PROTOCOL: The Value of Rural Provider-To-Provider Telehealth for Emergency and Inpatient Care: An Evidence and Gap Map

Abstract

This is the protocol for a Campbell evidence and gap map. The aim is to identify and describe the available evidence on Rural Provider-to-Provider Telehealth (RPPT) used in emergency and inpatient healthcare in rural and remote settings, and to categorise reported outcomes according to the domains of the Model for Assessment of Telemedicine Applications (MAST) framework.

Background

Introduction

The Problem, Condition or Issue

Barriers to equitable access to healthcare in rural and remote areas include limited service availability, higher costs of delivery, and social determinants of health (Baazeem et al., 2024; Thorn & Olley, 2023). The lack of specialised community services, as well as preventative and primary healthcare contribute to higher emergency department presentations and acute hospitalisations due to delayed care and illness complexity, increasing burden of disease and system costs (Australian Institute of Health and Welfare, 2024; Harper et al., 2021; World Health Organization and the United Nations Children’s Fund, 2018).

Many countries, including Australia, aspire to universal health coverage (World Health Organization, 2024). In this context, equity is a core goal of universal health coverage, often defined as the absence of avoidable, unfair, or remediable differences among groups (social, economic, demographic, geographic, or other forms of stratification (World Health Organization, 2024). However, equity is not automatically achieved by systems claiming universal health coverage, it requires deliberate policies and actions to address these disparities.

The World Health Organization (WHO) defines an accessible hospital system as one which delivers healthcare that is timely, within a reasonable geographic distance, and in settings where skills and resources match medical need (World Health Organization, 2006). Virtual health solutions have been advanced as a way to build, strengthen, and futureproof health systems (Australian Digital Health Agency, 2020, 2021; Baazeem et al., 2024; Deloitte, 2022). The COVID-19 pandemic accelerated innovation and adoption of virtual care globally, enabling swift implementation of services that either supplement in-person care or deliver care where it was previously unavailable (Deerain, 2022; Hall Dykgraaf et al., 2021). Evidence suggests multifaceted benefits, particularly in rural and remote areas where virtual healthcare has longstanding use (Bradford et al., 2016). Healthcare enabled by technology, encompassing the terms telehealth and telemedicine, has been associated with increased utlisation, improved access, reduced inconvenience, potential cost reductions, better care coordination for chronic disease management, and enhanced peer support for providers (Bradford et al., 2016; du Toit et al., 2019).

Persistent barriers coupled with the expanding role of virtual care, particularly for emergency and inpatient contexts, underscore the need to consolidate decision-relevant evidence to inform equitable service delivery in rural and remote health systems.

The Intervention

Technology enables clinicians to connect virtually with onsite staff to deliver collaborative care for patients in emergency departments and inpatient wards (Hutton et al., 2022; Totten, Womack, McDonagh, et al., 2022). In the literature, this model has been described as Rural Provider-to-Provider Telehealth (RPPT), “telehealth-guided provider-to-provider communication”, and “emergency medicine-staffed telehealth”, an area that continues to develop and diversify (Leonny et al., 2024; Mohr et al., 2020; Totten, Womack, McDonagh, et al., 2022; Totten et al., 2022). For this research we use the term RPPT to describe provider-provider telehealth in rural and remote settings. The authors recognise four RPPT types: emergency care, inpatient care, outpatient care, and mentoring/education; this research will focus on emergency and inpatient care.

Our evidence and gap map (EGM) is informed by the operational context of RPPT in country Western Australia (WA), specifically services delivered by the WA Country Health Service Command Centre. The Command Centre is a centralised facility within metropolitan Perth, WA, responsible for the oversight, management, and delivery of technology-enabled emergency and inpatient healthcare in rural and remote WA. Its aims are to:

(i) Ensure all country WA communities have equitable access to excellent emergency and inpatient healthcare.

(ii) Support the place-based workforce by providing guidance, advice, and access to specialist knowledge (WA Country Health Service, 2023).

Current clinical streams include the Emergency Telehealth Service, Inpatient Telehealth Service, Mental Health Emergency Telehealth Service, Midwifery and Obstetrics Emergency Telehealth Service, and Palliative Care Afterhours Telehealth Service. These streams are supported by operational and logistical services, including the Acute Patient Transfer Coordination Service and organisational governance (WA Country Health Service, 2023).

Similar RPPT models of care have been demonstrated in Australaisia (Leonny et al., 2024) and the United States (Heppner et al., 2021; Sterling et al., 2017) specifying telemedicine, telestroke, or tele-emergency. While the Command Centre context informs the EGM’s relevance and domain selection, the map is not restricted to WA, rather it aims to organise RPPT evidence across diverse rural and remote emergency and inpatient settings to support generalisable decision-making.

Importantly, the WA model has distinctive features, such as a centralised command centre with both centralised and virtual clinicians, integrated clinical streams, and governance structures designed for a geographically vast state with sparse populations. This may differ from RPPT models elsewhere, which can operate through decentralised networks, hub and spoke models, single service streams, or alternative funding and workforce arrangements. By mapping evidence globally, the EGM will help identify which components are context specific and which are transferable, clarifying how findings from WA can inform RPPT implementation in other regions and vice versa.

Why It is Important to Develop the EGM

An EGM systematically identifies, categorises, and visualises available evidence to inform strategy, policy, and program development (White, 2021). Although RPPT models have expanded, there remains deficiencies in the evidence base needed for long-term maintenance, sustainment, and potential scale up and out of services (Snilstveit et al., 2016). Specifically, many studies under-report costs and resource use, provide limited equity analyses or patient and provider perspectives, and implementation challenges (DeHart et al., 2021). Outcome measures vary widely, constraining synthesis, and many evaluations are single-site or pre-post designs, limiting casual inference (Rabbani et al., 2025). An EGM can present complex information in an accessible format for stakeholders (Snilstveit et al., 2016), while highlighting where evidence is strong, where it is thin, and what gaps matter for service and policy choices.

Evaluating RPPT using the Model for Assessment of Telemedicine Applications (MAST) provides a structured, decision-relevant approach to displaying evidence and knowledge gaps (Kidholm et al., 2012). MAST guides systematic assessment across domains such as the intervention characteristics, safety, technology, clinical effectiveness, patient perspectives, economic aspects, organisational aspects, and socio-cultural, ethical, and legal aspects (Kidholm et al., 2012). This perspective is particularly important for rural health systems operating under workforce and funding constraints, where decisions must balance quality, equity, and sustainability (Greenwood-Ericksen et al., 2020).

Mapping evidence to MAST domains offers a clear framework for categorising studies, highlighting gaps that matter for policy, service design, and resource allocation, and ensuring alignment with health system priorities that emphasise overall value rather than volume (Khalil et al., 2025). Previous reviews and expert workshops (Totten, Womack, McDonagh, et al., 2022; Wakefield et al., 2022) assessed RPPT effectiveness and implementation but were largely pre-COVID and from a United States perspective, with limited stratification for rural and remote emergency and inpatient care or alignment with comprehensive assessment domains. Given the acceleration of virtual care during COVID and the absence of an EGM in this area, a post-pandemic map structured around MAST domains and stakeholder priorities is needed. Importantly, the EGM will present complex evidence in an accessible, user-friendly format to support decision making for policy, service design, and resource allocation.

Objectives

The aim of this EGM is to identify and describe the available evidence on RPPT used in emergency and inpatient healthcare in rural and remote settings, and to categorise reported outcomes according to the domains of the Model for Assessment of Telemedicine Applications (MAST) framework.

Objectives.

(a) To map evidence to a value-based healthcare framework.

(b) To inform evidence-based practice, policy, and development of RPPT service delivery at a local, national, and international level.

(c) To identify gaps in the evidence base to support the direction of new research.

Methods

Evidence and Gap Map: Definition and Purpose

An EGM is part of the ‘big picture’ review family, which includes both mapping and scoping reviews (Campbell et al., 2023). EGMs address a broader question when compared to systematic reviews and are being used increasingly to inform decision making and guide research priorities (Campbell et al., 2023). This is important for industry and government who may lack the time or expertise to interpret the vast expanse of research evidence (White, 2021). An EGM is “a systematic evidence synthesis product which displays the available evidence relevant to a specific research question” (White et al., 2020). EGMs are crafted in accordance with the same principles as systematic reviews, but with a pre-specified framework which directs the search strategy and analyses (White et al., 2020). An EGM then maps the data visually into a matrix or table, based on the framework, which end users can interact with (White, 2021). This makes the research evidence more discoverable and accessible to policy and decision makers, thereby increasing the translation of evidence-based practice (White, 2021). This EGM follows Campbell Collaboration guidance for conduct and reporting (White et al., 2018a, 2018, 2020).

Framework Development and Scope

The measurement and evaluation of virtual healthcare has been widely studied (Abimbola et al., 2019; Chang, 2015; Garcia & Adelakun, 2019; Greenhalgh et al., 2017; Jebraeily & Khezri, 2025; Khoja et al., 2013; Kowatsch et al., 2019; Nepal et al., 2014), with calls for it to be considered no different from the measurement of traditional healthcare delivery (Demaerschalk et al., 2023). Virtual care does not inherently compromise quality, rather traditional quality frameworks can often be applied with minimal adjustment for services such as RPPT across multiple settings (Demaerschalk et al., 2023).

Defining, evaluating, and measuring value for RPPT is multi-dimensional. A framework aligned to MAST emphasise the integration of key domains over a cohesive structure. These domains reflect real-world priorities and align with health system objectives for sustainability, access, and efficiency. MAST has gained broad adoption, especially across Europe, including endorsement by the World Health Organization and the Pan American Health Organization, demonstrating validation and applicability of the framework (Centre for Innovative Medical Technolog, 2025; Kidholm et al., 2017). A recent review of evaluation techniques in telemedicine confirms the applicability and comprehensiveness of MAST (Jebraeily & Khezri, 2025).

Foundational work by Kidholm and colleagues (Kidholm et al., 2012, 2017) highlights a three-element model of assessment: preceding assessment, multidisciplinary assessment, and transferability assessment. This EGM will focus on the seven domains of the multidisciplinary assessment, as defined by Kidholm et al. (2012) in Table 1, with example topics demonstrating what can be included under each.

Table 1.

Model for Assessment of Telemedicine Applications (MAST) Domains, Definition, and Example Topics

Domain	Definition	Topics
Health problem and characteristics of assessment	Description of the health problem of the patients expected to use the telemedicine application and the application being assessed incl. Description of the current use	• Health problem • Description of the application • Technical characteristics • Current use of the application
Safety	Identification and assessment of harms	• Clinical safety (patients and staff) • Technical safety (technical reliability)
Clinical effectiveness	Effects on the patients’ health	• Effects on mortality • Effects on morbidity • Effects on health related quality of life (HRQL) • Behavioural outcomes • Usage of health services
Patient perspectives	Issues related to the perception of the patient or the relatives of the telemedicine application including the patients and relatives’ acceptance of the technology.	• Satisfaction and acceptance • Understanding of information • Confidence in the treatment • Ability to use the application • Access and accessibility • Empowerment, self-efficacy
Economic aspects	A societal economic evaluation comparing a telemedicine application with relevant alternatives in terms of costs and consequences and a business case describing the expenditures and revenues for the healthcare institutions using the telemedicine application.	Economic evaluation: • Amount of resources used when delivering the application and comparators • Prices for each resource • Related changes in use of health care • Clinical effectiveness Business case: • Expenditures per year • Revenue per year
Organisational aspects	Assessment of what kind of resources have to be mobilized and organized when implementing a new technology, and what kind of changes or consequences the use can further produce in the organisation.	• Process • Structure • Culture • Management
Socio-cultural, ethical, and legal aspects	The socio-cultural aspects include the social-cultural arenas where the patient lives and acts during use of the application. The ethical analysis appraises the ethical questions raised by the application itself and by the consequences of implementing it or not. Legal aspects focus on the legal obligations which must be met and any specific legal barriers that may exist to the implementation of the application.	• Ethical issues • Legal issues • Social issues

Several alternative frameworks were considered, including the Quintuple Aim, value-based healthcare, and person-centred value-based healthcare (Itchhaporia, 2021; Lewis, 2024; Nundy et al., 2022; PCVBHC Project Team et al., 2021; Porter, 2010). MAST builds on these frameworks to integrate virtual, organisational change, and socio-cultural elements, plus clinical, safety, patient, economic factors, all integrated and critical for implementing or enhancing RPPT services.

Stakeholder Engagement

The scope of the EGM is driven and informed by Command Centre leadership, who identified the need to compare RPPT models globally and inform strategies for long-term sustainment (Toll et al., 2024). An advisory body from the Command Centre contributes to scope, framework development, and interpretation of findings, meeting fortnightly and ad hoc as required. The framework and pilot EGM was shared with this advisory group early in development and was updated to MAST, based on feedback, to ensure relevance, resonance, and usability for intended end-users.

Conceptual Framework and Dimensions

The EGM conceptual framework designates the population of interest, the intervention (RPPT) assessed, and the outcomes based on MAST. We will use a matrix with intervention types as rows and MAST domains as columns.

This framework was piloted on an initial search, tested, and refined by the researcher, in consultation with the advisory group. This has ensured functionality and usability for the end-user.

Types of Study Design

As the purpose of this EGM is to provide a resource for decision makers to ascertain the evidence for implementation and enhancement of RPPT, as well as identify gaps in the research, the EGM will target both systematic reviews and primary studies (Snilstveit et al., 2016). The systematic review focus must be on RPPT. If the review is too broad (i.e. all types of virtual care) it will be excluded, but the primary studies included will be assessed separately against the eligibility criteria.

Primary studies will include experimental and non-experimental designs, such as randomised control trials, quasi-experimental studies, observational studies, case studies, mixed-method research, qualitative studies, implementation studies, economic evaluations, and process or impact evaluations. To be eligible, all studies must demonstrate an outcome (positive or negative) within any of the MAST domains. Studies without a comparison group will not be excluded.

Publication types excluded will include narrative reviews, theses, dissertations, conference abstracts, news articles, policy briefs, letters to the editor, and opinion pieces, as these typically lack sufficient detail on the model of care or reported outcomes. Protocols for any study design will be excluded, because they do not present demonstrated outcomes.

Types of Intervention/Problem

The intervention is defined as RPPT, the model of care broadly defined by Totten, Womack, McDonagh, et al. (2022) as “a subset of telehealth interventions focused on supporting health care providers that treat rural patients and populations through consultations and collaborative patient care” (p. 2). This is the collaborative care during a patient episode of care between the patient, place-based and virtual providers. RPPT is initiated by providers, rather than directly by the patient. The intervention will be focused on two of the four types of RPPT: emergency care and inpatient care. These will be filtered to subgroups based primarily on Australian emergency care categories (Independent Health and Aged Care Pricing Authority, 2023).

Additionally, the model of care for each RPPT intervention will be defined and used as a filter. This process may prove challenging due to differences in how models of care are defined across studies, or in some cases a lack of description. To address this, definitions will be developed iteratively as patterns emerge during data extraction, while remaining informed by existing definitions, such as those provided by the Agency for Clinical Innovation (2025). This approach ensures flexibility to capture diverse care models while maintaining consistency and transparency (Table 2).

Table 2

Example of RPPT Models of Care

Specific RPPT models	Description
Hub-and-spoke	A larger hospital or site, often in metropolitan areas, that provide virtual care and support to smaller sites (spokes), often in rural or remote areas.
Collaborative care models	Multi-site integration to deliver collaborative care, without a main hub.
Peer-to-peer pathways	Rural and remote provider connects to peers in another location, sometimes other countries. This could be an official or unofficial pathway.

Types of Population (as Applicable)

Both the provider (user of RPPT) and the patient (recipient of RPPT) are included in the assessed population. A provider is defined as any health professional, including doctors, nurses, and midwives, plus specialized clinician services if all other eligibility is met. The offsite (virtual) provider and onsite (place-based) provider will be defined. The patient population is framed by the Levesque et al. (2013) conceptual framework for patient-centred access to health care, where the patient has the ability to perceive a medical need, seek appropriate care, reach the location (health facility), and pay for the treatment (free at public health facilities in Australia). The patient’s presenting diagnosis will be described when defined by the included studies.

Types of Outcome Measures (as Applicable)

Outcomes measures are informed by MAST across seven domains, as demonstrated in Table 1. These domains serve as key drivers for evaluation and ensuring equitable access to excellent emergency and inpatient care.

Types of Location/Situation (as Applicable)

All populations who encounter RPPT in rural, remote, or resource limited settings will be included. A resource limited setting is defined as a limited to basic critical care resources, including trained staff (Geiling et al., 2014). Examples include low-to-middle-income countries, COVID-impacted settings (causing reduced resources in metropolitan hospitals), conflict zones, and offshore health facilities.

Types of Settings (as Applicable)

Settings will include emergency department, inpatient wards, intensive care unit, surgery, field hospital, and additional settings which meet all other criteria.

Search Methods and Sources

The search will be conducted according to Campbell standards as per the Campbell Collaboration Checklist for EGMs (White et al., 2018a, 2018). This will include academic databases (MEDLINE, Embase (OVID), CINAHL (EBSCO), and ProQuest); libraries of reviews (Campbell Library, Cochrane Library, Database of Abstracts of Reviews of Effects [DARE], R4D, https://Healthsystemsevidence.org, https://Healthevidence.org, 3ie database of systematic reviews); impact evaluations (3ie′s Database of Impact Evaluations, J-PAL, Cochrane Register of Trials); grey literature (Google, WHO IRIS, Trove, and IEEE Xplore); and reference lists and citation tracking.

The search strategy was developed with an expert librarian, with consideration of the population, intervention, comparison, and outcome (PICO), and piloted in MEDLINE (Table 3). The search strategy is designed to capture variable definitions to RPPT, following advice and methodology by Parkhill et al. (2011). Terms are based on the concepts of telehealth, rural health, emergency and inpatient care, and outcomes of the service. The search will be adapted based on database requirements. The search will be limited to English language only and from 1 January 2018 to 31 December 2025 ensure relevance and currency in the rapidly evolving field, and to cover the COVID-19 implementation.

Table 3.

Search Strategy Piloted in MEDLINE

Concept 1	Concept 2	Concept 3	Concept 4
Telehealth	Emergency, acute, urgent, inpatient	Rural and remote	MAST domains
(Telemedic* or “tele-medic*” or telehealth* or “tele-health*” or teleconsult* or “tele-consult*” or econsult* or “e-consult*” or “tele-ED” or teleED or “virtual care” or “digital health”).ti,ab,kf.	(Emergenc* or inpatient).ti,ab,kf.	(Region* or rural* or remote* or countr* or “resource limited”).ti,ab,kf.	See full search for detail

Analysis and Presentation

Report Structure

This EGM will follow the Campbell EGM guidelines and reporting structure to produce a publication and a visualisation of results. Descriptive statistics, including frequency counts, will be utilised and presented in tables and figures to report and convey key findings. The number of studies will be shown by the size of the bubble in the map, level of evidence by the colour of the bubble, and quality of the critical appraisal as a filter.

Filters for Presentation

Along with intervention and outcomes, additional dimensions will be captured in the map and presented as filters. This will include year published, country, study region, study design, model of care, COVID-19 (if the intervention was implemented during or as a result of covid), evidence guide, quality appraisal, and equity-relevant data. PROGRESS-Plus will be used to identify studies reporting on equity considerations (Karran et al., 2023). First introduced by Evans and Brown (2003), the acronym stands for Place; Race, ethnicity, culture, language; Occupation; Gender and sex; Religion; Education, Socioeconomic status; Social capital, with Plus sub-categories (age, sexual orientation, insurance status, immigrant/citizenship status, chronic disease/disability, and other/not classified). Detail presented in Table 4.

Table 4

Coding Form

Parent code	Child code	Grandchild code/info
Author
Year (filter)	2018,2019,2020,2021,2022,2023,2024, 2025
Country (filter)	List of countries
Study region (filter)	Africa, Asia, Caribbean, Central America, Europe, North America, Oceania, South America	Africa, Asia, Caribbean, Central America, Europe, North America, Oceania, South America
Title
Model of care (filter)
Intervention (filter)	Emergency care	Nervous system and neurological; Eye; ear, nose, throat, mouth; respiratory; Circulatory; digestive; liver, gall bladder, bile duct, and pancreas; musculoskeletal; Skin, subcutaneous, and breast tissue; Endocrine, nutritional, and metabolic; metabolic and nutritional disorders, other; kidney and urinary tract; male genitourinary; gynaecology; Obstetrics; perinatal; blood and immunology; Neoplasms; infectious diseases; mental, behavioural, and neurodevelopmental; injuries and other externally-caused morbidity; general symptoms without diagnosis; other factors influencing health status; paediatric; pharmacy; palliative care; diagnostic, critical care, Surgical
	Inpatient care
Outcomes (filter)	Health problem and characteristics of intervention
	Safety
	Clinical effectiveness
	Patient perspectives
	Economic aspects
	Organisational aspects
	Socio-cultural, ethical, legal
Evidence guide (filter)	Level I, level II, level III, level IV, level V
Quality appraisal (filter)	High quality, good quality, low quality
COVID-19 (filter)	Yes/No
PROGRESS-plus (filter)	Place; race, ethnicity, culture, language; Occupation; gender and sex; religion; education, Socioeconomic status; social capital, with plus sub-categories (age, sexual orientation, insurance status, immigrant/citizenship status, chronic disease/disability, and other/not classified).

Dependency

Primary studies will be analysed by study, as each study is expected to present a different set of outcomes. This may cause duplication of studies, but the evidence for each outcome in the study will be presented separately. Primary studies may also be included in eligible systematic reviews.

Data Collection and Analysis

Screening and Study Selection

All identified citations will be uploaded into EndNote (2013) and duplicates removed. Titles and abstracts will then be uploaded to Covidence (Veritas Health Innovation) and screened by any two of the four independent researchers (KT, DJ, ZH, and AC) for assessment against the eligibility criteria, with any conflicts discussed between KT and another reviewer. Full text review will be independently completed by two researchers (KT and DJ), with a discussion between the two on conflicts.

Data Extraction and Management

EPPI Reviewer (Thomas et al., 2023) will be used for coding and data extraction of the included articles. The coding key can be found in Table 4. The coding and extraction will be completed by the lead researcher (KT), piloting 10% of the included studies, with any refinements to the extraction form and framework made in consultation with the research team accordingly. Systematic reviews will be coded according to their eligibility criteria. Primary studies in the included systematic reviews may also be included separately and will be coded accordingly. 10% of data extraction will be duplicated randomly by a second researcher (DJ) to identify systematic errors or inconsistencies in coding, with researchers meeting to discuss any discrepancies. Resource constraints will prevent full duplication.

Tools for Assessing Risk of Bias/Study Quality of Included Reviews

Traditional evidence hierarchies rank meta-analyses, systematic reviews, and randomised control trials highest, with non-randomised and observational studies lower. These rankings emphasise internal validity, but overlook external validity, local applicability, and practical quality. For RPPT, we expect much of the evidence to come from pilot and feasibility studies, especially those introduced during COVID-19.

To provide clinicians with actionable insights, this EGM will use the Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals (Dang et al., 2022). Each study will be.

• Ranked by evidence level (five levels based on study design).

• Appraised for quality (high, good, or low) using structured criteria for each study design.

In the final map, evidence will be colour-coded by quality and include a filter for level of evidence, enabling clinicians and decision-makers to quickly gauge strength and reliability (White et al., 2018b).

Methods for Mapping

Visualisation will use EPPI-Mapper (Digital Solution Foundry and EPPI Centre, 2023) and will be available online demonstrating the current evidence base and gaps in MAST outcomes for RPPT.