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Technological advances using telemedicine and telehealth are growing in healthcare fields, but the evaluation framework for them is inconsistent and limited.This paper suggests a comprehensive evaluation framework for telemedicine system implementation and will support related stakeholders' decision-making by promoting general understanding, and resolving arguments and controversies.Although many countries, especially developed countries, tend to pursue telemedicine services aiming to improve healthcare accessibility and lower healthcare expenditures , telemedicine is not utilized and developed actively due to lack of legal and policy support for responsibility of services, absence of effective evidence, instability of information and communication technology, and insufficient infrastructure for education and training systems .
On the other hand, most success factors for telemedicine service can be expanded to telehealth since both systems use much of the same infrastructure of ICT equipment and networks, and they are used by the same types of professionals and consumers.
Therefore, this study mainly emphasizes clinical telemedicine services for developing the factors of the evaluation framework. Need for Evaluation Framework We need a comprehensive evaluation framework for telemedicine and telehealth because the systems are very complex with multiple stakeholders and indirectly valued by multiple factors.
Therefore, there must be sufficient understanding of a comprehensive and multilateral evaluation framework to converge the opinions from the government, healthcare sector, industry, and academia, as well as the public.
This paper suggests a comprehensive evaluation framework for telemedicine and telehealth system implementation and is intended to support related stakeholders' decision-making by promoting general understanding and resolving arguments and controversies.
Therefore, evaluation frameworks for telemedicine can also be complex with many potential inputs, activities, outputs, outcomes, and stakeholders.
This may be one reason for a lack of established telehealth evaluation protocols .The suggested framework consists of six major dimensions and the subsequent branches for each dimension.To implement telemedicine and telehealth services, stakeholders should make decisions based on sufficient evidence in quality and safety measured by the comprehensive evaluation framework.There is no standardization of definitions, criteria, and measures across the literature, which leads to ambiguity and confusion.Moreover, the methodologies for conducting telemedicine evaluations are not consistent.Moreover, the fundamental reason is that understanding and evidence of its advantages are insufficient.The government raises the aspect of advantages through implementing telemedicine, which are improvement of accessibility, cost saving, quality of medical service, and satisfaction of patients.Specifically, the following research objectives were taken into consideration: 1) analyzing the existing alternative evaluation strategies, methodologies, frameworks, and approaches for telemedicine and telehealth in addition to those for health information systems in general, 2) gaining insight into multiple dimensions and factors that influence the quality and outcomes of telemedicine and telehealth systems by determining the attributes that may serve as barriers or facilitate the system, and 3) identifying common themes and issues in constructing an evaluation framework. However, while telemedicine refers to remote clinical services, such as consultation, diagnosis, treatment, and transfer of medical data, telehealth can refer to remote non-clinical services, such as administrative procedures, training, and education, in addition to clinical services .However, more studies and published documents on telemedi cine are found than on telehealth because the clinical practice of telemedicine services involves more obstacles and barriers, such as licenses, reimbursement, etc.Recently, Poultney  summarized the current problems for evaluating telemedicine and telehealth services with three issues: no universally accepted standard, varying weaknesses of current methodologies in terms of appropriateness, and limited coverage of evaluation focus on clinical-benefit and cost-benefit.A variety of factors influence the implementation and operation of telemedicine services.