © 2015 National Rural Health Alliance Inc.
Figure 1 and to expand the scope of practice and enhance the rural workforce as illustrated in Figure 3. As a result of such models rural patients are able to receive their specialist services closer to home without travelling long distances and suffering disruption to work and family routine.
More needs to be done Current telehealth and outreach models serve patients from larger rural centres and patients from smaller centres; however, many are unable to receive cancer care closer to home due to shortages of chemotherapy nurses and oncology pharmacists. Therefore, new models of remote chemotherapy supervision incorporating telenursing and telepharmacy are needed in addition to the specialist consultations via telehealth. One such model is the Queensland Remote Chemotherapy Supervision model; endorsed by the Queensland Health for state-wide implementation.
22
FIGURE 3:
S. SABESAN
Impact of telehealth on rural service capabilities.
Another issue for rural centres is the limited access to clinical trials, which are important aspect of modern cancer care. Because one of the barriers to participation in clinical trials is distance and travel,20 pharmaceutical companies and corporate trial groups need to accept telehealth models as part of their protocols. Telehealth models can be used for consenting, monitoring of toxicities, supervising oral medications and follow up as part of clinical trials. Because communication skills are paramount in oncology, health professionals, such as doctors, nurses, allied health professionals and cancer care coordinators, involved in cancer care of rural patients need to have some training in telehealth consultations in order to provide effective and culturally appropriate cancer care. Finally, to increase the uptake of telehealth, hospitals need to incorporate telehealth as part of their core business and implement it through appropriate key performance indicators and allocation of necessary resources.
Conclusion Telehealth models are applicable to all fields of oncology and all health professionals. These models not only facilitate the provision of specialist services closer to home but also help expand the rural scope of practice and enhance service capabilities at rural centres. New models of telehealth are needed to decrease the disparity of access and survival outcomes between rural and urban patients.
References 1 Underhill C, Bartel R, Goldstein D et al. Mapping oncology services in regional and rural Australia. Australian Journal of Rural Health 2009; 17: 321–329.
2 Sabesan S, Piliouras P. Disparity in cancer survival between urban and rural patients – how can clinicians help reduce it? Rural and Remote Health 2009; 9: 1146. 3 DOHA (Department of Health and Ageing). Report on the audit of health workforce in rural and regional Australia. 2008. [Cited 13 Oct 2012]. Available from URL: http:// www.health.gov.au/internet/main/publishing.nsf/content/ work-res-ruraud-toc 4 Mueller B, Obcemea C, Lee J, Sim S. Pilot study of a radiation oncology telemedicine platform. Journal of Radiation Oncology Informatics 2010; 2: 20–30. 5 Norum J, Bruland ØS, Spanne O et al. Telemedicine in radiotherapy: a study exploring remote treatment planning, supervision and economics. Journal of Telemedicine and Telecare 2005; 11: 245–250. 6 Sabesan S, Larkins S, Evans R et al. Telemedicine for rural cancer in North Queensland:Bringing cancer care home. The Australian Journal of Rural Health 2012; 20: 259–264. 7 Doolittle GC, Spaulding A. Providing access to oncology care for rural patients via telemedicine. Journal of Oncology Practice 2006; 2: 228–230. 8 Kidd L, Cayless S, Johnston B, Wengstrom Y. Telehealth in palliative care in the UK: a review of the evidence. Journal of Telemedicine and Telecare 2010; 16: 394–402. 9 Bradford N, Herbert A, Walker R et al. Home telemedicine for paediatric palliative care. Studies in Health Technology and Informatics 2010; 161: 1–9. 10 Price S, Roberts S, Bloomfield A A pilot project to improve access to chemotherapy/biotherapy for rural patients: the Townsville Tele Nursing Model. Paper presented to Annual Scientific Meeting; Cancer Nursing Society of Australia, Brisbane. 2013. [Cited 16 Nov 2014]. Available from URL: www.cnsa.org.au/content/documents/reports/ Handbook%202013.pdf 11 Shepherd L, Goldstein D, Whitford H. The utility of videoconferencing to provide innovative delivery of psychological treatment for rural cancer patients. Journal of Pain and Symptom Management 2006; 32: 453–461.
© 2015 National Rural Health Alliance Inc.
CANCER CARE THROUGH TELEHEALTH MODELS
12 Burns CL, Ward EC, Hill AJ et al. A pilot trial of a speech pathology telehealth service for head and neck cancer patients. Journal of Telemedicine and Telecare 2012; 18: 443–446. 13 Olver I, SelvaNayagam S. Evaluation of a telemedicine link between Darwin and Adelaide to facilitate cancer management. Telemedicine Journal 2000; 6: 213–218. 14 Mair F, Whitten P, May C, Doolittle GC. Patients’ perceptions of a telemedicine specialty clinic. Journal of Telemedicine and Telecare 2000; 6: 36–40. 15 Mooi JK, Whop LJ, Valery PC, Sabesan SS. Teleoncology for Indigenous patients: the responses of patients and health workers. The Australian Journal of Rural Health 2012; 20: 265–269. 16 Sabesan S, Simcox K, Marr I. Medical oncology clinics via videoconferencing: an acceptable tele health model for rural patients and health workers. Internal Medicine Journal 2012; 42: 780–785.
© 2015 National Rural Health Alliance Inc.
23 17 Chan B, Sabesan S Safety of tele-oncology and chemotherapy delivery in rural centres. 2012. [Cited 16 Feb 2013]. Available from URL: http://cosa-ipos-2012.p.asnevents .com.au/event/abstract/2677 18 Doolittle GC, Williams AR, Spaulding A, Spaulding RJ, Cook DJ. A cost analysis of a tele-oncology practice in the United States. Journal of Telemedicine & Telecare 2004; 10 (Suppl. 1): 27–29. 19 Thaker D, Monypenny R, Olver I, Sabesan S. Cost savings from a telemedicine model of care in northern Queensland, Australia. The Medical Journal of Australia 2013; 199: 414–417. 20 Sabesan S, Burgehr B, Buettner P et al. Attitudes, knowledge and barriers to participation in cancer clinical trials among rural and remote patients. Asia-Pacific Journal of Clinical Oncology 2011; 7: 27–33.
Copyright of Australian Journal of Rural Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Aust. J. Rural Health (2015) 23, 19–23
Special Issue – Rural Cancer Original Research Specialist cancer care through Telehealth models Sabe Sabesan, BMBS(Flinders), FRACP Tropical Centre for Telehealth Practice and Research, Townsville Cancer Centre, Townsville Hospital, and School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
Abstract Objective: Disparities in outcomes are experienced between people who live in rural and remote areas and those who live in larger cities. This paper explores the ability to deliver specialist cancer care through the use of telehealth models. Design: Review of telehealth models for cancer care. Setting, participants and intervention: Cancer patients in rural, remote and Indigenous communities who receive their care through telehealth. Outcome measures and results: Telehealth models seem to be applicable to all fields of oncology and all health professionals. These models not only facilitate the provision of specialist services closer to home in an acceptable, safe and cost-effective manner, but also help expand the rural scope of practice and enhance service capabilities at rural centres. Conclusion: New models of telehealth are another avenue to help further decrease the disparity of access and survival outcomes between rural and urban patients. Implementation of these models requires health system wide approach for development key performance indicators and allocation of resources. KEY WORDS: cancer, rural, telehealth, telemedicine.
Introduction
overall work force shortages. These three factors create and perpetuate a vicious cycle (Fig. 1), with the end result of lack of availability of specialist services closer to home and the need for often costly long distance travel. In this vicious cycle, lack of availability of specialists or specialist visits may be due to true shortage of specialist workforce, or low patient numbers, which does not justify the time and cost of specialist travel to many rural centres.3 Telehealth is an example of one solution to break this vicious cycle by increasing the rural access to specialists from tertiary or larger regional centres. It appears that there is a role for teleoncology (telehealth in oncology) models in almost all the subspecialties in cancer care including medical and radiation oncology, haematology and bone marrow transplantation, palliative care, nursing and allied health. Table 1 summarises the nature of services provided by various subspecialties. In addition, teleoncology models are increasingly used for providing clinicians from smaller centres access to multidisciplinary team meetings at larger cancer centres.13
Outcomes of teleoncology models Several evaluation studies have reported positive findings with telehealth and teleoncology. These findings include:
Limited and/or lack of access to specialist cancer services is a well-known health and societal problem faced by patients from rural and remote areas in Australia and other countries with large travel distances.1–3 These access problems are partly due to lack of specialist visits or availability of specialists locally, narrow scope of practice for rural health professionals and
High rates of satisfaction of telehealth models among patients and rural health professionals,14–16 • Safety of chemotherapy supervision remotely,17 • Cost savings to the health systems.18,19 However, literature on true savings to the patients and their carers and survival outcomes is limited. These outcomes are summarised in Table 2.
Correspondence: A/Prof Sabe Sabesan, Tropical Centre for Telehealth Practice and Research, Townsville Cancer Centre, Townsville Hospital, 100 Angus Smith Drive, Townsville, Queensland, 4814, Australia. Email: sabe.sabesan@health .qld.gov.au
Requirements for teleoncology services
Accepted for publication 4 December 2014. © 2015 National Rural Health Alliance Inc.
•
Various colleges and professional associations have developed guidelines to assist with the effective doi: 10.1111/ajr.12170
20
S. SABESAN
What is already known on this subject: • There are disparities in outcomes between people who live in metropolitan and rural/ remote Australia. These disparities are complex and are not simply related to differentials in access. • New models of care allow a number of therapies to be provided safely closer to home and some ongoing assessment that otherwise would require travel.
TABLE 1: Examples of telehealth services provided by oncology sub-specialities Subspecialty
Examples of services
Radiation oncology4,5 Medical oncology6,7
Radiotherapy treatment planning Patient consultations Patient consultations Remote supervision of chemotherapy Acute care management Patient consultation and home management Patient consultations
Palliative care8,9 Haematology/ Bone marrow Transplantation Nursing10
Allied health11,12
FIGURE 1:
Patient education Supervision of oral and intravenous chemotherapy administration Swallow assessment, lymphoedema management psychosocial counselling
What this study adds: • This paper is a worked example of telehealth in the real world, delivering care in the Australian context. • It provides a framework for models that can deliver systems change. • It is a successful demonstration project of the use telehealth, significantly improving specialist access over a large geographic region within existing funding mechanisms.
implementation of telehealth models. Although these guidelines are not specific to oncology, the requirements and principles of establishing such models are same for all specialities. One such example is the Royal Australasian College of Physicians (RACP) Guidelines and Practical Tips for Telehealth accessible via http:// www.racptelehealth.com.au/guidelines/. Another useful resource is the practical aspects of Telehealth series of articles produced by the RACP Telehealth Working Group. Essentially, all these guidelines assist the clinicians and health managers in several requirements of telehealth including issues such as technology, funding and resources, training, governance and other aspects of health care. Specific to oncology, more guidance is needed in relation to breaking bad news and discussing prognosis on technology-based consultations.
Enhancing rural capabilities through telehealth Telehealth models can improve the access to specialists closer to home.6 Providing telehealth consultations will
The vicious cycle of issues related to rural specialist services. © 2015 National Rural Health Alliance Inc.
21
CANCER CARE THROUGH TELEHEALTH MODELS
TABLE 2:
Summary of reported outcomes on telehealth models
Outcome
Results
Comments
Patient satisfaction
High levels of satisfaction among patients including Indigenous patients High levels of acceptance of telehealth models
Benefits include reduction in travel, reduced cost of travel, less disruption to family and work routine Major benefits for continuity of care, ability to network with tertiary colleagues and to receive support This is based on a single centre study.
Perspectives of health professionals Safety of chemotherapy supervision Cost
Dose intensity and safety profile was similar to reports in the literature Telehealth models can save money to the health system
FIGURE 2: A Townsville teleoncology network model of rural specialist service.
Townsville Cancer Centre Medical oncology Staff specialists
When the number of consultations increases, savings also increase. Limited studies on cost savings to patients.
Mt Isa Cancer Care Unit Telemedicine
Staff Allied health, local senior and junior medical officers, nursing Services Specialist clinics-new, routine and on demand, ward consults, urgent reviews, most cancer types, all chemotherapy regimens, in patient admissions
reduce the need for unnecessary travel to major centres. If specialist treatment is not provided as part of the model, it is unlikely that the scope of practice and workforce will improve at rural centres. The following case study illustrates how rural service capability can be improved by shifting specialist services closer to home.
Townsville-Mt Isa case study Prior to the establishment of the Townsville teleoncology network (TTN)6, all patients had to travel to Townsville for specialist consultations and most types of chemotherapy regimens. Because the establishment of the TTN, by shifting specialist medical oncology services to Mt Isa gradually over 6 years, the scope of practice has expanded and the number of health professionals increased to accommodate the new services and scope of practice. As a result, Mt Isa has become a stand-alone rural cancer care unit as depicted in Figure 2. This case study illustrates how telehealth models have the potential to break the rural viscous cycle depicted in © 2015 National Rural Health Alliance Inc.
Figure 1 and to expand the scope of practice and enhance the rural workforce as illustrated in Figure 3. As a result of such models rural patients are able to receive their specialist services closer to home without travelling long distances and suffering disruption to work and family routine.
More needs to be done Current telehealth and outreach models serve patients from larger rural centres and patients from smaller centres; however, many are unable to receive cancer care closer to home due to shortages of chemotherapy nurses and oncology pharmacists. Therefore, new models of remote chemotherapy supervision incorporating telenursing and telepharmacy are needed in addition to the specialist consultations via telehealth. One such model is the Queensland Remote Chemotherapy Supervision model; endorsed by the Queensland Health for state-wide implementation.
22
FIGURE 3:
S. SABESAN
Impact of telehealth on rural service capabilities.
Another issue for rural centres is the limited access to clinical trials, which are important aspect of modern cancer care. Because one of the barriers to participation in clinical trials is distance and travel,20 pharmaceutical companies and corporate trial groups need to accept telehealth models as part of their protocols. Telehealth models can be used for consenting, monitoring of toxicities, supervising oral medications and follow up as part of clinical trials. Because communication skills are paramount in oncology, health professionals, such as doctors, nurses, allied health professionals and cancer care coordinators, involved in cancer care of rural patients need to have some training in telehealth consultations in order to provide effective and culturally appropriate cancer care. Finally, to increase the uptake of telehealth, hospitals need to incorporate telehealth as part of their core business and implement it through appropriate key performance indicators and allocation of necessary resources.
Conclusion Telehealth models are applicable to all fields of oncology and all health professionals. These models not only facilitate the provision of specialist services closer to home but also help expand the rural scope of practice and enhance service capabilities at rural centres. New models of telehealth are needed to decrease the disparity of access and survival outcomes between rural and urban patients.
References 1 Underhill C, Bartel R, Goldstein D et al. Mapping oncology services in regional and rural Australia. Australian Journal of Rural Health 2009; 17: 321–329.
2 Sabesan S, Piliouras P. Disparity in cancer survival between urban and rural patients – how can clinicians help reduce it? Rural and Remote Health 2009; 9: 1146. 3 DOHA (Department of Health and Ageing). Report on the audit of health workforce in rural and regional Australia. 2008. [Cited 13 Oct 2012]. Available from URL: http:// www.health.gov.au/internet/main/publishing.nsf/content/ work-res-ruraud-toc 4 Mueller B, Obcemea C, Lee J, Sim S. Pilot study of a radiation oncology telemedicine platform. Journal of Radiation Oncology Informatics 2010; 2: 20–30. 5 Norum J, Bruland ØS, Spanne O et al. Telemedicine in radiotherapy: a study exploring remote treatment planning, supervision and economics. Journal of Telemedicine and Telecare 2005; 11: 245–250. 6 Sabesan S, Larkins S, Evans R et al. Telemedicine for rural cancer in North Queensland:Bringing cancer care home. The Australian Journal of Rural Health 2012; 20: 259–264. 7 Doolittle GC, Spaulding A. Providing access to oncology care for rural patients via telemedicine. Journal of Oncology Practice 2006; 2: 228–230. 8 Kidd L, Cayless S, Johnston B, Wengstrom Y. Telehealth in palliative care in the UK: a review of the evidence. Journal of Telemedicine and Telecare 2010; 16: 394–402. 9 Bradford N, Herbert A, Walker R et al. Home telemedicine for paediatric palliative care. Studies in Health Technology and Informatics 2010; 161: 1–9. 10 Price S, Roberts S, Bloomfield A A pilot project to improve access to chemotherapy/biotherapy for rural patients: the Townsville Tele Nursing Model. Paper presented to Annual Scientific Meeting; Cancer Nursing Society of Australia, Brisbane. 2013. [Cited 16 Nov 2014]. Available from URL: www.cnsa.org.au/content/documents/reports/ Handbook%202013.pdf 11 Shepherd L, Goldstein D, Whitford H. The utility of videoconferencing to provide innovative delivery of psychological treatment for rural cancer patients. Journal of Pain and Symptom Management 2006; 32: 453–461.
© 2015 National Rural Health Alliance Inc.
CANCER CARE THROUGH TELEHEALTH MODELS
12 Burns CL, Ward EC, Hill AJ et al. A pilot trial of a speech pathology telehealth service for head and neck cancer patients. Journal of Telemedicine and Telecare 2012; 18: 443–446. 13 Olver I, SelvaNayagam S. Evaluation of a telemedicine link between Darwin and Adelaide to facilitate cancer management. Telemedicine Journal 2000; 6: 213–218. 14 Mair F, Whitten P, May C, Doolittle GC. Patients’ perceptions of a telemedicine specialty clinic. Journal of Telemedicine and Telecare 2000; 6: 36–40. 15 Mooi JK, Whop LJ, Valery PC, Sabesan SS. Teleoncology for Indigenous patients: the responses of patients and health workers. The Australian Journal of Rural Health 2012; 20: 265–269. 16 Sabesan S, Simcox K, Marr I. Medical oncology clinics via videoconferencing: an acceptable tele health model for rural patients and health workers. Internal Medicine Journal 2012; 42: 780–785.
© 2015 National Rural Health Alliance Inc.
23 17 Chan B, Sabesan S Safety of tele-oncology and chemotherapy delivery in rural centres. 2012. [Cited 16 Feb 2013]. Available from URL: http://cosa-ipos-2012.p.asnevents .com.au/event/abstract/2677 18 Doolittle GC, Williams AR, Spaulding A, Spaulding RJ, Cook DJ. A cost analysis of a tele-oncology practice in the United States. Journal of Telemedicine & Telecare 2004; 10 (Suppl. 1): 27–29. 19 Thaker D, Monypenny R, Olver I, Sabesan S. Cost savings from a telemedicine model of care in northern Queensland, Australia. The Medical Journal of Australia 2013; 199: 414–417. 20 Sabesan S, Burgehr B, Buettner P et al. Attitudes, knowledge and barriers to participation in cancer clinical trials among rural and remote patients. Asia-Pacific Journal of Clinical Oncology 2011; 7: 27–33.
Copyright of Australian Journal of Rural Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
