**1. Introduction**

Telemedicine nowadays coexists alongside conventional healthcare in most healthcare systems [1]. Although systematic reviews of its economic impact sugges<sup>t</sup> that, for the time being, it is not suited to widespread implementation in all specialties and contexts [2,3], recent studies sugges<sup>t</sup> that it is cost-e ffective in fields such as emergency medicine, cardiology, the managemen<sup>t</sup> of diabetes and ophthalmology [4–11].

In Catalonia, the integration of the health information systems between primary care and specialized care allows for a fluid telemedicine-based case management. This implies relatively low coordination costs among di fferent health specialties and incentivizes the use of these tools by health providers. Furthermore, the availability of information on healthcare activities provides an excellent opportunity to evaluate their impacts. To this end, this study case includes four telemedicine specialties (teledermatology, teleulcers, teleophthalmology and teleaudiometries) which are currently conducted in the Catalan public healthcare system, Central Catalonia Health Region. This includes the counties of Bages, Moianès and Berguedà, located in a large, mainly rural area, which also includes two major cities (Manresa and Berga) with an overall population of approximately 230,000 inhabitants.

A cost-minimization analysis performed in the same setting for the specific case of teledermatology [12] showed social savings of approximately €11.4 per visit, which have an impact, especially on users (77% of the total amount saved) as opposed to the healthcare system (23%). This is due to the size of the reduction in the commuting time and travel costs, which is especially significant in rural settings, a thesis which has been backed up by subsequent research [13]. Nevertheless, the study evaluated a short time period (teledermatology in 2016) and did not take into account other indirect costs such as the time spent by caregivers. In this context, the objective of the study is to broaden evidence on the economic impact of telemedicine with respect to usual care including other types of telemedicine (teleulcers, teleophthalmology and teleaudiometries) using a cost-minimization analysis from a societal perspective, including all feasible and significant direct and indirect costs.
