In developing countries, health-care services are not available to people living in remote areas. Physicians also live mainly in urban areas and do not desire to live in remote areas with fewer amenities. In geographically isolated areas, the situation is far more complicated, and it is challenging to provide health services to people living in these areas. People living in such areas may not receive the services they need, leading to social disparity and injustice in accessing health services. ^{Reference Rey-Moreno, Bebea-Gonzalez and Foche-Perez1} In mountainous areas with complex orography, access to different places is difficult, increasing the time of patient transfer to the hospital. ^{Reference Brunetti, Dell’Anno and Martone2,Reference Chen, Wong and Chen3}

Today, the application of technology in health care has led to improved care delivery. Digital interventions and evolution in communication have significantly changed the way the services are delivered. Thus, telemedicine has become part of health care. The World Health Organization (WHO) defines telemedicine as the provision of remote health-care services by information and communication technologies (ICTs) to provide information on the diagnosis, treatment, and prevention of diseases, research, and education of health-care providers to promote the health of individuals and communities. ^{Reference Almathami, Win and Vlahu-Gjorgievska4}

Mountains cover 24% of the earth’s surface, and a large percentage of the world’s population lives in these areas. ⁵ The Himalayas is one of the most well-known mountain ranges stretching over India, Pakistan, China, Nepal, and Bhutan, with around 52.7 million people living in this region. ⁵ Forests cover approximately 30% of the earth’s surface. ^{Reference Carlowicz6} Thus, because many people dwell in these areas, by means of telemedicine, the desired medical services can be provided to the residents of these areas, which can reduce the need to travel for these people. Telemedicine can save time and money by reducing the number of travels. ^{Reference Scott Kruse, Karem and Shifflett7}

People who live in remote areas, such as mountains and forests, or people who do not live in these areas but are present as tourists can benefit from health-care services through telemedicine. Telemedicine, with its facilities, is a practical and low-cost solution for high altitude and expedition medicine. ^{Reference Martinelli, Moroni and Bastiani8}

In addition to the mentioned reasons for needing telemedicine, mountainous and forested areas have always faced natural and man-made disasters, such as train accidents in mountainous areas, mountain falls, avalanches, landslides, floods, mudslides, debris, and forest fire. ^{Reference Mishra, Ghate and Maharjan9–Reference Melis and Hilhorst11} They cause massive injuries and losses every year. In these cases, immediate disaster response is required, where the lack of facilities related to providing health services in these remote areas is more serious. Providing health services in disasters is one of the essential applications of telemedicine. In the event of a disaster, local health facilities can be severely damaged, local hospitals and clinics may be damaged or inaccessible, in which case various telemedicine services may be available. ^{Reference Litvak, Miller and Boyle12}

The use of telemedicine in remote areas is faced with advantages and challenges, requiring special equipment. This field demands a comprehensive study to examine the challenges, opportunities, and equipment required for telemedicine in these regions, guiding policy-makers and organizations that intend to implement telemedicine for peoples living in mountainous and forested areas. Thus, the purpose of this review is to comprehensively examine the studies conducted on the use of telemedicine in the mountains and forests, and to answer the following questions:

RQ1: What are the opportunities of telemedicine in forested and mountainous areas?

RQ2: What are the challenges of telemedicine in forested and mountainous areas?

RQ3: What equipment do we need to use telemedicine in these areas?

Methods

The present study was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes extension for Scoping Reviews (PRISMA-ScR) checklist.

A comprehensive search was conducted on May 12, 2021, in the Medline (through PubMed), Scopus, IEEE Xplore Digital Library, and ISI Web of Science databases to answer the mentioned questions. A combination of Medical Subject Headings (MeSH) terms and keywords related to telemedicine (eg, telehealth, mHealth, mobile health, remote consultation, teleconference, telecare), mountain (eg, mountaineering, altitude), and forest (eg, jungle) were used in the search strategy (Table 1).

Table 1. Search strategy for each database

The results of the search conducted in these 4 databases were entered into the EndNote library and duplicates were removed, so that from the 1062 articles identified, 807 articles remained after removing the duplicates (Figure 1).

Figure 1. Flow diagram of the literature search and study selection.

Titles and abstracts of the articles were reviewed by 2 reviewers independently. After removing irrelevant items and considering the inclusion and exclusion criteria, 35 articles remained for full-text review. The full-text of selected articles was reviewed and required information was extracted by 2 researchers (S.S. and S.R.). Also, any disagreement between the authors in selecting eligible studies was resolved through consultation with N.M. No time limits were imposed, and articles that had examined the challenges, benefits, and equipment used to provide telemedicine services in forests and mountains were included in the final review. The inclusion and exclusion criteria for the articles are shown in Figure 2.

Figure 2. Inclusion and exclusion criteria for selecting articles.

Results

After reviewing the full text of selected articles, 20 articles met our inclusion and exclusion criteria, of which 3 were related to the use of telemedicine in the forest, and 17 dealt with the use of telemedicine in the mountains. After reviewing these articles, the opportunities, challenges, equipment, and services provided by telemedicine in these areas were extracted from the articles.

Forest ^{Reference Rey-Moreno, Bebea-Gonzalez and Foche-Perez1,Reference Miscione13,Reference Latifi, Stanonik Mde and Merrell14}

Of the studied articles, 3 were related to telemedicine in forested areas. The opportunities, challenges, and equipment required for implementing telemedicine in forests were examined in these articles.

Opportunities

The use of telemedicine in forested areas facilitates inhabitants’ access to health care, diminishes the need to travel long distances to hospitals, reduces the number of travels, and plays an essential role in reducing costs.

Challenges

This study indicated that telemedicine and telehealth services in forested areas have many advantages, but their implementation is faced with many challenges and barriers. Groups that want to implement telemedicine in these regions should pay attention to these issues and consider appropriate solutions.

Challenges for telemedicine in the forested areas include: (1) poor communication in forested areas due to high trees, (2) dependence of communication on the atmospheric condition, (3) energy supply, (4) connection increment and attenuation due to heavy rains, (5) frequent storms, (6) vulnerability of electronic equipment against the rain and moisture, (7) network instability, (8) cost of maintenance and training of technicians and health-care workers, (9) the need for a large number of resources, people, and time to prepare telemedicine, (10) allocation of a suitable place for the installation of telemedicine equipment, (11) difficult transportation of equipment by small aircraft due to the high weight of the equipment, and (12) the need for a local guide for passing through difficult and dangerous terrains.

Equipment

Large numbers of equipment were needed to implement and use telemedicine in forested areas, which can be classified into 2 main categories; (1) general equipment such as telemedicine hardware and software and (2) special equipment needed for the implementation of telemedicine in forested areas that may not be used in other areas. The required equipment for the implementation of telemedicine is listed in Table 2.

Table 2. Equipment needed to implement telemedicine in the forest

Mountain

Seventeen articles were related to the use of telemedicine in mountainous areas. They have mentioned issues such as telemedicine users, the use of telemedicine to manage specific diseases, telemedicine services, and opportunities, challenges, and equipment required for telemedicine.

Telemedicine Users and Diseases

Telemedicine users in the mountainous area and the use of telemedicine for most common diseases are presented in Figure 3. ^{Reference Martinelli, Moroni and Bastiani8,Reference Otto, Hamilton and Levine15–Reference Satava, Angood and Harnett21}

Figure 3. Telemedicine users and diseases that telemedicine is used to manage.

Service Provided ^{Reference Brunetti, Dell’Anno and Martone2,Reference Martinelli, Moroni and Bastiani8,Reference Otto, Hamilton and Levine15,Reference Satava, Angood and Harnett21–Reference McBeth, Hamilton and Kirkpatrick26}

Telemedicine technology has been used in mountainous areas to provide many services to patients, as shown in Figure 4. These services are essential and can save patients’ lives.

Figure 4. Telemedicine services provided for patients.

Opportunities ^{Reference Brunetti, Dell’Anno and Martone2,Reference Martinelli, Moroni and Bastiani8,Reference White and Angood16,Reference Ganapathy, Alagappan and Rajakumar24,Reference Otto27}

The results of studies revealed that the use of telemedicine in mountainous areas has many benefits and opportunities, which are listed as follows: saving costs, avoiding inappropriate rescue interventions, reducing the distance between patients and health-care centers, facilitating patient follow-up, saving time for patients, shortening treatment time, improving patients’ quality of life, reducing patient travel to seek medical consultation, improving the attractiveness of mountainous areas for tourists, providing real-time consultation with physicians, avoiding admission to emergency and specialized departments, mitigating traffic and pollution, reducing the waiting time, monitoring multiple pathologies, providing teleconsultation even from the doctors’ home, reducing car traffic and carbon footprint, mitigating physical and emotional stress of users, improving patient satisfaction and happiness, providing opportunities for monitoring parameters that should be checked daily, and providing emergency services.

Challenges ^{Reference Otto, Hamilton and Levine15,Reference Ganapathy, Chawdhry and Premanand19,Reference Satava, Angood and Harnett21,Reference Kreshak23,Reference Ganapathy, Alagappan and Rajakumar24,Reference Otto and Remote28}

Implementing and using telemedicine in mountainous areas has many challenges that can be divided into 2 categories of general challenges and ethical issues ^{Reference Szawarski and Hillebrandt29} :

General Challenges

• Reimbursement policies and licensing barriers.

• Device’s failures in the cold and hypobaric conditions of extreme altitudes.

• Snowstorms may damage camps and health-care centers.

• Lack of continuous and reliable power supply.

• Costs related to equipment and implementation of telemedicine.

• Lack of necessary facilities for some diagnostic tests.

• Impossibility of sophisticated investigation for patients.

• Nonfamiliarity with software, hardware, and reluctance to use tools by health-care providers.

• Internet connectivity problems.

• Use of local dialect by patients.

• Lack of awareness and transport, and harsh weather conditions.

• Melting snow and landslides.

• Bandwidth issues.

• Local staff who perceived telehealth as a threat.

• Poor health-seeking behavior.

• Lack of definite regulations regarding the implementation of telemedicine in mountainous areas.

• Lack of support from the Ministry of Health for plans related to the implementation of telemedicine.

• Provision of convincing conditions for physicians to live in mountainous areas.

Ethical Issues

• According to USA federal legislation known as the “Ryan Haight Act,” which is related to the prescription of controlled drugs over the Internet, the prescription and distribution of drugs over the Internet without a valid prescription are not possible. According to this law, a prescription is valid if the practitioner has at least 1 in-person examination of the patient. Thus, it is impossible to prescribe medication for some patients in telemedicine.

• Obtaining patient consent for examination through telemedicine is 1 of the issues that should be considered.

• Confidentiality of information and management of legal aspects, and data security are also important issues that should be considered before implementing telemedicine.

• Most of the time, climbers ascend mountains in groups. In the event of an accident for a climber in the group, the medical team must provide medical information to the patient in the presence of group members, and in such cases, the confidentiality of patients’ information is endangered.

• The patient’s medical record and clinical information should be kept secure to facilitate the provision of clinical care as well as subsequent reviews and claims in the event of medical malpractice. Thus, due to the unfavorable weather conditions in the mountainous areas, necessary measures should be considered.

Equipment

Studies have revealed that the use of telemedicine in mountainous areas requires a considerable amount of equipment. ^{Reference Martinelli, Moroni and Bastiani8,Reference Otto, Hamilton and Levine15,Reference Angood, Satava and Doarn17–Reference Ganapathy, Chawdhry and Premanand19,Reference Satava, Angood and Harnett21,Reference Singh, Kapoor and Basnet22,Reference Ganapathy, Alagappan and Rajakumar24–Reference McBeth, Hamilton and Kirkpatrick26,Reference Otto and Remote28,Reference Szawarski and Hillebrandt29} Such equipment can be divided into 3 categories: (1) medical equipment, (2) software and hardware related to the implementation of telemedicine, and (3) special equipment that is used in mountainous areas and may not be applied in other areas. The list of equipment needed in mountainous areas is provided in Table 3.

Table 3. Equipment needed to implement telemedicine in mountains

Costs of Telemedicine in Forests and Mountains

The costs related to the implementation of telemedicine in the mountains and forests include establishing telemedicine, maintenance, and training technicians and health-care workers. In telemedicine in forests, the cost of installing towers, sometimes more than 90 meters, is usually high. Transporting equipment by the river also augments the costs drastically. ^{Reference Rey-Moreno, Bebea-Gonzalez and Foche-Perez1} However, in mountains, its use has led to direct and indirect savings by leaving helicopters, ambulances, structures, and personnel free where needed, reducing traffic and pollution. ^{Reference Martinelli, Moroni and Bastiani8} Telemedicine in the mountains can also save considerable effort, time, physical discomfort, and emotional stress. ^{Reference Martinelli, Moroni and Bastiani8,Reference Ganapathy, Alagappan and Rajakumar24}