Tripartite Data Analysis For Optimizing Telemedicine Operations - Evidence From Guizhou Province in China

International Journal of
Environmental Research
and Public Health
Article
Tripartite Data Analysis for Optimizing Telemedicine
Operations: Evidence from Guizhou Province
in China
Jinna Yu 1 , Tingting Zhang 2 , Zhen Liu 3 , Assem Abu Hatab 4,5 and Jing Lan 6, *
1 Business School, Guizhou Minzu University, Guiyang 550025, China; [email protected]
2 School of Economics and Management, University of Science and Technology Beijing, Beijing 100083, China;
[email protected]
3 School of Business, Nanjing Normal University, Nanjing 210023, China; [email protected]
4 Department of Economics, Swedish University of Agricultural Sciences, P.O. Box 7013, SE-750 07 Uppsala,
Sweden; [email protected]
5 Department of Economics & Rural Development, Arish University, Al-Arish 45511, North Sinai, Egypt
6 College of Public Administration, Nanjing Agricultural University, Nanjing 210095, China
* Correspondence: [email protected]

Received: 20 November 2019; Accepted: 3 January 2020; Published: 6 January 2020
Abstract: Telemedicine is an innovative approach that helps alleviate the health disparity in developing
countries and improve health service accessibility, affordability, and quality. Few studies have focused
on the social and organizational issues involved in telemedicine, despite in-depth studies of and
significant improvements in these technologies. This paper used evolutionary game theory to
analyze behavioral strategies and their dynamic evolution in the implementation and operation
of telemedicine. Further, numerical simulation was carried out to develop management strategies
for promoting telemedicine as a new way of delivering health services. The results showed that:
(1) When the benefits are greater than the costs, the higher medical institutions (HMIs), primary
medical institutions (PMIs), and patients positively promote telemedicine with benign interactions;
(2) when the costs are greater than the benefits, the stability strategy of HMIs, PMIs, and patients
is, respectively, ‘no efforts’, ‘no efforts’, and ‘non-acceptance’; and (3) promotion of telemedicine
is influenced by the initial probability of the ‘HMI efforts’, ‘PMI efforts’, and ‘patients’ acceptance’
strategy chosen by the three stakeholders, telemedicine costs, and the reimbursement ratio of such
costs. Based on theoretical analysis, in order to verify the theoretical model, this paper introduces the
case study of a telemedicine system integrated with health resources at provincial, municipal, county,
and township level in Guizhou. The findings of the case study were consistent with the theoretical
analysis. Therefore, the central Chinese government and local governments should pay attention to
the running cost of MIs and provide financial support when the costs are greater than the benefits.
At the same time, the government should raise awareness of telemedicine and increase participation
by all three stakeholders. Lastly, in order to promote telemedicine effectively, it is recommended
that telemedicine services are incorporated within the scope of medical insurance and the optimal
reimbursement ratio is used.
Keywords: telemedicine; tripartite data analysis; optimizing telemedicine operations
1. Introduction
Telemedicine is widely used in global health systems, especially in developing countries, as a new
way to deliver healthcare services. China is the largest developing country in the world, 70% of
its population live in rural areas, and there are serious disparities in medical resources between
Int. J. Environ. Res. Public Health 2020, 17, 375; doi:10.3390/ijerph17010375 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2020, 17, 375 2 of 23
rural areas and cities [1]. Therefore, telemedicine is regarded as an important policy tool to narrow
health disparities. In recent years, telemedicine in China has developed rapidly as telecommunication
networks have expanded [1]. After several years of development, however, the adoption of telemedicine
into mainstream health services has been slower than expected [2]. Telemedicine adapts conventional
medical practice to enable patients to access medical services via telecommunication. Telemedicine has
therefore established a new kind of relationship between smaller hospitals and larger ones, as well as
between patients and hospitals in general. Patients and primary hospitals benefit from the resources
of larger hospitals via digital tele-consultation, digital tele-diagnosis, and digital tele-monitoring.
This is particularly beneficial for patients living in rural areas where the healthcare system is less
developed than in cities. However, the interests of each side in telemedicine need to be balanced in
order to promote the sustainable development of telemedicine in future. It is therefore appropriate
to analyze the behavior of stakeholders in the telemedicine system to improve the promotion of
telemedicine. In this study, evolutionary game theory was applied to analyze the behaviors and
evolutionary framework of HMIs, PMIs, and patients, as well as theoretically explore whether the
tripartite game will achieve an evolutionary stability strategy or only realize local stability. A numerical
simulation was used to provide suggestions for the promotion and development of telemedicine and
lay the foundation for a ‘hierarchical medical system’ in China.
2. Literature Reviews
Telemedicine has been researched for more than a century, but there is a lack of clarity and
an absence of agreement about the definitions of key concepts in relation to the terminology in this
field [3]. To date, although there is no single, commonly accepted definition of telemedicine, the use of
technology to deliver healthcare services and information at a distance to improve access and quality
and reduce costs is a common theme throughout professional descriptions of these services [4].
In developing countries in particular, telemedicine can help address the shortage of health workers
and medical specialists by providing timely access to specialist and other forms of healthcare [5].
Recognizing the extreme shortage in health professionals in developing countries [6], a major challenge
for promoting telemedicine is whether clinicians are willing to use telemedicine technology. Chau and
Hu [7] examined physicians’ acceptance of telemedicine technology and suggest that the technology
acceptance model (TAM) may be more appropriate than the theory of planned behavior (TPB) model
for examining technology acceptance by individual professionals. As an extension of TAM, the UTAUT
(Unified Theory of Acceptance and Use of Technology) model, which overcomes the limitations of the
early TAM models, was adopted to explore the adoption and usage of telemedicine among clinicians
in Nigeria [8]. Furthermore, existing literature also focuses on acceptance and the influencing factors
of other entities, e.g., hospitals [9], technology suppliers, and service providers [10], whose research
shows that the most frequently reported patient barriers to telehealth acceptance are technical issues.
The technology supplier and service providers were thus able to design and deliver higher quality
telemedicine services, adopting a user-centric approach. However, they are not the only ones involved.
Patients’ willingness to use telemedicine is also crucial for expanding telemedicine’s usage due to
increased demand. Previous telemedicine research has concentrated on technology development and
technology acceptance from the standpoint of either an organization or a healthcare professional,
hence, offering limited insights for patients’ acceptance of this technology. In this context, Liu [11] uses
a quantitative survey research to address pervasive tele-monitoring acceptance among patients Gorst
et al. [12] assess the levels of uptake of home telehealth by patients diagnosed with heart failure and
chronic obstructive pulmonary diseases and the factors determining patients’ willingness to continue
using telehealth. Moreover, Domingo et al. [13] explore the acceptance of telemedicine and its impact
on patient behavior.
Researchers have tended to focus on the evaluation of telemedicine services, the mainstream view
being that telemedicine has advantages over traditional medicine, such as saving patients substantial
time and money with less travel [14], delivering greater continuity of care and patient satisfaction [14],
and yielding better clinical results [15,16]. Telemedicine may also reduce pollution and the greenhouse
gases associated with travel to hospitals [17], as well as reduce apprehension regarding sexual and
reproductive health consultations [18]. That is not to say however that all researchers have found
the same positive results. Some studies have even concluded that telemedicine does not seem to be
a cost-effective addition to standard support and treatment [19].
In the existing studies evaluating telemedicine, researchers have neglected the role of healthcare
providers and only focused on the effectiveness and satisfaction of patients using telemedicine [20].
This preference should be addressed in future research.
3. Methods
By and large, modelling human decision-making processes or actual human behavior is harder
than that of the transparent physical systems dealt by traditional science and engineering, because the
governing mathematical models are usually unknown. What we can guess concerning these processes
is not expressed as a set of transparent, deterministic, and explicit equations but black box-like models
or, in some cases, stochastic models. At any rate, in order to solve those problems in the real world,
we must build a holistic model that covers not only environment as physical systems, but also human
beings and society as complex systems. One effective tool to do this is evolutionary game theory [21].
3.1. Game Theory in Health

The concept of game theory has been used among the access to the healthcare services. Game theory
has the potential to provide models of the consultation that can be used to generate empirically testable
predictions about the factors that promote quality of care. In the research of Tarrant et al. [22],
they indicated that game theory can been applied to the medical consultation and used to generate
predictions about how the context of a doctor–patient interaction influences cooperation and quality of
care, and further empirical work is needed to uncover the underlying game structures that occur most
commonly in medical consultations. Blake and Carroll [23] analyze how game theory can provide
a framework for understanding the strategic decision-making that occurs in everyday scenarios in
medical training and practice, and ultimately serves as a tool for improving the work environment
and patient care, through analyses, they found that trainees and physicians can work to better
recognize where competing priorities exist, understand the motivations and interactions of the various
players, and learn to adjust their approaches in order to ‘change the game’ when their preferred
outcome is not the most likely one. Dasgupta et al. [24] describe a mixed reality-based testbed and
a framework for studying social interactions using a game theory approach and present a case study
for exposure therapy treatment of individuals with Social Anxiety Disorder using the proposed testbed.
Based on multi-player cooperation game theory, Kumar et al. [25] propose a novel E-healthcare model
coupled with cloud computing platform to provide health related services in IoV (Internet of Vehicles)
environment on-the-fly. Through these studies, game theory has the potential to provide a new
conceptual and theoretical basis for future empirical work on the interaction between doctors and
their patients.
3.2. Evolutionary Game Theory and ESS

Evolutionary game theory (e.g., Weibull 1995 [26]) has evolved by merging game theory with the
basic concept of Darwinism so as to compensate for the idea of time evolution, which is partially lacking
in the original game theory that primarily deals with equilibrium. In our study, the evolution refers to
the strategies adopted by the agents and, in most agent-based models, the mechanism responsible
for this evolution is a process usually defined ‘strategy revision phase’. The latter allows agents to
change their strategy according to a particular rule, where usually ‘rationality’ constitutes the main
ingredient [27]. Maynard Smith [28] formulated a central concept of evolutionary game theory called
the evolutionarily stable strategy (ESS). To briefly illustrate this, suppose that a population consists of
individuals adopting strategies I or J with frequencies p and q, where p + q = 1. What is the fitness of
an individual adopting strategy?
Fitness of I = p·EI (I ) + q·E J (I )
Fitness of J = p·EI ( J ) + q·E J ( J )
If a particular strategy, say I, is to be an ESS, it must have the following property. A population
of individuals playing I must be ‘protected’ against invasion by any mutant strategy, say J. That is,
when I is common, it must be fitter than any mutant. That is, I is an ESS if for all J , I,
either EI (I ) > EI ( J ),
or EI (I ) = EI ( J ),
and E J (I ) > E J ( J ).
If these conditions are satisfied, then a population of individuals playing I is stable; no mutant
can establish itself in such a population. This follows from the fact that when q is small, the fitness of I
is greater than the fitness of J.
In research of Zeeman [29], an ESS is an attractor of the replicator dynamics, and the population
converges to the ESS for every strategy sufficiently close to it. If I is an internal ESS, then global
convergence to I is assured.
3.3. Data Collection

In order to comprehend the implementation and operation of telemedicine in poor Guizhou
Province, our team conducted a social survey in Qiandongnan Miao and Dong Autonomous Prefecture
in Guizhou between 7 and 22 February 2018. This field work focused primarily on the opinion, attitude,
and behavior of rural residents regarding telemedicine. Interviews were conducted with the head of
the township and county hospitals. In the survey, residents of 10 administrative villages (Leye Village,
Longma Village, Anping Village, Longtian Community, Zongyuan Village, Luxi Village, Daidian
Village, Juntun Village, Hujia Village, and Dusu Village) were samples under the jurisdiction of the
town of Longtian. Furthermore, 10 households were randomly sampled from each village, resulting in
a total sample of 100 observations. For the interviews, we only get information on the implement and
operation of telemedicine, and the key issues during the telemedicine. With an estimated Cronbach’s
Alpha of 0.547, the information we collected through the questionnaire as well as the interviews can
be considered as moderately reliable. In addition, data were also collected from policy documents,
reports, and news with regard to telemedicine in Guizhou Province. Our filed survey data as well as
the secondary information together suggest the validity and rationality of the theoretical model and
the numerical simulation of this paper.
4. Tripartite Evolutionary Game Model of Stakeholders in Telemedicine
4.1. The Hypothesis of the Tripartite Evolutionary Game Model

In China, MIs are required to sign telemedicine cooperation agreements to provide telemedicine
services. The content of the agreements should include the purpose of the cooperation, its conditions,
contents, the process of providing telemedicine services, the rights and obligations of both parties,
the risks and liabilities involved in sharing responsibility for medical damages, etc. Telemedicine
service fees are settled regularly by means of special financial accounts. It is strictly prohibited to
obtain funds for telemedicine services in any other way. The daily operational costs of telemedicine in
MIs includes expert diagnosis and treatment fees, training fees, site fees, equipment fees, network fees,
operation and maintenance fees, management fees, full-time personnel fees, technical maintenance
fees, and system maintenance fees. Here, HMIs mainly refer to hospitals at or above county level,
while primary MIs mainly refer to township hospitals.
In China, telemedicine is a complex system that involves many services; thus, it is impossible
to analyze each item in detail given the limited space of this paper. To simplify the analysis without
compromising its accuracy, this paper only considers the treatment provided through telemedicine,
e.g., tele-consultation, tele-diagnosis, and tele-monitoring. The following hypotheses were tested in
this study:
(1) The promotion of telemedicine is influenced by the behavior of three groups: Inviters of
telemedicine (mainly the primary MIs), the invitees of telemedicine (HMIs), and patients. All the
players with bounded rationality can adjust their own strategies by imitating and learning proven
behaviors to guarantee maximum revenues.
(2) When providing telemedicine, HMIs take two courses of action: One strategy is to prioritize the
provision of telemedicine (showing effort), while the other is to provide telemedicine without prioritizing
it (not showing effort). Thus, the strategy space of HMIs is S1 {efforts, no efforts}. Likewise, the strategy

space of primary MIs and patients are S2 {efforts, no efforts} and S3 acceptance, non − acceptance
respectively. Meanwhile, it is assumed that the efforts of HMIs are e1 and those of primary MIs are e2 .
It is also assumed that hthe efforts
i of HMIs and PMIs are independent of each other, and that the range
of the efforts values is ei , ei , where i = 1, 2.
(3) The tripartite game is a cooperative game without rent-seeking behaviors, i.e., the three groups
do not collude or collaborate with one other. It is an asymmetric game. The assumptions are that
HMIs may with x probability adopt the ‘efforts’ strategy, and with (1 − x) probability adopt the ‘no
efforts’ strategy; primary MIs may with y probability adopt the ‘efforts’ strategy, and with (1 − y)
probability adopt the ‘no efforts’ strategy; patients may with z probability adopt the ‘acceptance’
strategy, and with (1 − z) probability adopt the ‘non-acceptance’ strategy, in which 0 < x < 1, 0 < y < 1,
and 0 < z < 1, respectively.
(4) The payment of HMIs is E1 (e1 ) when they make efforts to provide telemedicine, while
the corresponding
operating costs are C1 (e1 ). In contrast, the payment and operating costs are
E1 e1 and C1 e1 , respectively, when HMIs do not make efforts to provide telemedicine. Since
government funds support HMIs in the provision of telemedicine, they are based on patient satisfaction
assessments and distributed through the post payment system; moreover, the level of financial support
of effort. In the aforementioned situation, the levels of government support are R1 (e1 )
is a function
and R1 e1 respectively.
(5) In the process of the cooperative use of telemedicine between primary MIs and HMIs, there are
two situations: (1) Where primary MIs make an effort to cooperate with HMIs, where the benefits and
operation costs are E2 (e2 ) and C2 (e2 ), respectively, and the financial support provided by government
is R2 (e2 ); and (2) where primary MIs donot try to cooperate with HMIs; in this situation, the benefits
and operational costs are E2 e2 and C2 e2 , respectively, and the financial support provided by the

government is R2 e2 . In either situation, if primary MIs seek help from HMIs, they need to pay a fee
to the HMIs according to their cooperative agreement. According to the telemedicine regulations
in many provinces, the fee is a proportion of the total telemedicine expenses B paid by the patients.
In this paper, it was assumed that the proportion is ε(0 < ε < 1) and is decided by both sides through
consultation according to the government’s guidance price.
(6) When patients accept telemedicine services, their utility depends on the effort level ei of
the HMIs and PMIs, indexed as E3 (e1 , e2 ). Considering
the range of HMIs and primary MIs efforts,
the patients’ utility set is defined as {E(e1 , e2 ), E e1 , e2 , E e1 , e2 , E e1 , e2 }. To simplify the calculation,

it was assumed that E3 e1 , e2 = E3 e1 , e2 . Furthermore, during the process of telemedicine, the utility of
patients as telemedicine terminal mostly relies on the efforts of primary MIs that are agent of both HMIs
and patients. Regardless of the level of HMIs efforts, patients would not get better telemedicine services
if the primary MIs hold less or none efforts. Besides, if the HMIs negatively provide telemedicine service,
even though the primary MIs put more efforts in the process of telemedicine, the utility of patients
would still be low. Accordingly, the following simplified assumption is drawn: E(e2 ) = E(e1 , e2 ),
which implies
a better utility of patients through telemedicine, and others of patients’ utility set are all
equal to E e2 , which represents a worse utility of patients through telemedicine. The telemedicine
fee the patients pay is B once they accept the telemedicine service, regardless of the utility level.
Assuming that the reimbursement ratio of New Rural Cooperative Medical Insurance (which has
been incorporated into the basic medical insurance for urban and rural residents) is b(0 < b < 1),
if telemedicine services are under the social medical insurance scheme, the real telemedicine fees that
patients need to pay are (1 − b)B. If telemedicine services are not incorporated into the social medical
insurance scheme, then b = 0. In addition, complaint costs G must be paid if patients are not satisfied
with the telemedicine they accepted. When patients do not accept telemedicine, then the utility level
and costs are both zero.
4.2. Payoff Matrix of the tripartite Evolutionary Game in Telemedicine

Based on the above assumptions, a tripartite evolutionary game model including HMIs, primary
Mis, and patients under bounded rationality was constructed. The payoff matrix of the three groups is
shown in Table 1.
Table 1. The payoff matrix of higher medical institutions (HMIs), primary medical institutions (PMIs),
and patients.
HMIs
Efforts (x) No Efforts (1−x)
PMIs
Patients Efforts (y) No Efforts (1−y) Efforts (y) No Efforts (1−y)

E1 (e1 ) + R1 (e1 ) − E 1 ( e1 ) + E1 e1 + E1 e1 + R1 e1 −

C1 (e1 ) R 1 ( e1 ) − C 1 ( e1 ) R1 e1 − C1 e1 C1 e1
E2 (e2 ) +

Acceptance (z) E2 (e2 ) + R2 (e2 ) − E 2 e2 + R 2 e2 − E2 e2 + R2 e2 −
R2 (e2 ) −
C2 (e2 ) − εB

C2 e2 − εB C2 (e2 ) − εB C2 e2 − εB

E 3 e2 − E3 (e2 ) −
E3 (e2 ) − (1 − b)B E3 e2 − (1 − b)B − G
(1 − b)B − G (1 − b)B − G

R1 (e1 ) − C1 (e1 ) R 1 ( e1 ) − C 1 ( e1 ) R1 e1 − C1 e1 R1 e1 − C1 e1

Non-acceptance (1 − z) R2 (e2 ) − C2 (e2 ) R2 e2 − C2 e2 R2 (e2 ) − C2 (e2 ) R2 e2 − C2 e2
0 0 0 0
5. Analysis of the Tripartite Evolutionary Game Model in Telemedicine
5.1. Replicator Dynamics Equation of the Tripartite Evolutionary Game

Under the aforementioned assumption, the marginal expected revenue when HMIs implement
the ‘more efforts’ strategy is U11 :
U11 = yz(E1 (e1 ) + R1 (e1 ) − C1 (e1 )) + y(1 − z)(R1 (e1 ) − C1 (e1 )) + (1−
y)z(E1 (e1 ) + R1 (e1 ) − C1 (e1 )) + (1 − y)(1 − z)(R1 (e1 ) − C1 (e1 )).
The marginal expected revenue when HMIs implement the ‘less efforts’ strategy is U12 :

U12 = yz E1 e1 + R1 e1 − C1 e1 + y(1 − z) R1 e1 − C1 e1 +

(1 − y)z E1 e1 + R1 e1 − C1 e1 + (1 − y)(1 − z) R1 e1 − C1 e1 .
The expected revenue of the HMIs is U1 :

U1 = xU11 + (1 − x)U12 = xzE1 (e1 ) + (z − xz)E1 e1

+xR1 (e1 ) − xC1 (e1 ) + (1 − x)R1 e1 − (1 − x)C1 e1 .
Thus, the replicator dynamics equation of the ‘efforts’ strategy chosen by HMIs can be written as
F(x) in Formula (1):

F(x) = dx/dt = x(U11 − U1 ) = x(1 − x) R1 (e1 ) − C1 (e1 ) − R1 e1 + C1 e1 +
(1)
zE1 (e1 ) − zE1 e1 .
Likewise, the marginal expected revenues when PMIs implement the ‘more efforts’ and ‘less
efforts’ strategies are U21 and U22 , respectively:
U21 = xz(E2 (e2 ) + R2 (e2 ) − C2 (e2 ) − εB) + x(1 − z)(R2 (e2 ) − C2 (e2 ))+
(1 − x)z(E2 (e2 ) + R1 (e2 ) − C2 (e2 ) − εB) + (1 − x)(1 − z)(R2 (e2 ) − C2 (e2 )),

U22 = xz E2 e2 + R2 e2 − C2 e2 − εB + x(1 − z) R2 e2 − C2 e2 +

(1 − x)z E2 e2 + R2 e2 − C2 e2 − εB + (1 − x)(1 − z) R2 e2 − C2 e2 .
The expected revenue of PMIs is U2 :

U2 = yU21 + (1 − y)U22 = yzE2 (e2 ) + (z − yz)E2 e2 + yR2 (e2 ) − yC2 (e2 )+

(1 − y)R2 e2 − (1 − y)C2 e2 − zεB.
Then, the replicator dynamics equation of the ‘efforts’ strategy chosen by PMIs can be written as
F( y) in Formula (2):

F( y) = dy/dt = y(U21 − U2 ) = y(1 − y) R2 (e2 ) − C2 (e2 ) − R2 e2 + C2 e2 +
(2)
zE2 (e2 ) − zE2 e2 .
Finally, the marginal expected revenues when patients carry out the ‘acceptance’ and
‘non-acceptance’ strategies are U31 and U32 , respectively:

U31 = xy(E3 (e2 ) − (1 − b)B) + x(1 − y) E3 e2 − (1 − b)B − G
+(1 − x) y(E3 (e2) −(1− b)B − G)
+(1 − x)(1 − y) E3 e2 − (1 − b)B − G
U32 = 0

U3 = zU31 + (1 − z)U32 = yzE3 (e2 ) + z(1 − y)E3 e2 + z(1 − xy)G − z(1 − b)B.
The replicator dynamics equation of the ‘acceptance’ strategy chosen by patients can be written as
F(z) in Formula (3):

F(z) = dz/dt = z(U31 − U3 ) = z(1 − z) yE3 (e2 ) + (1 − y)E3 e2 −
(3)
(1 − xy)G − (1 − b)B).
5.2. Replicator Dynamic Analysis of the Tripartite Evolutionary Game
5.2.1. Replicator Dynamic Analysis of the Patient Group

Formula (3) is the patient group’s replicator dynamic equation when they choose the ‘acceptance’
strategy. According to the stability theorem of differential equations and the property of evolutionary
stability strategies (ESS), the stability point is required to satisfy the condition of F0 (z) < 0.
yE3 (e2 )+(1−y)E3 (e2 )−G−(1−b)B
When x = x∗ = − yG , then F(z) ≡ 0. This means that no matter the value z
takes, each z value is the replicator dynamics’ steady state.
When x , x∗ , then F(z) = 0, yielding z = 0, z = 1, both of which are fixed points and
the steady states for the replicator dynamics of patients. The derivative of F(z) as regards z is
∂F(z)

F0 (z) = ∂z = (1 − 2z) yE3 (e2 ) + (1 − y)E3 e2 − (1 − xy)G − (1 − b)B , because yG > 0(1 > y > 0).
These two situations are discussed as follows:
(1) When yE3 (e2 ) + (1 − y)E3 e2 − G − (1 − b)B > 0, which means that the expected utility is more
than the telemedicine fees and complaint costs, then x∗ < 0 is obtained. For every x that satisfies the
∂F(z) ∂F(z)
condition 1 > x > 0, then x > x∗ is held. Based on the above, ∂z > 0 and ∂z < 0. Thus,
z=0 z=1
z = 1 is the steady state, and ‘acceptance’
the stable strategy.
(2) When yE3 (e2 ) + (1 − y)E3 e2 − G − (1 − b)B < 0, which means that the expected utility is less
than the telemedicine fees and complaint costs, then x∗ > 0 is obtained. For every x that satisfies the
condition 1 > x > 0, two situations result, discussed as follows:
∂F(z) ∂F(z)
O1 When x > x∗ , then
∂z z=0
> 0 and ∂z < 0. Thus, z = 1 is the steady state, and ‘acceptance’
z=1
∂F(z) ∂F(z)
O2 When x < x∗ , then
∂z z=0
< 0 and ∂z > 0. Thus, z = 0 is the steady state,
z=1
and ‘non-acceptance’ the stable strategy.
According to the above analysis, the dynamic evolutionary processes of patients’ ESS under
various conditions are shown in Figure 1. In Figure 1, the x-axis, y-axis, and z-axis are stand for the
value of x, y, and z, respectively. That is, the x-axis, y-axis, and z-axis represent the probability of
adopting strategy of ‘HMI efforts’, ’PMI efforts’, and ’patients’ acceptance’, respectively. In Figure 1,
Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 8 of 23
the arrow points out to the direction of dynamic evolution of patients’ strategy. The box in Figure 1
indicates the probability of strategy space of three groups, HMIs, PMIs, and patients. For constraint
threshold ‫ כ∗ݔ‬, it is a function of ‫ݕ‬. Therefore, in the three-dimensional coordinate system, when we
threshold x , it is a function of y. Therefore, in the three-dimensional coordinate system, when we
consider the variable ‫ݖ‬, others are paramenter.
consider the variable z, others are paramenter.
Figure 1. Dynamic evolution of patients’ evolutionarily stable strategy (ESS).

Figure 1. Dynamic evolution of patients’ evolutionarily stable strategy (ESS).
Based on the analysis of the evolutionary game model, the following can be concluded:
Based on the1:analysis
Conclusion Patientsoftend
the evolutionary
to choose thegame model, the
‘acceptance’ following
strategy can be concluded:
in telemedicine when (1) their
Conclusion 1: Patients tend to choose the ‘acceptance’ strategy in
expected utility or benefits are greater than the sum of the telemedicine fees and complaint telemedicine when (1) or
costs, their
(2)
expected utility or benefits are greater than the sum of the telemedicine fees and
their expected utility or benefits are smaller than the sum of the telemedicine fees and complaint costs complaint costs, or
(2)
whentheir expectedthe
x satisfies utility or benefits
condition 1>x> arex∗smaller
. than the sum of the telemedicine fees and complaint
‫כ‬
when ‫ ݔ‬satisfies
costs Conclusion the condition ͳ ൐ ‫ݔ‬ ൐ ‫ݔ‬ .
2: Patients tend to choose the ‘non-acceptance’ strategy in telemedicine when (1) their
Conclusion 2: Patients tend to choose the ‘non-acceptance’
expected utility or benefits are less than the sum of the telemedicine strategy in telemedicine
fees and when
complaint costs or (1)
(2)
their
their expected
expected utility
utility or benefits are
or benefits are greater
less than thethe
than sum of the
sum telemedicine
of the telemedicine feesfees
andand
complaint
complaintcosts or
costs,
(2) their expected utility or benefits
when x satisfies the condition of x > x > 0.
∗ are greater than the sum of the telemedicine fees and complaint
costs, when ‫ ݔ‬satisfies the condition of ‫ כ ݔ‬൐ ‫ ݔ‬൐ Ͳ.
5.2.2. Replicator Dynamic Analysis of PMIs
5.2.2. Replicator Dynamic Analysis of PMIs
Formula (2) is the PMI group’s replicator dynamic equation when they choose the ‘efforts’ strategy.
As perFormula
the above(2) analysis,
is the PMIthegroup’s
necessary replicator
conditiondynamic equation
for ESS is when they choose the ‘efforts’
F0 ( y) < 0.
strategy. As per the above analysis, the necessary condition for ESS is ‫ ܨ‬ᇱ ሺ‫ݕ‬ሻ ൏ Ͳ.
ோమ ൫௘మ ൯ି஼మ ൫௘మ ൯ିோమ ሺ௘మ ሻା஼మ ሺ௘మ ሻ
When ‫ ݖ‬ൌ ‫ כ ݖ‬ൌ , then ‫ܨ‬ሺ‫ݕ‬ሻ ‫Ͳ ؠ‬. This means that no matter the value ‫ݕ‬
ாమ ሺ௘మ ሻିாమ ൫௘మ ൯
takes, each ‫ ݕ‬value is the replicator dynamics’ steady state.
When ‫ כ ݖ ് ݖ‬, then ‫ܨ‬ሺ‫ݕ‬ሻ ൌ Ͳ, yielding ‫ ݕ‬ൌ Ͳ, ‫ ݕ‬ൌ ͳ. Both fixed points are the steady states for
డிሺ௬ሻ
the replicator dynamics of PMIs. The derivative of ‫ܨ‬ሺ‫ݕ‬ሻ regards ‫ ݕ‬is ‫ ܨ‬ᇱ ሺ‫ݕ‬ሻ ൌ ൌ ሺͳ െ
డ௬
ʹ‫ݕ‬ሻ ቀܴଶ ሺ݁ଶ ሻ െ ‫ܥ‬ଶ ሺ݁ଶ ሻ െ ܴଶ ൫݁ଶ ൯ ൅ ‫ܥ‬ଶ ൫݁ଶ ൯ ൅ ‫ܧ‬ଶ ሺ݁ଶ ሻ െ ‫ܧ‬ଶ ൫݁ଶ ൯ቁ because ‫ܧ‬ଶ ሺ݁ଶ ሻ െ ‫ܧ‬ଶ ൫݁ଶ ൯ ൐ Ͳ. There are
R2 (e2 )−C2 (e2 )−R2 (e2 )+C2 (e2 )

When z = z∗ = , then F( y) ≡ 0. This means that no matter the value y
E2 (e2 )−E2 (e2 )
takes, each y value is the replicator dynamics’ steady state.
When z , z∗ , then F( y) = 0, yielding y = 0, y = 1. Both fixed points are the steady
∂F( y)
states for the replicator dynamics of PMIs. The derivative of F( y) regards y is F0 ( y) = ∂y =

(1 − 2y) R2 (e2 ) − C2 (e2 ) − R2 e2 + C2 e2 + zE2 (e2 ) − zE2 e2 because E2 (e2 ) − E2 e2 > 0. There are
two situations to be discussed:

(1) When R2 e2 − C2 e2 < R2 (e2 ) − C2 (e2 ), which means that the net revenue under the ‘efforts’
strategy is more than that under the ‘no efforts’ strategy, for every z that satisfies the condition 1 > z > 0,
∂F( y) ∂F( y)
then z > z∗ . Based on the above, ∂y y=0
> 0 and ∂y y=1
< 0. Thus, y = 1 is the steady state and
‘efforts’ the stablestrategy.

(2) When R2 e2 − C2 e2 > R2 (e2 ) − C2 (e2 ), which means that the net revenue under the ‘efforts’
strategy is less than that under the ‘no efforts’ strategy, then z∗ > 0 is obtained. For every z that satisfies
the condition 1 > z > 0, there are two situations that result:
∂F( y) ∂F( y)
O1 When z > z∗ , then
∂y
> 0 and ∂y < 0. Thus, y = 1 is the steady state, and ‘efforts’
y=0 y=1
∂F( y) ∂F( y)
O
2 When z < z∗ , then
∂y y=0
< 0 and ∂y y=1
> 0. Thus, y = 0 is the steady state, and ‘no
efforts’ the stable strategy.
According to the above analysis, the dynamic evolutionary processes of ESS of PMIs under various
conditions are shown in Figure 2.
Figure 2. Dynamic evolution of ESS for PMIs.

Figure 2. Dynamic evolution of ESS for PMIs.
Based on the
Conclusion 1: analysis
PMIs tend of the evolutionary
to choose gamestrategy
the ‘efforts’ model, in thetelemedicine
following can whenbe concluded:
(1) the net revenue
underConclusion
the ‘efforts’ 1: strategy
PMIs tend is to choose
greater thethat
than ‘efforts’
understrategy
the ‘noinefforts’
telemedicine
strategy when (1)the
or (2) thenetnet revenue
revenue
under the ‘efforts’ strategy is greater than that under the ‘no efforts’ strategy
under the ‘efforts’ strategy is less than that under the ‘no efforts’ strategy when z satisfies the condition or (2) the net revenue
1under z∗ . ‘efforts’ strategy is less than that under the ‘no efforts’ strategy when ‫ ݖ‬satisfies the
> z > the
‫כ‬
condition ͳ൐‫ݖ‬൐
Conclusion 2: ‫ݖ‬PMIs . tend to choose the ‘no efforts’ strategy in telemedicine, when (1) the net
revenue under the ‘efforts’ tend
Conclusion 2: PMIs strategyto choose
is less thanthe ‘nothat efforts’
under the strategy in telemedicine,
‘no efforts’ strategy or (2)when (1)revenue
the net the net
revenue
under theunder thestrategy
‘efforts’ ‘efforts’ isstrategy
greater isthan lessthat thanunder
that under
the ‘nothe ‘no efforts’
efforts’ strategy,strategy
when zorsatisfies
(2) the the
net
revenue under
condition 0 < z < z . the ∗ ‘efforts’ strategy is greater than that under the ‘no efforts’ strategy, when ‫ݖ‬
satisfies the condition Ͳ ൏ ‫ ݖ‬൏ ‫ כ ݖ‬.
5.2.3. Replicator Dynamics Analysis of HMIs
5.2.3. Replicator Dynamics Analysis of HMIs
Formula (1) is the HMI group’s replicator dynamics equation when they choose the ‘efforts’
Formula
strategy. As per (1)theis above
the HMI group’s
analysis, thereplicator
necessary dynamics
condition for equation
ESS is when
F0 (x) <they
0. choose the ‘efforts’
strategy. As per 0the above R1 (e1 )−Canalysis,
1 (e1 )−R1 (the
e1 )+Cnecessary
1 (e1 ) condition for ESS is ‫ ܨ‬ᇱ ሺ‫ݔ‬ሻ ൏ Ͳ.
When z = z = ோ ൫௘ ൯ି஼ ൫௘ ൯ିோ ሺ௘ ሻା஼ ሺ௘ ሻ , then F(x) ≡ 0. This means that no matter the value that
(e1భ)−E1భ(e1భ) భ భ
When ‫ ݖ‬ൌ ‫ ݖ‬ᇱ ൌ భ భ Eభ1 ሺ௘ , then ‫ܨ‬ሺ‫ݔ‬ሻ ‫Ͳ ؠ‬. This means that no matter the value that
x takes, each x value is the replicator ாభ భ ሻିாభ ൫௘భdynamics’
൯ steady state.
‫ ݔ‬takes,
When each z ,‫ݔ‬z0value
, then is F(the
x) = replicator
0, yielding dynamics’
x = 0, x = steady state.
1, both of which are fixed points and the steady
ᇱ
‫ݖ‬ ് ‫ݖ‬ ‫ܨ‬ሺ‫ݔ‬ሻ ൌ0,
states for the replicator dynamics of HMIs. The derivative of Fof
When , then yielding ‫ݔ‬ ൌ Ͳ, ‫ݔ‬ ൌ ͳ, both (x)which are fixed
as regards x is Fpoints
∂F(x) the
0 (x) = and =
∂x
steady states for the replicator dynamics of HMIs. The derivative of ‫ܨ‬ሺ‫ݔ‬ሻ as regards ‫ ݔ‬is ‫ ܨ‬ᇱ ሺ‫ݔ‬ሻ ൌ
డிሺ௫ሻ
ൌ ሺͳ െ ʹ‫ݔ‬ሻ ቀܴଵ ሺ݁ଵ ሻ െ ‫ܥ‬ଵ ሺ݁ଵ ሻ െ ܴଵ ൫݁ଵ ൯ ൅ ‫ܥ‬ଵ ൫݁ଵ ൯ ൅ ‫ܧ‬ଵ ሺ݁ଵ ሻ െ ‫ܧ‬ଵ ൫݁ଵ ൯ቁ because ‫ܧ‬ଵ ሺ݁ଵ ሻ െ ‫ܧ‬ଵ ൫݁ଵ ൯ ൐
డ௫
Ͳ. There are two situations to discuss:
(1) When ܴଵ ൫݁ଵ ൯ െ ‫ܥ‬ଵ ൫݁ଵ ൯ ൏ ܴଵ ሺ݁ଵ ሻ െ ‫ܥ‬ଵ ሺ݁ଵ ሻ , which means that the net revenue under the
‘efforts’ strategy is greater than that under the ‘no efforts’ strategy, for every ‫ ݖ‬that satisfies the

(1 − 2x) R1 (e1 ) − C1 (e1 ) − R1 e1 + C1 e1 + zE1 (e1 ) − zE1 e1 because E1 (e1 ) − E1 e1 > 0. There are
two situations to discuss:
(1) When R1 e1 − C1 e1 < R1 (e1 ) − C1 (e1 ), which means that the net revenue under the ‘efforts’
strategy is greater than that under the ‘no efforts’ strategy, for every z that satisfies the condition
∂F(x) ∂F(x)
1 > z > 0, then z > z0 . Based on the above, ∂x > 0 and ∂x < 0. Thus, x = 1 is the steady
x=0 x=1
state and ‘efforts’the stable strategy.

(2) When R1 e1 − C1 e1 > R1 (e1 ) − C1 (e1 ), which means that the net revenue under the ‘efforts’
strategy is less than that under the ‘no efforts’ strategy, then z0 > 0 is obtained. For every z which
satisfies the condition 1 > z > 0, there are two situations that require discussion:
∂F(x) ∂F(x)
O1 When z > z0 ,
∂x x=0
> 0 and ∂x < 0. Thus, x = 1 is the steady state, and ‘efforts’ the
x=1
stable strategy.
∂F(x) ∂F(x)
O2 When z < z0 , then
∂x x=0
< 0 and ∂x > 0. Thus, x = 0 is the steady state, and ‘no
x=1
efforts’ the stable strategy.
According to the above analysis, the dynamic evolutionary processes of ESS of HMIs under
various conditions are shown in Figure 3.
Figure
Figure 3. Dynamic evolution
3. Dynamic evolution of
of ESS
ESS of
of HMIs.
HMIs.
Conclusion 1: HMIs tend to choose the ‘efforts’ strategy in telemedicine when (1) the net revenue
Conclusion 1: HMIs tend to choose the ‘efforts’ strategy in telemedicine when (1) the net revenue
under the ‘efforts’ strategy is greater than that under the ‘no efforts’ strategy or (2) the net revenue
under the ‘efforts’ strategy is greater than that under the ‘no efforts’ strategy or (2) the net revenue
under the ‘efforts’ strategy is less than that under the ‘no efforts’ strategy, when z satisfies the condition
under the ‘efforts’ strategy is less than that under the ‘no efforts’ strategy, when ‫ ݖ‬satisfies the
1 > z > z0 .
condition ͳ ൐ ‫ ݖ‬൐ ‫ ݖ‬ᇱ .
Conclusion 2: HMIs tend to choose the ‘no efforts’ strategy in telemedicine when (1) the net
Conclusion 2: HMIs tend to choose the ‘no efforts’ strategy in telemedicine when (1) the net
revenue under the ‘efforts’ strategy is less than that under the ‘no efforts’ strategy or (2) the net revenue
revenue under the ‘efforts’ strategy is less than that under the ‘no efforts’ strategy or (2) the net
under the ‘efforts’ strategy is greater than that under the ‘no efforts’ strategy when z satisfies the
revenue under the ‘efforts’ strategy is greater than that under the ‘no efforts’ strategy when ‫ݖ‬
condition 0 < z < z0 .
satisfies the condition Ͳ ൏ ‫ ݖ‬൏ ‫ ݖ‬ᇱ .
5.3. Stability Analysis of the Local Equilibrium Points (EPs)
5.3. Stability Analysis of the Local Equilibrium Points (EPs)
According to the above three replicator equations, F(x), F( y), and F(z), a three-dimensional
According to the above three replicator equations, ‫ܨ‬ሺ‫ݔ‬ሻ, ‫ܨ‬ሺ‫ݕ‬ሻ, and ‫ܨ‬ሺ‫ݖ‬ሻ, a three-dimensional
dynamic evolutionary system of HMIs, PMIs, and patients can be obtained, as in Equation (4).
dynamic evolutionary system of HMIs, PMIs, and patients can be obtained, as in Equation (4).

F(x) = x(1 − x) R1ሺ݁ (e1 )ሻ − C1 (ሺ݁
e1 )ሻ − R1 e1 + C1 e1 + zE1 (ሺ݁
e1 ) ሻ− zE1 e1
‫ۓ‬‫ܨ‬ሺ‫ݔ‬ሻ ൌ ‫ݔ‬ሺͳ െ ‫ݔ‬ሻ ቀܴ ଵ ଵ െ ‫ܥ‬ଵ ଵ െ ܴଵ൫݁ଵ൯ ൅ ‫ܥ‬ଵ൫݁ଵ൯ ൅ ‫ܧ‬ଵ ଵ െ ‫ܧ‬ଵ ൫݁ ଵ ൯ቁ



ۖ F( y) = y(1 − y) R2 (e2 ) − C2 (e2 ) − R2 e2 + C2 e2 + zE2 (e2 ) − zE2 e2 (4)
‫ܨ‬ሺ‫ݕ‬ሻ ൌ ‫ݕ‬ሺͳ െ ‫ݕ‬ሻ ቀܴ ሺ݁ ሻ െ ‫ ܥ‬ሺ݁ ሻ െ ܴ ൫݁ ൯ ൅ ‫ ܥ‬൫݁ ൯ ൅ ‫ ܧ‬ሺ݁ ሻ െ ‫ ܧ‬൫݁ ൯ቁ (4)


ଶ ଶ ଶ ଶ ଶ ଶ ଶ ଶ ଶ ଶ ଶ ଶ
‫۔‬ F(z) = z(1 − z) yE3 (e2 ) + (1 − y)E3 e2 − (1 − xy)G − (1 − b)B


ۖ ‫ܨ‬ሺ‫ݖ‬ሻ ൌ ‫ݖ‬ሺͳ െ ‫ݖ‬ሻ൫‫ܧݕ‬ଷ ሺ݁ଶ ሻ ൅ ሺͳ െ ‫ݕ‬ሻ‫ܧ‬ଷ ൫݁ଶ ൯ െ ሺͳ െ ‫ݕݔ‬ሻ‫ ܩ‬െ ሺͳ െ ܾሻ‫ܤ‬൯
‫ە‬
According to the method introduced by Friedman [30], the local stability of the Jacobian matrix
According to the method introduced by Friedman [30], the local stability of the Jacobian matrix
system can be used to determine the evolutionary stability strategies of the dynamic equation set.
system can be used to determine the evolutionary stability strategies of the dynamic equation set.
The Jacobian matrix of the replication dynamic Equation (4) is shown below:
The Jacobian matrix of the replication dynamic Equation (4) is shown below:
߲‫ܨ‬ሺ‫ݔ‬ሻ ോ ߲‫ݔ‬ ߲‫ܨ‬ሺ‫ݔ‬ሻ ോ ߲‫ݕ‬ ߲‫ܨ‬ሺ‫ݔ‬ሻ ോ ߲‫ݖ‬
‫ ܬ‬ൌ ቎߲‫ܨ‬ሺ‫ݕ‬ሻ ോ ߲‫ݔ‬ ߲‫ܨ‬ሺ‫ݕ‬ሻ ോ ߲‫ݕ‬ ߲‫ܨ‬ሺ‫ݕ‬ሻ ോ ߲‫ݖ‬቏ ൌ
߲‫ܨ‬ሺ‫ݖ‬ሻ ോ ߲‫ݔ‬ ߲‫ܨ‬ሺ‫ݖ‬ሻ ോ ߲‫ݕ‬ ߲‫ܨ‬ሺ‫ݖ‬ሻ ോ ߲‫ݖ‬
ሺଵିଶ௫ሻሺோభ ሺ௘భ ሻି஼భ ሺ௘భ ሻିோభ ൫௘భ ൯
‫ۍ‬ Ͳ ‫ݔ‬ሺͳ െ ‫ݔ‬ሻ ቀ‫ܧ‬ଵ ሺ݁ଵ ሻ െ ‫ܧ‬ଵ ൫݁ଵ ൯ቁ ‫ې‬
ା஼భ ൫௘భ ൯ା௭ாభ ሺ௘భ ሻି௭ாభ ൫௘భ ൯ቁ
‫ێ‬ ‫ۑ‬
ሺଵିଶ௬ሻ൫ோమ ሺ௘మ ሻି஼మ ሺ௘మ ሻିோమ ൫௘మ ൯
‫ێ‬ Ͳ ‫ݕ‬ሺͳ െ ‫ݕ‬ሻ ቀ‫ܧ‬ଶ ሺ݁ଶ ሻ െ ‫ܧ‬ଶ ൫݁ଶ ൯ቁ‫ۑ‬. (5)
ା஼ ൫௘ ൯ା୸ா ሺ௘ ሻି୸ா ൫௘ ൯ቁ
 ∂F(x)/∂x ∂F(x)/∂y ∂F(x)/∂z

 

J =  ∂F( y)/∂x ∂F( y)/∂y ∂F( y)/∂z
 
 =

∂F(z)/∂x ∂F(z)/∂y ∂F(z)/∂z
 
 
 (1 − 2x)(R1 (e1 ) − C1 (e1 ) − R1 e1 
 0 x(1 − x) E1 (e1 ) − E1 e1 

 +C1 e1 + zE1 (e1 ) − zE1 e1 

 
 (1 − 2y) R2 (e2 ) − C2 (e2 ) − R2 e2 
. (5)

 0 y(1 − y) E2 (e2 ) − E2 e2 

 + C2 e2 + zE2 (e2 ) − zE2 e2 


 (1 − 2z)( yE3 (e2 ) − (1 − b)B 
 z(1 − z) yG z(1 − z) E3 (e2 ) − E3 e2 + xG 
+ (1 − y)E3 e2 − (1 − xy)G
In the system (4), let F(x) = F( y) = F(z) = 0, whereby nine local EPs can be obtained, respectively:
D1 (0, 0, 0), D2 (0, 0, 1), D3 (0, 1, 0), D4 (0, 1, 1), D5 (1, 0, 0), D6 (1, 0, 1), D7 (1, 1, 0), D8 (1, 1, 1), D9 (x0 , y0 , z0 ).
According to the research of Selten and Ritzberger [31], only if the strategy combination is a strict Nash
equilibrium (NE) will it be asymptotically stable in the replicator dynamic system of the multi-group
evolutionary game; which is to say that if the evolutionary game equilibrium strategy combination
is asymptotically stable, then this strategy combination must be a strict NE, and the strict NE a pure
strategy NE (PSNE). Thus, for the replicator dynamics among HMIs, PMIs, and patients, only the first
eight EPs need to be explored. From an analysis of the local EP D1 (0, 0, 0) and its Jacobian matrix,
the following can be shown:
 
 R1 (e1 ) − C1 (e1 ) − R1 e1 + C1 e1 0 0 
 

 0 R2 (e2 ) − C2 (e2 ) − R2 e2 + C2 e2 0 

 
0 0 E3 e2 − (1 − b)B − G

It is clear that the eigenvalues of the above Jacobian matrix are λ1 = R1 (e1 ) − C1 (e1 ) − R1 e1 +

C1 e1 , λ2 = R2 (e2 ) − C2 (e2 ) − R2 e2 + C2 e2 + E2 (e2 ) − E2 e2 , λ3 = E3 e2 − (1 − b)B − G, respectively.
Likewise, all eigenvalues for the other seven EPs can be obtained when these EPs are replaced in the
Jacobian matrix. This is expressed by Formula (4). All eigenvalues of each EP’s Jacobian matrix are
shown in Table 2.
Table 2. The eigenvalues of each equilibrium point’s (EP’s) Jacobian matrix.
EP Eigenvalue

D1 (0, 0, 0) R1 (e1 ) − C1 (e1 ) − R1 e1 + C1 e1 R2 (e2 ) − C2 (e2 ) − R2 e2 + C2 e2 E3 e2 − (1 − b)B − G

E1 (e1 ) − E1 e1 + R1 (e1 ) R2 (e2 ) − C2 (e2 ) − R2 e2
D2 (0, 0, 1) − E3 e2 − (1 − b)B − G
−C1 (e1 ) − R1 e1 + C1 e1 +C2 e2 + E2 (e2 ) − E2 e2

D3 (0, 1, 0) R1 (e1 ) − C1 (e1 ) − R1 e1 + C1 e1 − R2 (e2 ) − C2 (e2 ) − R2 e2 + C2 e2 E3 (e2 ) − (1 − b)B − G
 
E1 (e1 ) − E1 e1 + R1 (e1 )  R2 (e2 ) − C2 (e2 ) − R2 e2 
D4 (0, 1, 1) −  −(E3 (e2 ) − (1 − b)B − G)
−C1 (e1 ) − R1 e1 + C1 e1 + C 2 e2 + E 2 ( e2 ) − E 2 e2 

D5 (1, 0, 0) − R1 (e1 ) − C1 (e1 ) − R1 e1 + C1 e1 R2 (e2 ) − C2 (e2 ) − R2 e2 + C2 e2 E3 e2 − (1 − b)B − G
 
 E1 (e1 ) − E1 e1 + R1 (e1 )  R2 (e2 ) − C2 (e2 ) − R2 e2
D6 (1, 0, 1) −   − E3 e2 − (1 − b)B − G
−C1 (e1 ) − R1 e1 + C1 e1  +C2 e2 + E2 (e2 ) − E2 e2

D7 (1, 1, 0) − R1 (e1 ) − C1 (e1 ) − R1 e1 + C1 e1 − R2 (e2 ) − C2 (e2 ) − R2 e2 + C2 e2 E3 (e2 ) − (1 − b)B
   
 E1 (e1 ) − E1 e1 + R1 (e1 )   R2 (e2 ) − C2 (e2 ) − R2 e2 
D8 (1, 1, 1) −  −  −(E3 (e2 ) − (1 − b)B)
−C1 (e1 ) − R1 e1 + C1 e1  + C 2 e2 + E 2 ( e2 ) − E 2 e2 
According to research by Friedman [30], the judgement criterion of EP’s stability can be summarized
as follows: When the symbol of each eigenvalue is negative, then the evolution EP is a stable point;
when the symbol of each eigenvalue is positive, then the evolution equilibrium is an unstable point;
when the eigenvalues are neither all negative nor positive at the same time, then the evolution
equilibrium is a saddle point.
The effect or performance of telemedicine is mainly influenced by the behavior of HMIs, PMIs,
and patients, and the key factors that influence these three groups are the relationships between the
costs and benefits of their behavioral strategies. To simplify the analysis of the eigenvalue symbols
that correspond to different EPs, in general there are two situations to discuss: (1) When the costs
are greater
than the benefits for all
three groups,
three conditions
C1 (e1 )
should be met, namely −
C1 e1 > (E1 (e1 ) + R1 (e1 )) − E1 e1 + R1 e1 , C2 (e2 ) − C2 e2 > (E2 (e2 ) + R2 (e2 )) − E2 e2 + R2 e2 ,
and (1 − b)B > E3 (e2 ); (2) when the costsare less than the benefits for
all
three
groups,
three conditions

should also be met, namely C1 (e1 ) − C1 e1 < (E1 (e1 ) + R1 (e1 )) − E1 e1 + R1 e1 , C2 (e2 ) − C2 e2 <

(E2 (e2 ) + R2 (e2 )) − E2 e2 + R2 e2 , and (1 − b)B + G < E3 e2 . Table 3 shows the eigenvalue symbols
that correspond to different EPs under the aforementioned two situations.
Table 3. Local stability analysis results.
Scenario 1 Scenario 2
EP Costs Are More Than Revenue Costs Are Less Than Revenue
Eigenvalue Symbol Stability Eigenvalue Symbol Stability
D1 (0, 0, 0) −−− Stable point +++ Unstable point
D2 (0, 0, 1) −−+ Saddle point ++− Saddle point
D3 (0, 1, 0) −+− Saddle point +−+ Saddle point
D4 (0, 1, 1) −++ Saddle point +−− Saddle point
D5 (1, 0, 0) +−− Saddle point −++ Saddle point
D6 (1, 0, 1) +−+ Saddle point −+− Saddle point
D7 (1, 1, 0) ++− Saddle point −−+ Saddle point
D8 (1, 1, 1) +++ Unstable point −−− Stable point
By analyzing the local stability of the Jacobian matrix, in situation 1, point D1 (0, 0, 0) is the evolution
stabilization point, point D8 (1, 1, 1) is the unstable point, and the other six points make up the saddle
point. This means that the tripartite dynamic system will gradually converge on point D1 (0, 0, 0),
which is to say that when the HMIs and PMIs choose the ‘no efforts’ strategy, patients choose the
‘non-acceptance’ strategy. Thus, when the costs are greater than the benefits, the evolutionary behavior
of the three groups will hinder the promotion of telemedicine.
Likewise, in situation 2, point D8 (1, 1, 1) is the evolution stabilisation point, point D0 (0, 0, 0) is
the unstable point, and the other six points make up the saddle point. This means that the tripartite
dynamic system will gradually converge on point D8 (1, 1, 1). In other words, when the HMIs and
PMIs choose the ‘efforts’ strategy, patients choose the ‘acceptance’ strategy. Thus, when the costs are
less than the benefits, the evolutionary behaviors of the three groups will improve the promotion of
telemedicine. This evolutionary state is ideal given the policy objective of implementing telemedicine
in China. Therefore, the government should take measures to increase the benefits and decrease the
costs of using telemedicine across all three groups. This includes increasing the financial support
for MIs to provide telemedicine, promoting payment reforms to reflect the efforts MIs are making
to provide telemedicine, decreasing telemedicine fees and complaint costs, and improving the social
medical insurance reimbursement system. These measures will promote telemedicine and optimize
the allocation of limited health resources.
6. Simulation Analysis
To more intuitively show the evolutionary process of the behavior/strategy of the players (patients,
PMIs, and HMIs) and to verify the fitness of the tripartite evolutionary game model constructed above,
Matlab was used to simulate the evolutionary process and interactivity of HMIs, PMIs, and patients.
It was also used to analyze the conditions under which the tripartite evolutionary game’s ESS takes
less time, given the parameters in situation 1. Lastly, it yielded policy implications for the promotion
of telemedicine in China.
When the costs are less than the benefits for all three groups,
the EP is D8 (1, 1, 1)

under the conditions C1 (e1 ) − C1 e1 < (E1 (e1 ) + R1 (e1 )) − E1 e1 + R1 e1 , C2 (e2 ) − C2 e2 <

(E2 (e2 ) + R2 (e2 )) − E2 e2 + R2 e2 , and (1 − b)B + G < E3 e2 . In this paper, it was assumed that the
initial time of simulation was 0 and the end time was
20. For the parameters in the model, it was assumed
that R1 (e1 ) = 4, R1 e1 = 3, R2 (e2 ) = 2, R2 e2 = 1, C1 (e1 ) = 4, C1 e1 = 3, C2 (e2 ) = 2, C2 e2 =

1, E1 (e1 ) = 5, E1 e1 = 4, E2 (e2 ) = 3, E2 e2 = 2, E3 (e2 ) = 5, E3 e2 = 4, G = 1, B = 2, and b = 0.7.
In addition, it was assumed that the initial intention of the ‘efforts’ strategy chosen by HMIs and PMIs
ranged from 0.05 to 0.95, and that the time interval was 0.15. Likewise, it was assumed that the initial
intention of the ‘acceptance’ strategy chosen by patients ranged from 0.05 to 0.95, with 0.15 as the time
interval. The three-dimensional simulation results were then obtained, as shown in Figure 4. It is clear
that‘PMI
all the curves
efforts’, converge
‘patients’ on EP D8 (is
acceptance’) 1, 1)when
1, ESS , whichtheverifies
costs aretheless
analysis
than theofbenefits
the above EPsthree
of all andgroups’
confirms
thebehaviors.
dynamic evolution
Thus, if the government can increase the benefits and decrease the costs for MIsefforts’,
results. This means that the strategy combination (‘HMI efforts’, ‘PMI and
‘patients’
patientsacceptance’)
either through is ESS when
policy the or
tools costs are less than
technological the benefits
innovation, theofthree-dimensional
all three groups’ dynamic
behaviors.
Thus, if thewill
system government
evolve to EP can ሺͳǡͳǡͳሻ, which
‫଼ܦ‬increase the benefits and decrease
will stimulate the costs
the promotion of for MIs and patients
telemedicine in China.either
For
EP ‫଼ܦ‬
through ሺͳǡͳǡͳሻ,
policy tools or technological innovation, the three-dimensional dynamic
the HMIs and PMIs both chose the ‘efforts’ strategy for providing telemedicine, while system will evolve
the D
to EP 8 (1, 1, 1chose
patients ), whichthe will stimulate
‘acceptance’ the promotion
strategy. The positiveof telemedicine
interaction of in China.
these three For EP D
groups 8 (1,
not 1, 1),
only
thepromotes
HMIs andtelemedicine
PMIs both chosein China, but alsostrategy
the ‘efforts’ optimizes forthe foundation
providing of the hierarchical
telemedicine, while themedical
patients
system.
chose the ‘acceptance’ strategy. The positive interaction of these three groups not only promotes
telemedicine in China, but also optimizes the foundation of the hierarchical medical system.
Figure 4. Three-dimensional evolutionary game for EP D8 (1, 1, 1).

Figure 4. Three-dimensional evolutionary game for EP ‫ ଼ܦ‬ሺͳǡͳǡͳሻ.
6.1. Change in the Initial Intention of the Strategy Combination (‘HMI Efforts’, ‘PMI Efforts’,
‘Patients’ Acceptance’)
6.1. Change in the Initial Intention of the Strategy Combination (‘HMI Efforts’, ‘PMI Efforts’, ‘Patients’
Acceptance’)
6.1.1. Scenario x < y < z
6.1.1. Scenario
In the ‫ ݔ‬൏ ‫ ݕ‬൏ the
first scenario, ‫ ݖ‬initial intention of patients’ ‘acceptance’ strategy was higher than both
that of In
PMIs’ ‘efforts’
the first strategy
scenario, and intention
the initial HMIs’ ‘efforts’ strategy.
of patients’ Apart strategy
‘acceptance’ from thewas parameter
higher than assigned
both
above, only an initial value was assigned here of ( x, y, z ) as ( 0.2, 0.3, 0.4 ) and ( 0.3,
that of PMIs’ ‘efforts’ strategy and HMIs’ ‘efforts’ strategy. Apart from the parameter assigned above, 0.4, 0.5 ) , respectively.
Theonly
results of thevalue
an initial numerical simulation
was assigned areሺ‫ݔ‬ǡ
here of shown
‫ݕ‬ǡ ‫ݖ‬ሻ as in ሺͲǤʹǡͲǤ͵ǡͲǤͶሻ
Figures 5 and and 6. ሺͲǤ͵ǡͲǤͶǡͲǤͷሻ,
Comparing respectively.
these two figures,The
theresults
initial intention of the strategy
of the numerical simulationcombination
are shown (‘efforts’,
in Figures‘efforts’,
5 and 6.‘acceptance’)
Comparing these was two(0.2,figures,
0.3, 0.4)the
and
ESSinitial
was achieved
intention at = 8.55.
of tthe However,
strategy when(‘efforts’,
combination the initial‘efforts’,
intention was ሺͲǤʹǡͲǤ͵ǡͲǤͶሻ
of the strategy
‘acceptance’) combinationand was
ESS was achieved at ‫ ݐ‬ൌ ͺǤͷͷǤ However, when the initial intention of the strategy combination was
increased by 0.1 to ሺͲǤ͵ǡͲǤͶǡͲǤͷሻ, ESS was achieved at ‫ ݐ‬ൌ ͹ǤͺͲ. Furthermore, we also simulated the
situations ofሺͲǤͶǡͲǤͷǡͲǤ͸ሻ, ሺͲǤͷǡͲǤ͸ǡͲǤ͹ሻ, ሺͲǤ͸ǡͲǤ͹ǡͲǤͺሻDQG ሺͲǤ͹ǡͲǤͺǡͲǤͻሻZKLFKUHVSHFWLYHO\DFKLHYHGESS
at ‫ ݐ‬ൌ ͹Ǥ͸ͷ, ‫ ݐ‬ൌ ͸ǤͻͲ, ‫ ݐ‬ൌ ͸Ǥͳͷ, and ‫ ݐ‬ൌ ͷǤͺͷ. This result shows that the higher the initial intention of
the strategy combination (‘HMI efforts’, ‘PMI efforts’, ‘patiens’ acceptance’), the less time it takes for
increased by 0.1 to (0.3, 0.4, 0.5), ESS was achieved at t = 7.80. Furthermore, we also simulated the
situations of (0.4, 0.5, 0.6), (0.5, 0.6, 0.7), (0.6, 0.7, 0.8), and (0.7, 0.8, 0.9), which respectively achieved
ESS at t = 7.65, t = 6.90, t = 6.15, and t = 5.85. This result shows that the higher the initial intention of
the strategy combination (‘HMI efforts’, ‘PMI efforts’, ‘patiens’ acceptance’), the less time it takes for
ESS to be achieved. In addition, if x < y < z, regardless of the values they hold, the evolutionary time
of patients, PMIs, and HMIs choosing (‘efforts’, ‘efforts’, or ‘acceptance’) increase in turn. This shows
that in the process of promoting telemedicine, patients’ behavior is not the largest obstacle compared to
the MIs. At the same time, it also shows that in the process of implementing telemedicine, government
information should be in place so that patients can understand the new telemedicine services
and
more easily accept them. Moreover, patients can enjoy the same high quality of service provided by
HMIs Thus,
without
Int. thetravelling
J. Environ. government longshould
Res. Public Health distances,
2020, FOR which
17, xfocus more
PEER cuts their costs
on HMIs
REVIEW and and
PMIsincreases their benefits.
in the process However,
of promoting
14 of 23
telemedicine,
in contrast, using various
the evolutionary timeincentive
of PMIs and and benefits
HMIs lags mechanisms. This
behind that ofwould enhance
patients. Thus,the
thequality of
government
shouldMIs,
Thus,
focus ensuring
the
more they
government
on provide
HMIs and top-rate
should
PMIsfocusintelemedicine
themore on services.
process HMIs
of and PMIs
promoting in the process
telemedicine, of promoting
using various incentive
telemedicine,
and benefits using various
mechanisms. Thisincentive and benefits
would enhance the mechanisms. Thisensuring
quality of MIs, would enhance the quality
they provide of
top-rate
MIs, ensuring they provide top-rate telemedicine services.
telemedicine services.
Figure 5. Time series of EP 𝐷8 (1,1,1) (initial value (0.2,0.3,0.4), 𝑏 = 0.7).
Figure 5. Time
Figure series
5. Time series EPEPD8𝐷(81,(1,1,1)
of of 1, 1) (initial
(initial value (0.2, 0.3, 0.4)𝑏, b==0.7).
value (0.2,0.3,0.4), 0.7).
Figure 6. Time
Figure series
6. Time of of
series D8𝐷(1,(1,1,1)
EPEP 1, 1) (original (0.3, 0.4, 0.5)𝑏, b==
value (0.3,0.4,0.5),
(original value 0.7).
0.7).
8
> 𝑦 >6.𝑧Time series of EP 𝐷8 (1,1,1) (original value (0.3,0.4,0.5), 𝑏 = 0.7).

6.1.2. Scenario 𝑥Figure
In the second scenario, the initial intention of patients’ ‘acceptance’ strategy is less than that of
6.1.2. Scenario 𝑥 > 𝑦 > 𝑧
both PMIs’ ‘efforts’ strategy and HMIs’ ‘efforts’ strategy. Apart from the parameter assigned at the
6.1.2. Scenario x > y > z

In the second scenario, the initial intention of patients’ ‘acceptance’ strategy is less than that
of both PMIs’ ‘efforts’ strategy and HMIs’ ‘efforts’ strategy. Apart from the parameter assigned at
the beginning, only an initial value of (x, y, z) was assigned here as (0.4, 0.3, 0.2) and (0.5, 0.4, 0.3),
respectively. Comparing these two numerical simulation situations, when the initial intention of the
strategy combination (‘HMI efforts’, ‘PMI efforts’, ‘patients’ acceptance’) was (0.4, 0.3, 0.2), ESS was
achieved at t = 8.1. However, when the initial intention of the strategy combination was increased
by 0.1 to (0.5, 0.4, 0.3), ESS was achieved at t = 7.50. Similarly, we get t = 7.05, t = 6.60, t = 5.85,
and t = 5.10, if we continue to increase the initial probability of the strategy combination to (0.6, 0.5, 0.4),
(0.7, 0.6, 0.5), (0.8, 0.7, 0.6), and (0.9, 0.8, 0.7), respectively. This result shows that the higher the initial
intention of the strategy combination (‘HMI efforts’, ‘PMI efforts’, ‘patients’ acceptance’), the less time
it takes to achieve ESS. In addition, if x > y > z, regardless of the values they hold, the evolutionary
time of patients, HMIs, and PMIs in choosing (‘efforts’, ‘efforts’, or ‘acceptance’) increases. Combined
with the above analysis, whether the initial intention of the ‘acceptance’ strategy chosen by patients is
highest or lowest among the three groups, the results are that the patients reach the steady state in the
evolutionary game in the shortest time. Therefore, if the government can take measures to shorten the
evolution time of MIs, this will help the promotion of telemedicine.
6.1.3. Scenario x = y = z
In the third scenario, the initial intention of patients’ ‘acceptance’ strategy is the same as that of PMIs’
‘efforts’ strategy and HMIs’ ‘efforts’ strategy. Apart from the parameter assigned at the beginning, only
an initial value of (x, y, z) was assigned here as (0.2, 0.2, 0.2) and (0.3, 0.3, 0.3), respectively. Comparing
these two simulation situations, when the initial intention of the strategy combination (‘HMI efforts’,
‘PMI efforts’, ‘patients’ acceptance’) was (0.2, 0.2, 0.2), ESS was achieved at t = 8.40. However, when the
initial intention of the strategy combination was increased by 0.1 to (0.3, 0.3, 0.3), ESS was achieved
at t = 7.95. Similarly, we get t = 7.65, t = 7.50, t = 7.35, t = 6.90, t = 6.15, and t = 5.70 if we
continue to increase the initial probability of the strategy combination to (0.4, 0.4, 0.4), (0.5, 0.5, 0.5),
(0.6, 0.6, 0.6), (0.7, 0.7, 0.7), (0.8, 0.8, 0.8), and (0.9, 0.9, 0.9), respectively. This shows that the higher the
initial intention of the strategy combination (‘HMI efforts’, ‘PMI efforts’, ‘patients’ acceptance’), the less
time it takes to achieve ESS. In addition, if x = y = z, regardless the values they hold, the evolutionary
time of patients in choosing the ‘acceptance’ strategy is the shortest of all three groups, which is
consistent with the above reported results. In addition, HMIs and PMIs show the same evolutionary
time in choosing the ‘efforts’ strategy, revealing a time lag behind that of the patient group. Therefore,
even if the initial intention of the three parties is the same, the patient group will reach the steady state
in the evolutionary game in the shortest time.
6.2. Change in Telemedicine Fees for Patients

To verify whether a reduction in telemedicine fees further promotes telemedicine and has a positive
impact on all the groups involved, with other parameters unchanged, B = 2 was reduced to B = 1;
moreover, the initial value for choosing the (‘HMI efforts’, ‘PMI efforts’, or ‘patients’ acceptance’) strategy
was given as increasing trend from (0.2, 0.3, 0.4) to (0.7, 0.8, 0.9), decreasing trend from (0.4, 0.3, 0.2)
to (0.9, 0.8, 0.7), and same value from (0.2, 0.2, 0.2) to (0.9, 0.9, 0.9), respectively. The results of the
numerical simulation can be summarized as follows:
(1) The evolution results of the three groups with reduced telemedicine fees (Scenario x < y <
z). By comparing all situations that were assumed before and after changing telemedicine fees (B),
it can be concluded that before the telemedicine fees were reduced, ESS of all groups was achieved at
t = 8.55, t = 7.80, t = 7.65, t = 6.90, t = 6.15, and t = 5.85 of the six situations, respectively. However,
after reducing the telemedicine fees, ESS of all groups was achieved to t = 8.47, t = 7.35, t = 7.05,
t = 6.45, t = 6.00, and t = 5.40 of the six situations, respectively. Thus, it is clear that reducing patients’
telemedicine fees can shorten the evolutionary time. This means that reducing telemedicine fees is
beneficial for promoting telemedicine. Such a result has important policy implications, namely that
the government should focus on the pricing of telemedicine and reducing fees through technological
innovation or other policy measures.
(2) The evolution results of the three groups with reduced telemedicine fees (Scenario x >
y > z). Before reducing the telemedicine fees, ESS of all groups was estimated at t = 8.1, t = 7.80,
t = 7.65, t = 6.90, t = 6.15, and t = 5.85 of the six situations, respectively. However, after reducing
the telemedicine fees, ESS of all groups was estimated at t = 7.65, t = 6.95, t = 6.90, t = 6.67,
t = 6.00, and t = 5.55 of the six situations respectively. Therefore, it is obvious that reducing patients’
telemedicine fees can shorten the evolutionary time, implying that a reduction in telemedicine fees can
be a means for promoting telemedicine.
(3) The evolution results of the three groups with reduced telemedicine fees (Scenario x =
y = z). Before the telemedicine fees were reduced, ESS of all groups was achieved at t = 8.4, t = 7.95,
t = 7.65, t = 7.50, t = 7.35, t = 6.90, t = 6.15, and t = 5.70 of the eight situations, respectively.
However, after reducing the telemedicine fees, ESS of all groups was achieved at t = 8.02, t = 7.88,
t = 7.20, t = 7.12, t = 6.92, t = 6.30, t = 5.85, and t = 5.25 of the eight situations, respectively. Thus,
reducing patients’ telemedicine fees can shorten the evolutionary time.
Together, these results suggest that after reducing telemedicine fees and regardless the initial
intention of HMIs, PMIs, and patients in choosing the strategy combination (‘efforts’, ‘efforts’,
‘acceptance’), the time required for the three parties to evolve to ESS was significantly shortened,
indicating that a reduction in telemedicine fees can effectively promote the telemedicine system.
6.3. Change in the Reimbursement Ratio of Telemedicine Fees
6.3.1. Telemedicine Services Are Embedded in Social Medical Insurance Reimbursements

(1) Scenario x < y < z. To simplify the analysis, it was assumed that the two reimbursement
ratio standards for telemedicine fees were 0.9 and 0.3, respectively. The former was the highest
reimbursement ratio of Chinese medical insurance in very poor areas, while the latter was the
lowest reimbursement ratio of Chinese medical insurance for non-referral patients in rural areas.
In addition, to discuss the optimal range of the reimbursement ratio, 0.4, 0.5, 0.6, 0.7, and 0.8 were
chosen as reimbursement ratio standards. The initial intention of the strategy combination (‘HMI
efforts’, ‘PMI efforts’, ‘patients’ acceptance’) was (0.2, 0.3, 0.4), but when parameter b was modified,
the results were t = 8.70, t = 8.98, t = 8.85, t = 8.91, t = 8.55, t = 8.63, and t = 8.85, respectively,
when b = 0.3 ∼ 0.9, with 0.1 as interval across the three strategies. Thus, compared with the initial
parameter value b = 0.7, increasing (b = 0.9, or b = 0.8) or decreasing ( b = 0.3 ∼ 0.6, with 0.3 as
interval) the reimbursement ratio influences the evolutionary results of the three groups. Compared
with situation of different b value, when the reimbursement ratio increases (decreases), the evolutionary
time required for ESS increases slightly, showing that the optimal reimbursement ratio of medical
insurance is neither the higher one nor the lower one. Combined with the above-mentioned results,
the reimbursement ratio between 0.7 and 0.8 in our model is the appropriate ratio.
(2) Scenario x > y > z. In this scenario, 0.3~0.6 and 0.8~0.9 both with 0.1 as interval were chosen
as the reimbursement ratios, compared with the scenario in which 0.7 was the reimbursement ratio.
Here, (0.4, 0.3, 0.2) was the initial intention of the strategy combination (‘HMI efforts’, ‘PMI efforts’,
‘patients’ acceptance’); and we can obtain a total of seven situations when the value b changes. A look
at the ESS time of these seven situations shows that the results are the same as in scenario x < y < z,
i.e., the optimal reimbursement ratio range is 0.7–0.8.
(3) Scenario x = y = z. In this scenario, 0.3~0.6, and 0.8~0.9 with 0.1 as interval were chosen
as the reimbursement ratios, compared with the scenario in which 0.7 was the reimbursement ratio.
Here, (0.2, 0.2, 0.2) was the initial intention of the strategy combination (‘HMI efforts’, ‘PMI efforts’,
‘patients’ acceptance’). The seven results of ESS time are obtained by means of the numerical simulation.
By analyzing these evolutionary time series of the three parties, the results were found to be the same
as in scenarios x < y < z and x > y > z, i.e., the optimal reimbursement ratio range is still 0.7–0.8.
In summary, after incorporating telemedicine fees into the medical insurance reimbursement
scheme, based on numerical simulation, the optimal reimbursement ratio for promoting telemedicine
is in the range of 0.7–0.8.
6.3.2. Telemedicine Services Are Not Embedded in Medical Insurance Reimbursements

In China, some provinces or cities explicitly stipulate that telemedicine services are embedded in
medical insurance reimbursements while others do not. Therefore, a discussion was required about
the situation when telemedicine services are not embedded in such reimbursements. In Section 6.3.1,
the reimbursement ratio of telemedicine fees is zero. The initial intention of strategy combination
(‘HMI efforts’, ‘PMI efforts’, ‘patients’ acceptance’) remained (0.2, 0.3, 0.4), but b = 0.7 was changed to
b = 0 in this simulation. This means that telemedicine services are not embedded in medical insurance
reimbursement, which is common in some areas in China. Therefore, the situation in this case also has
policy implications. There are still three situations with considerable differences in the initial intention
of strategy combination (‘HMI efforts’, ‘PMI efforts’, ‘patients’ acceptance’).
The first is scenario x < y < z. Comparing evolutionary time of b = 0 with that of b = 0.3 ∼ 0.9,
when b = 0, telemedicine services are not embedded in social medical insurance reimbursement;
moreover, the strategy combination (‘efforts’, ‘efforts’, ‘acceptance’) chosen by HMIs, PMIs and patients
respectively will only reach ESS at t = 10.05. Comparing evolutionary times at t = 8.55 ∼ 8.98 (when
b = 0.3 ∼ 0.9), it can be concluded that telemedicine services are embedded in medical insurance
reimbursements, which is beneficial for shortening the evolutionary time of ESS.
The second scenario is x > y > z. Comparing evolutionary time of b = 0 with that of b = 0.3 ∼ 0.9,
there is a similar conclusion to that of situation x < y < z, i.e., with differing initial intentions regards
the strategy combination (‘HMI efforts’, ‘PMI efforts’, ‘patients’ acceptance’), telemedicine services that
are not embedded in medical insurance reimbursements will hinder the promotion of telemedicine.
Finally, assuming that the initial intentions of the strategy combination (‘HMI efforts’, ‘PMI efforts’,
‘patients’ acceptance’) are the same, the impact of parameter b = 0 on the evolutionary time of ESS was
discussed. Comparing the situation when of b = 0 with that of when b = 0.3 ∼ 0.9, we found that
telemedicine fees that are not embedded in medical insurance reimbursement hinder the promotion
of telemedicine. Considering the optimal reimbursement ratio (0.7–0.8), the impact of telemedicine
fees not embedded in medical insurance reimbursement on evolutionary times was not significant
compared with the highest or lowest reimbursement ratio (highest being 0.9, lowest being 0.3).
In summary, regardless of the initial intention, the conclusions are consistent in finding that
telemedicine services that are not embedded in medical insurance reimbursement will hinder the
promotion of such services.
7. The Telemedicine Service of Guizhou Province
7.1. The Price Reform of Telemedicine in Guizhou

Since 2014, telemedicine has been developing rapidly in Guizhou province. The province was
the first in China that has successfully built a comprehensive telemedicine system integrated across
provincial, municipal, county, and township levels. At the same time, the price of telemedicine services
has been reduced, and a price ceiling has been set up across the range of telemedicine services to the
benefit of patients. Tables 4 and 5 show how the government determined the price of telemedicine
before and after the adjustment. MIs at all levels can set the price of telemedicine according to the
guidance price.
Table 4. The price of telemedicine services in Guizhou province.
Price Ceiling (Yuan)

Items Unit
National Level Provincial Level Municipal/City Level
Tele-consultation Hour 1550 700 595
Traditional Chinese Medical (TCM)
Hour 1550 700 595
tele-diagnosis and tele-consultation
Synchronized tele-pathological
Per visit 500 400 340
consultation
Asynchronized tele-pathological
Per visit 400 300 255
consultation
Remote imaging conference Per visit 400 200 170
Source: Guizhou Provincial Health Commission of Guizhou Province ‘Standardizing the price standard of
telemedicine consultation service in our province’ (Implementation from 1 December 2015).
Table 5. The price of telemedicine services in Guizhou province after the price adjustment.
Price Ceiling (Yuan)

Items Unit
National Level Provincial Level Municipal/City Level
Not exceed 100 100 for chief
100 for chief physician
Unidisciplinary per visit physician
Per visit
tele-consultation Not exceed 80 per 80 for associate 80 for associate chief
visit chief physician physician
Multidisciplinary
Hour 1200 320 270
tele-consultation
TCM tele-diagnosis and
Hour 1200 320 270
tele-consultation
Synchronized tele-pathological
Per visit 300 180 150
consultation
Asynchronized tele-pathological
Per visit 300 140 120
consultation
Remote electrocardiogram
Per visit
(ECG) diagnosis The price is charged according to the current
medical price of the inviting party of the ECG
Remote imaging diagnosis Per visit
project in Guizhou Province
Remote laboratory diagnosis Per visit
Telepathological diagnosis Per visit
Source: Guizhou Province Government ‘Guizhou Province adjusts and perfects the price scheme of telemedicine
service projects in public MIs’ (Implementation from 1 July 2016).
By the end of 2018, telemedicine has expanded and covered the four levels of province, city, county,
and township. Today, 291 public hospitals at or above the county level, and 1543 township hospitals
and community health centers are connected to the telemedicine platform of Guizhou. There are
16,347 experts, 1352 remote diagnosticians, and 6239 imaging, ECG, and B-ultrasound technicians
registered on the platform to provide telemedicine services. When Guizhou province began developing
its telemedicine system in 2016, there were fewer than 100 instances in which telemedicine services
were used. In 2018, this number had reached nearly 400,000. Among them were more than 40,000
disease teleconsultations, nearly 300,000 remote imaging diagnoses, more than 80,000 tele-cardiogram
diagnoses, and 423 tele-training events reaching 458,000 trainees.
At present, a number of 321 public MIs in 14 poverty-stricken counties in Guizhou are incorporated
into the province’s telemedicine system. In 2018, a total of 496,000 telemedicine services were provided
across 14 counties, saving more than 7 million yuan in medical, transportation, accommodation,
and other expenses. Guizhou has also explored and built a team of ‘long-stay’ experts. Each poor
county has selected doctors above deputy senior level to form telemedicine expert service teams in
county’s hospitals and conduct tele-consultations for township hospitals and village clinics. At present,
a professional team of 496 consultants, 89 imaging diagnostic doctors, and 59 electrocardiographic
diagnostic doctors are set up to cover 14 poverty-stricken counties so that people can access expert
medical services at home.
To alleviate burdens on the poor, Guizhou has adjusted and improved the pricing of telemedicine
services in public MIs, and stipulated that HMIs participating in counterpart assistance schemes
should not charge tele-consultation fees for the hospitals they aid. At present, 25 provincial tertiary
hospitals have exempted 66 poverty-stricken county hospitals from costs associated with telemedicine
projects. At the same time, municipalities have reduced the cost of telemedicine services in hospitals in
poverty-stricken areas. For example, in Qiandongnan prefecture, telemedicine charges were reduced by
10% on the basis of provincial pricing; in a deeply impoverished county such as Ceheng, county-wide
public hospitals have carried out telemedicine projects at 85% of provincial pricing, meaning that
the price of unidisciplinary and multidisciplinary tele-consultations were 85 yuan per visit to chief
physicians and 68 yuan per visit to associate chief physicians.
The local government in Guizhou classifies and manages the prices of telemedicine services to
promote their coverage across the province and share the high-quality medical resources between
cities and rural MIs by remote manipulation. These efforts are designed to reduce the telemedicine
operating costs of public MIs at all levels, ensure that the burden of disease (BOD) for residents is not
increased, and provide satisfactory telemedicine for the people.
7.2. The Reimbursement Ratio of Telemedicine in Guizhou

After Guizhou province embedded telemedicine fees in medical insurance reimbursements,
the reimbursement ratio of telemedicine expenses for patients in poverty-stricken counties ranged
between 70% and 85%. On this basis, the reimbursement ratio of telemedicine for registered
poverty-stricken households under the Filing Riser Policy increased by 5 percentage points, with 90%
as the maximum reimbursement ratio. For example, in 2018, the total telemedicine fees for Qijiang
County in Qiandongnan Prefecture was 728,400 yuan, while total medical insurance reimbursements
amounted to 582,200 yuan. Self-payments amounted to 145,680 yuan and the reimbursement ratio was
80%. For patients in non-poverty-stricken counties, the reimbursement ratio of telemedicine expenses
ranged from 55% to 65%. Based on the results of this study, we recommend that the reimbursement
scope and ratio for residents in non-poverty-stricken areas should be increased to further promote
telemedicine services in Guizhou.
7.3. The Initial Probability of (‘HMI Efforts’, ‘PMI Efforts’, ‘Patients’ Acceptance’) in Guizhou
The results of our social survey indicated that the initial intention of patients’ ‘acceptance’ strategy
was higher than that of MIs (both PMIs and HMIs) ‘efforts’ strategy. The results showed that residents’
awareness of digital telemedicine policies was 72%, and that their willingness to accept telemedicine
was 89%. In most cases, residents were aware of telemedicine policies through online media and
government information. In addition, the majority (around 85%) of those who had already received
telemedicine services were quite satisfied about the quality of the service provided. In relation to
those who expressed their dissatisfaction about telemedicine services, the main reasons included high
telemedicine fees; network security issues; and human–computer interactions leading to poor medical
outcomes due to a lack of face-to-face communication. This is because, in the past, patients were used
to traditional methods of diagnosis and preferred face-to-face consultations with a doctor. Nonetheless,
the initial intention of residents in Guizhou, especially in remote areas, to accept telemedicine services
was still high. However, the initial intention of MIs was not as high as that of patients and was lower
than expected. In the survey, through interviews with doctors and administrators, it was discovered
that in the practice of telemedicine, both the inviter and invitee have little motivation or incentive to
change from traditional practices, given that they would not be paid differently regardless of their effort
level, particularly MIs in poor areas such as Guizhou province. Therefore, in such places, the success
of telemedicine is dependent more on the MIs than on the patients.
8. Discussion
By studying the initial intentions in the three scenarios in Section 5.1, it was found that the patients
of all scenarios were the first to achieve ESS, with the evolution time being shorter than that of both
PMIs and HMIs. Furthermore, for all the three groups, we conclude that the higher initial probability
of strategy combination (‘HMI efforts’, ‘PMI efforts’, ‘patients’ acceptance’), the shorter evolution time.
From a theoretical perspective, this conclusion is rational because patients have a higher acceptance
probability due to the higher convenience, accessibility, and benefits they achieve from telemedicine
compared to traditional alternatives. Indeed, the HMIs and PMIs can also save proportions of referral
costs, e.g., costs related to the bi-directional referral between PMIs and HMIs. Although the patients
have a higher acceptance willingness, the efforts put by HMIs and PMIS on the telemedicine is more
important for the operation and quality of telemedicine. In the existing literatures, some researchers
argued that the capacity of telemedicine service providers is more important for telemedicine success
than the competence of the individuals receiving the service care [28,32,33]. Therefore, in the process
of promoting telemedicine, the government should pay special attention to MIs and make full use
of them. Considering financial incentives, to ensure that the benefits of MIs largely outweigh the
costs, the government should adopt measures to improve the effort levels of MIs in the provision
of telemedicine, which would thereby shorten their evolution time. Hofmann-Wellenhof et al. [34]
examined the feasibility and acceptance of teledermatology for wound management of patients with
chronic leg ulcers by home-care nurses, the results show that there was a significant decrease in visits
to a general physician or the wound care center, and the acceptance of teledermatology was high in
patients, home-care nurses, and wound experts. Telemedicine seems to be accepted both by patients
and healthcare persons.
Through numerical simulation, it was concluded that if the cost of telemedicine is reduced,
the evolutionary time of the tripartite game to reach ESS is shortened, which is beneficial for the
promotion of the telemedicine system. In the same respect, it is unsurprising that patients will choose
traditional face-to-face health service direct from HMIs via a long travel, if the telemedicine fees are
comparatively much higher. Likewise, it is expected that if the telemedicine fees are so low, both HMIs
and PMIs will not operate normally with less telemedicine income. Thus, it is obvious that the
telemedicine has a rational range.
In fact, the changes in the reimbursement ratio of telemedicine fees are indirect changes in
telemedicine fees. Therefore, if the reimbursement ratio increases, the telemedicine fees paid by
patients decreases. Mapping together these findings, we can conclude that a higher reimbursement
ratio will further promote the development of telemedicine. However, the numerical analysis suggests
that the proportion of the medical insurance reimbursement ratio is neither as high as possible nor as
low as possible; between 0.7 and 0.8 is the appropriate ratio for shorter evolution times. Although,
it was found that telemedicine fees that are embedded in medical insurance reimbursements promote
telemedicine more effectively than if they are not embedded. Thus, having the optimal reimbursement
ratio is key for promoting telemedicine. Furthermore, if telemedicine service fees are not embedded
within the scope of medical insurance reimbursement, the promotion of telemedicine is hindered
because it increases the costs that patients have to pay.
This paper used evolutionary game theory to analyze behavioral strategies and their dynamic
evolution in the implementation and operation of telemedicine and did numerical simulation by
software Matlab with a view to developing management strategies that promote telemedicine as
a new way of delivering health services. Although we found some implication of telemedicine
promotion, there still work need to do in the future, e.g., the same as the important determinants of
telemedicine cost, why reimbursement ratio of telemedicine fees have a turning point during value [0,
1], while among the appropriate domain, the lower the cost, the greater promotion of telemedicine,
and the rational range of telemedicine fees also were not analyzed in this paper. Owing to the small
sample, the reliability of questionnaire designed by our team are not bigger than 0.7. Furthermore,
the survey was conducted in a small county of Qiandongnan Miao and Dong Autonomous Prefecture in
Guizhou, therefore the case study in this paper may not be reflective of China or even other developing
countries. In the future, we need to broaden our sample domain to do further research related to
telemedicine system.
9. Conclusions
We found that the benefits being greater than the costs is the premise of implementing
telemedicine. When this premise was satisfied, we further found that the higher initial probability
of strategy combination (‘HMI efforts’, ‘PMI efforts’, ‘patients’ acceptance’), reducing telemedicine
fees, and propriety reimbursement ratio range from 0.7 to 0.8 all contributed to better development
of telemedicine.
Therefore, in the process of promoting telemedicine, the central Chinese government and local
governments should pay attention to the operation of HMIs and PMIs and offer financial support when
the costs are greater than the benefits. At the same time, the government should improve awareness
of telemedicine and increase the participation of all three parties. Lastly, for effective telemedicine
promotion, it is recommended that telemedicine services are incorporated within the scope of medical
insurance and that the optimal reimbursement ratio is used.
Author Contributions: J.Y. conceived and designed this study and wrote the introduction and literature reviews.
J.Y., T.Z. and Z.L. wrote methods, analysis and discussed the results. A.A.H. and J.L. gave review suggestions on
the entire writing process and went through all the sections. All authors have read and agreed to the published
version of the manuscript.
Funding: This research was funded by the Research Funding Project of Guizhou Minzu University, grant number
GZSKLLH[2019]YB09; the National Natural Science Foundation of China, grant number 71603126 and 71911530164;
and the Swedish Foundation for International Cooperation in Research and Higher Education (STINT), grant
number CH2018-7762.
Conflicts of Interest: The authors declare no conflict of interest.
Abbreviations
ESS evolutionarily stability strategies
EP equilibrium point
MI medical institution
HMI higher medical institution
PMI primary medical institution
TAM technology acceptance model
TPB theory of planned behaviour
References
1. Wang, Z.; Gu, H. A review of telemedicine in China. J. Telemed. Telecare 2009, 15, 23–27. [CrossRef]
2. AlDossary, S.; Martin-Khan, M.G.; Bradford, N.K.; Smith, A.C. A systematic review of the methodologies
used to evaluate telemedicine service initiatives in hospital facilities. Int. J. Med. Inform. 2017, 97, 171–194.
[CrossRef]
3. Fatehi, F.; Wootton, R. Telemedicine, telehealth or e-health? A bibliometric analysis of the trends in the use of
these terms. J. Telemed. Telsecare 2012, 18, 460–464. [CrossRef] [PubMed]
4. Kvedar, J.; Coye, M.J.; Everett, W. Connected Health: A Review of Technologies and Strategies to Improve
Patient Care with Telemedicine and Telehealth. Health Aff. 2014, 33, 194–199. [CrossRef] [PubMed]
5. Kiberu, V.M.; Scott, R.E.; Mars, M. Assessing core, e-learning, clinical and technology readiness to integrate
telemedicine at public health facilities in Uganda: A health facility—based survey. BMC Health Serv. Res.
2019, 19, 266. [CrossRef]
6. Mars, M. Telemedicine and Advances in Urban and Rural Healthcare Delivery in Africa. Prog. Cardiovasc.
Dis. 2013, 56, 326–335. [CrossRef] [PubMed]
7. Chau, P.Y.K.; Hu, P.J.-H. Investigating healthcare professionals’ decisions to accept telemedicine technology:
An empirical test of competing theories. Inform. Manag. 2002, 39, 297–311. [CrossRef]
8. Adenuga, K.L.; Iahad, N.A.; Miskon, S. Towards reinforcing telemedicine adoption amongst clinicians in
Nigeria. Int. J. Med. Inform. 2017, 104, 84–96. [CrossRef] [PubMed]
9. Adler-Milstein, J.; Kvedar, J.; Bates, D.W. Telehealth Among US Hospitals: Several Factors, Including State
Reimbursement and Licensure Policies, Influence Adoption. Health Aff. 2014, 33, 207–215. [CrossRef]
10. Greenhalgh, T.; Procter, R.; Wherton, J.; Sugarhood, P.; Hinder, S.; Rouncefield, M. What is quality in assisted
living technology? The ARCHIE framework for effective telehealth and telecare services. BMC Med. 2015,
13, 91. [CrossRef]
11. Liu, J.J. Pervasive Telemonitoring for Patients Living with Chronic Heart Failure: A Quantitative Study of Telemedicine;
ProQuest LLC (UMI): Ann Arbor, MI, USA, 2009.
12. Gorst, S.L.; Armitage, C.J.; Brownsell, S.; Hawley, M.S. Home telehealth uptake and continued use among
heart failure and chronic obstructive pulmonary disease patients: A systematic review. Ann. Behav. Med.
2014, 48, 323–336. [CrossRef]
13. Domingo, M.; Lupón, J.; González, B.; Crespo, E.; López, R.; Ramos, A.; Urrutia, A.; Pera, G.; Verdú, J.M.;
Bayes-Genis, A. Evaluation of a telemedicine system for heart failure patients: Feasibility, acceptance rate,
satisfaction and changes in patient behavior: Results from the CARME (CAtalan Remote Management
Evaluation) study. Eur. J. Cardiovasc. Nurs. 2011, 11, 410–418. [CrossRef] [PubMed]
14. Jue, J.; Spector, S.; Spector, S. Telemedicine broadening access to care for complex cases. J. Surg. Res. 2017,
220, 164–170. [CrossRef] [PubMed]
15. Tarraga Marcos, M.L.; Panisello Royo, J.M.; Carbayo-Herencia, J.A.; Rosich Domenech, N.; Alins Presas, J.;
Castell Panisello, E.; Tárraga López, P.J. Application of telemedicine in obesity management. Eur. Res.
Telemed. 2017, 6, 3–12. [CrossRef]
16. Sherwood, B.G.; Han, Y.; Nepple, K.G.; Erickson, B.A. Evaluating the Effectiveness, Efficiency and Safety of
Telemedicine for Urological Care in the Male Prisoner Population. Urol. Pract. 2018, 5, 44–51. [CrossRef]
[PubMed]
17. Dullet, N.W.; Geraghty, E.M.; Kaufman, T.; Kissee, J.L.; King, J.; Dharmar, M.; Smith, A.C.; Marcin, J.P. Impact
of a University-Based Outpatient Telemedicine Program on Time Savings, Travel Costs, and Environmental
Pollutants. Value Health 2017, 20, 542–546. [CrossRef] [PubMed]
18. Parajuli, R.; Doneys, P. Exploring the role of telemedicine in improving access to healthcare services by
women and girls in rural Nepal. Telemat. Inform. 2017, 34, 1166–1176. [CrossRef]
19. Henderson, C.; Knapp, M.; Fernández, J.-L.; Beecham, J.; Hirani, S.P.; Cartwright, M.; Rixon, L.; Beynon, M.;
Rogers, A.; Bower, P.; et al. Cost effectiveness of telehealth for patients with long term conditions (Whole
Systems Demonstrator telehealth questionnaire study): Nested economic evaluation in a pragmatic, cluster
randomised controlled trial. BMJ Br. Med. J. 2013, 346, f1035. [CrossRef]
20. Klaassen, B.; van Beijnum, B.J.F.; Hermens, H.J. Usability in telemedicine systems—A literature survey. Int. J.
Med. Inform. 2016, 93, 57–69. [CrossRef]
21. Tanimoto, J. Fundamentals of Evolutionary Game Theory and its Applications; Springer: Tokyo, Japan, 2015.
22. Tarrant, C.; Stokes, T.; Colman, A.M. Models of the medical consultation: Opportunities and limitations of
a game theory perspective. Qual. Saf. Health Care 2004, 13, 461–466. [CrossRef]
23. Blake, A.; Carroll, B. Game theory and strategy in medical training. Med. Educ. 2016, 50, 1094–1106.
[CrossRef] [PubMed]
24. Dasgupta, A.; Buckingham, N.; Gračanin, D.; Handosa, M.; Tasooji, R. A Mixed Reality Based Social
Interactions Testbed: A Game Theory Approach. In Virtual, Augmented and Mixed Reality: Applications in
Health, Cultural Heritage, and Industry; Chen, J., Fragomeni, G., Eds.; VAMR 2018; Lecture Notes in Computer
Science; Springer: Cham, Switzerland, 2018; Volume 10910.
25. Kumar, K.; Jindal, A.; Rodrigues, J.J.P.C. Providing healthcare services on-the-fly using multi-player
cooperation game theory in Internet of Vhiclees (IoV) environment. Digit. Commun. Netw. 2015, 1, 191–2013.
[CrossRef]
26. Weibull, J.W. Evolutionary Game Theory; MIT Press: Cambridge, MA, USA, 1995.
27. Javarone, M.A. Statistical Physics and Computational Methods for Evolutionary Game Theory; Springer: Cham,
Switzerland, 2018.
28. Maynard Smith, J. Evolution and the theory of games: In situations characterized by conflict of interest,
the best strategy to adopt depends on what others are doing. Am. Sci. 1976, 64, 41–45.
29. Zeeman, E.C. Population dynamics from game theory. In Lecture Notes in Mathematics; Springer: Berlin,
Germany, 1980; Volume 819.
30. Friedman, D. On economic applications of evolutionary game theory. J. Evol. Econ. 1998, 8, 15–43. [CrossRef]
31. Selten, R. A note on evolutionarily stable strategies in asymmetric animal conflicts. J. Theor. Biol. 1980, 84,
93–101. [CrossRef]
32. Rho, M.J.; Kim, H.S.; Chung, K.; Choi, I.Y. Factors influencing the acceptance of telemedicine for diabetes
management. Clust. Comput. 2015, 18, 321–331. [CrossRef]
33. Kohnke, A.; Cole, M.; Bush, R.; Ellis, M.; Hagan, M.; Cruz, J. Incorporating UTAUT Predictors for
Understanding Home Care Patients’ and Clinician’s Acceptance of Healthcare Telemedicine Equipment. J.
Technol. Manag. Innov. 2014, 9, 29–41. [CrossRef]
34. Hofmann-Wellenhof, R.; Salmhofer, W.; Binder, B.; Okcu, A.; Kerl, H.; Soyer, H.P. Feasibility and acceptance of
telemedicine for wound care in patients with chronic leg ulcers. J. Telemed. Telecare 2006, 12, 15–17. [CrossRef]
© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

Tripartite Data Analysis For Optimizing Telemedicine Operations - Evidence From Guizhou Province in China

Uploaded by

Copyright:

Available Formats

Tripartite Data Analysis For Optimizing Telemedicine Operations - Evidence From Guizhou Province in China

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Tripartite Data Analysis For Optimizing Telemedicine Operations - Evidence From Guizhou Province in China

Uploaded by

Copyright:

Available Formats

International Journal of

Keywords: telemedicine; tripartite data analysis; optimizing telemedicine operations

3.1. Game Theory in Health

3.2. Evolutionary Game Theory and ESS

Fitness of I = p·EI (I ) + q·E J (I )

Fitness of J = p·EI ( J ) + q·E J ( J )

3.3. Data Collection

4. Tripartite Evolutionary Game Model of Stakeholders in Telemedicine

4.1. The Hypothesis of the Tripartite Evolutionary Game Model

4.2. Payoff Matrix of the tripartite Evolutionary Game in Telemedicine

5. Analysis of the Tripartite Evolutionary Game Model in Telemedicine

5.1. Replicator Dynamics Equation of the Tripartite Evolutionary Game

The expected revenue of the HMIs is U1 :

5.2. Replicator Dynamic Analysis of the Tripartite Evolutionary Game

5.2.1. Replicator Dynamic Analysis of the Patient Group

Figure 1. Dynamic evolution of patients’ evolutionarily stable strategy (ESS).

R2 (e2 )−C2 (e2 )−R2 (e2 )+C2 (e2 )

Figure 2. Dynamic evolution of ESS for PMIs.

 ∂F(x)/∂x ∂F(x)/∂y ∂F(x)/∂z

Table 2. The eigenvalues of each equilibrium point’s (EP’s) Jacobian matrix.

Table 3. Local stability analysis results.

Figure 4. Three-dimensional evolutionary game for EP D8 (1, 1, 1).

Figure 5. Time series of EP 𝐷8 (1,1,1) (initial value (0.2,0.3,0.4), 𝑏 = 0.7).

> 𝑦 >6.𝑧Time series of EP 𝐷8 (1,1,1) (original value (0.3,0.4,0.5), 𝑏 = 0.7).

6.1.2. Scenario x > y > z

6.2. Change in Telemedicine Fees for Patients

6.3. Change in the Reimbursement Ratio of Telemedicine Fees

6.3.1. Telemedicine Services Are Embedded in Social Medical Insurance Reimbursements

6.3.2. Telemedicine Services Are Not Embedded in Medical Insurance Reimbursements

7. The Telemedicine Service of Guizhou Province

7.1. The Price Reform of Telemedicine in Guizhou

Table 4. The price of telemedicine services in Guizhou province.

Price Ceiling (Yuan)

Price Ceiling (Yuan)

7.2. The Reimbursement Ratio of Telemedicine in Guizhou

You might also like