**1. Introduction**

The distance travelled and time spent by patients when visiting a doctor may limit patients' access to medical care. Fortunately, telemedicine overcomes geographical barriers to healthcare, which is particularly beneficial for patients in rural communities or in places where there is a shortage of doctors or a shortage of health services [1–4].

In the central Catalan region, the Bages, Moianès and Berguedà counties have developed several telemedicine programs: the most consolidated is Teledermatology while the most innovative are Teleulcers, Teleeyelids and Teleaudiometries. Teledermatology is a service that has provided a speedy service to thousands of users, thus avoiding numerous unnecessary hospital visits [5], and representing a saving of €11.4 per face-to-face visit avoided [6]. Meanwhile, Teleulcers it is a more specialized service that, with less patient volume, has managed to improve the quality of care for people with chronic ulcers [7]. Teleeyelids and Teleaudiometries, which are in the process of being evaluated, are the most recent telemedicine programs introduced in the region.

The first three telemedicine programs all operate in the same way; the primary care physician or a nurse takes a photograph of the injury or injuries and attaches it to the patient's electronic health record together with their clinical notes. The use of the patient's electronic health record ensures the images are handled securely, since they do not need to be sent by email or uploaded to an external server. Hospital specialists can access the patient's electronic health record, review the images and sugges<sup>t</sup> treatment or an action plan. The primary care physician or nurse can review the instructions and telephone the patient to give them the results of the consultation. This can usually all be done in less than 5–7 working days. If the specialist has any doubts, they can ask the primary care professional to book the patient for a face-to-face consultation.

The teleaudiometry program is similar to other telemedicine programs, but it does not involve taking photographs. Patients are instead referred to a primary care center where an audiometry test is performed. This is uploaded to the patient's electronic health record, together with specific clinical information. The patient's otorhinolaryngologist accesses the electronic health record, reviews the audiometry test and suggests an action plan. The primary care physician reviews the instructions and telephones the patient to give them the results of the consultation as with the other programs.

Numerous studies provide evidence showing the benefits of telemedicine from the point of view of both the patient and the health system [8]. Recently some studies have analyzed the environmental impact of the savings o ffered by telemedicine programs due to the fact that the patient does not need to make a journey to their health center [9–12]. In the current climate of growing interest in reducing the environmental footprint of health care activities [13,14], this study evaluates the e ffect of a telemedicine program in lowering a procedure's environmental footprint by reducing the emission of atmospheric pollutants due to a reduction in the number of hospital visits involving journeys by road.

#### **2. Materials and Methods**

The cases that were studied came from the existing telemedicine program, which includes Teledermatology, Teleulcers, Teleeyelids and Teleaudiometries in the Institut Català de la Salut's primary health centers and tertiary referral hospitals in the Bages, Berguedà and Moianès counties; the Sant Joan de Déu Hospital (Althaia Foundation) in Manresa and the Hospital Comarcal Sant Bernabé de Berga, located in Central Catalonia. Patients from primary care centers in the Bages and Moianès counties are referred to the Hospital Sant Joan de Déu de Manresa, while patients in Berguedà are referred to the Hospital Comarcal Sant Bernabé de Berga (Figure 1). The analysis was conducted from January 2018 to June 2019.

This retrospective study uses administrative data and evaluates the impact of telemedicine services on reducing the distance travelled and the associated savings in terms of time and money, as well as the reduction in atmospheric pollutants. The savings in the distance travelled are calculated in terms of the round trip from the primary care center to the hospital.

The reduction in the emission of atmospheric pollutants and greenhouse gases is calculated by multiplying the kilometers that are not travelled by emissions per kilometer. The savings made are calculated as the di fference between the cost of travelling to the referral hospital and the cost of travelling to the nearest primary care center. Finally, the time saved through the use of telemedicine is defined as the total round-trip from the primary care center to the referral hospital. Google Maps was used to calculate both the distances travelled and the time saved on the trip via the existing road network. The "fastest route with the usual tra ffic" search option was used to make the calculations, and involved an equal number of diesel and petrol cars. The emission of atmospheric pollutants per km is shown in Table 1.

**Figure 1.** Map showing the primary care centers and their associated referral hospitals in Manresa and Berga.

**Table 1.** Emission of pollutants per km. Source: Mobility and emissions. Extra-urban cycle (gasoline and diesel fuel). Available at: http://mobilitat.gencat.cat/ca/detalls/Article/mobilitat\_emissions (Date of access: 20 September 2019).


The telemedicine service was considered to have replaced a face-to-face consultation when no face-to-face visit occurred in relation to the same type of specialist in the three months following the telemedicine consultation. Microsoft Excel and R 3.6.1 were used for data processing and quantitative analysis.
