The COVID-19 Pandemic and the Future of Telemedicine

1. Use of telemedicine has boomed during the COVID‑19 pandemic

Abstract

With the COVID‑19 pandemic causing massive disruptions in the delivery of essential health care services, governments moved quickly to simplify and promote the use of telemedicine. This chapter highlights some of the swift and extensive changes that policy makers enacted concerning the regulation and financing of telemedicine in the early months of the pandemic and demonstrates the large increases in the use of remote care services that followed. Despite growing interest in telemedicine before the start of the pandemic and significant growth in remote care use during the pandemic, the chapter emphasises that data on telemedicine, including data on the number of teleconsultations provided, are scarce, and that less than half of OECD countries have data on patient characteristics, type of telemedicine service, reasons for telemedicine use, and subsequent care.

In the beginning of 2020, as SARS‑CoV‑2 spread globally, everyone – from citizens to health workers and policy makers – tried to understand the effects of the virus and the disease it caused, COVID‑19. In the weeks and months that followed the identification of a cluster of cases of pneumonia of unknown cause in China, there was enormous uncertainty. Very little was known about how SARS‑CoV‑2 spread and how to limit its transmission, what the symptoms and the effects of COVID‑19 were and how to treat it, and which individuals were most at risk of severe disease and what could be done to protect them. As governments, societies and economies grappled with these unknowns, normal life came to a halt. Previously unthinkable far-reaching and drastic actions were taken by both governments and populations to limit the spread of SARS‑CoV‑2 and the health impact of COVID‑19. As health systems focused on preventing and treating COVID‑19, and with populations drastically altering their behaviours to limit infections, many essential in-person health services were either postponed or simply cancelled.

1.1. The COVID‑19 pandemic has massively disrupted in-person health services

The COVID‑19 pandemic has caused immense disruptions in the delivery of essential health care services, from prevention to curative to palliative care. The first wave of SARS‑CoV‑2 infections and COVID‑19 cases had the most significant impact on delivery of health services, but even today, well over two years since the first outbreak, most countries are still grappling with the effects of the pandemic on health care delivery (WHO, 2022[1]). In May 2020, the number of in-person primary care consultations plummeted, falling by 66% in Portugal, about 40% in Australia, 18% in Austria and 7% in Norway, compared with the same month in 2019 (OECD, 2021[2]). In-person consultations per capita dropped in seven of eight countries with 2020 data, and by up to 30% in Chile and Spain (ibid).

Elective surgeries were delayed, in turn causing waiting lists to grow. In seven OECD countries (Hungary, Ireland, New Zealand, Portugal, Slovenia, Spain and Sweden), for which data are available, waiting times for three elective surgeries – cataract surgery, hip replacement surgery, and knee replacement surgery – increased in 2020 compared with 2019 (OECD, 2021[2]). The median waiting times in these seven countries increased in 2020 by 88 days for knee replacement surgery, 58 days for hip replacement surgery, and 30 days for cataract surgery, compared to 2019 (ibid). In Canada, the number of procedures for knee replacement fell by 26% from 2019 to 2020, while the mean waiting time from specialist assessment to treatment increased from 121 days to 197 days (a 60% increase). In Spain, the number of procedures for knee replacement fell by 31% between 2019 and 2020.

Preventive health services dropped during the first year of the COVID‑19 pandemic. On average across seven OECD countries (Chile, Iceland, Lithuania, New Zealand, Slovenia, Spain and Türkiye) for which comparable data exist, the share of women screened for breast cancer within the previous two years fell by 5 percentage points in 2020, compared with 2019 (OECD, 2021[2]). It has been estimated that there were 100 million fewer cancer screening tests performed in the EU27 and the United Kingdom in 2020 because of the pandemic (European Cancer Organisation, 2021[3]). Delays in access to diagnostic services during the pandemic were reported in many OECD countries, including Australia, Belgium, Canada (in Ontario), Denmark, Finland, France, Ireland, Italy, Korea, the Netherlands, Slovenia and Sweden.

Emergency departments had fewer visits in 2020, compared to 2019, especially in March and April of 2020. In Australia, average daily visits to hospital emergency departments were down 38% between early March and early April 2020, compared to the same window of time in 2019 (AIHW, 2020[4]). In the United Kingdom, emergency department visits in March 2020 were 29% lower than in March 2019 (Appleby, 2020[5]). In Paris, France, the incidence of out-of-hospital cardiac arrest doubled between 16 March and 26 April 2020, compared to the same period in previous years (Marijon et al., 2020[6]). In Germany, all-cause admissions were 30% lower in calendar weeks 10 to 16 of 2020, compared to the same period in 2019 (Schwarz et al., 2020[7]). In some Italian regions, paediatric emergency department visits fell by 73% to 88% in March 2020, compared with March 2019 and 2018 (Lazzerini et al., 2020[8]).

The impact of the COVID‑19 pandemic on essential health services was especially hard on older people, as well as those living with one or more chronic health conditions. In a national Australian survey, over half of respondents aged 45 years and older who cited a need for health care or disability services reported that access to care had gotten worse (Cicuttini et al., 2022[9]). Responses to the Survey of Health, Ageing and Retirement in Europe indicate that individuals aged 50 years or older who had a chronic condition were, on average across EU27 countries, over 40% more likely to report forgoing or postponing medical care due to COVID‑19 than those who did not have a chronic condition. In a survey of adults aged 65 years or older in 11 OECD countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States), one in five respondents with two or more chronic conditions reported having a medical appointment cancelled or postponed because of the COVID‑19 pandemic (Williams II et al., 2021[10]).

In the United States, the Centers for Disease Control and Prevention (CDC) Morbidity Mortality Weekly Reports estimated that around 40% of adults delayed medical care due to COVID‑19. According to the CDC National Center for Health Statistics’ Research and Development Survey, among the overall population, after the start of the pandemic, 15.6% skipped regular check-ups, 10.1% skipped prescription medication, and 8% skipped ongoing treatment and diagnostic tests/screening. These rates were significantly higher in the diabetes subpopulation, with 24.1% skipping regular check-ups, 18.6% skipping prescription medication, 15.8% skipping diagnostic or medical screening tests, and 18.7% skipping treatment for an ongoing condition.

1.2. With the COVID‑19 pandemic causing significant disruptions to in-person care, governments swiftly adopted policies to promote the use of telemedicine

1.2.1. Before the COVID‑19 pandemic, telemedicine use was growing but very slowly

Before the COVID‑19 pandemic, there was already growing interest in digital health technologies, such as telemedicine, as means to tackle significant health policy challenges. Populations were ageing globally and the prevalence of multimorbidity – the presence of several chronic illnesses in the same person – was rising, along with demands for more responsive health care services. With health care systems struggling to address more complex needs, many OECD countries were also experiencing growing gaps between health care workers needed and those available. Health expenditure was growing at its fastest rate in seven years (OECD, 2018[11]), while much effort and money were spent on wasteful care: care that does not have benefits for patients and that could be replaced by cheaper or better alternatives (OECD, 2017[12]).

Health care providers and policy makers were increasingly looking towards new digitally enabled models of care, turning in particular to electronic or digital health, or eHealth: the use of information and communications technologies in support of health and health-related fields, from care services to surveillance and education (WHO, 2019[13]). The ecosystem of digital health or eHealth technologies was rich and varied, as illustrated in Figure 1.1. Many different terms were – and still are – used, often focusing on a specific aspect of the intervention: the technology or medium used (e.g. mobile health or mHealth), the medical specialty (e.g. teleradiology), the target disease or condition (e.g. telestroke and telediabetes), the type of care (e.g. telerehabilitation and telecare), and the activity or task (e.g. clinical decision support systems and ePrescribing). Among eHealth interventions, there was growing interest in telemedicine – the use of ICTs to deliver clinical services at a distance (see Box 1.1 for a comprehensive definition) – as a way to deliver quality health services: care that is effective, safe, timely, aligned with the preferences and needs of patients and communities, equitable and efficient (OECD/WHO/World Bank Group, 2018[14]).

The number of telemedicine services was growing, but it still represented a very small proportion of the overall volume of services provided by health care systems in OECD countries (Oliveira Hashiguchi, 2020[15]). Providers and patients seeking to make use of telemedicine services faced regulatory uncertainty, limited financing and reimbursement, and unclear governance. It was possible to use telemedicine services in most OECD countries, but many governments had requirements specific to telemedicine that effectively disincentivised its use (Oliveira Hashiguchi, 2020[15]). In the early days of 2020, Hungary required that physicians making a final diagnosis or a significant therapeutic change do so only in the presence of the patient, effectively barring the use of telemedicine. In Japan and France, patients were required to see a physician in-person before being able to consult that physician via telemedicine (with exceptions in France for urgent care and for when the patient’s usual physician was not available). Lithuania only allowed provider-to-provider interactions. The states of Georgia and Texas, in the United States required that patients have an in-person follow-up appointment after a teleconsultation (Thomas and Capistrant, 2017[16]). In Slovenia, only telestroke was covered by compulsory health insurance. In Poland, the National Health Fund reimbursed only a limited number of telemedicine services, including cardiac rehabilitation. In the Czech Republic, only in-person consultations were reimbursed.

Figure 1.1. Telemedicine and the broader eHealth ecosystem

Note: ICT stands for information and communication technology.

Source: OECD compilation building on glossaries from the American and German telemedicine associations, and from ISO/TS 13131:2014.

Box 1.1. The definition of telemedicine used in this report

There is no single widely used definition of telemedicine. For the purposes of this report, telemedicine is the use of information and communication technologies to deliver health care at a distance (Oliveira Hashiguchi, 2020[15]). This definition is aligned with the WHO’s definition of telemedicine. In some OECD countries, the term telehealth is used more commonly, and often interchangeably with telemedicine. However, as illustrated in Figure 1.1, in this report, telemedicine and telehealth are considered different, with telehealth being a broader concept (CDC, 2019[17]). Throughout this report, care has been taken to ensure that terms are used in line with the definitions in Figure 1.1. However, it is not always possible to establish clear definitions from all sources using these terms, and so this report uses the term telehealth whenever it is not clear whether sources are referring to telemedicine or telehealth. Whenever possible, details on the exact services provided are given.

To further expand on the definition of telemedicine used in this report, three categories of telemedicine are considered, which can be combined as appropriate (Flodgren et al., 2015[18]): telemonitoring, store and forward, and interactive telemedicine. Telemonitoring is the use of mobile devices and platforms to conduct routine medical tests, communicate the results to health care workers in real-time, and potentially launch pre‑programmed automated responses. Store and forward is similar but is used for clinical data that are less time‑sensitive and for which a delay between transmission and response is acceptable (e.g. store and forward is widely used in dermatology). Finally, interactive or real-time telemedicine involves direct and synchronous communication between providers and patients (e.g. direct-to-patient or in health care facilities).

Interventions that facilitate medical education of health care workers (e.g. physicians, nurses, etc.) at a distance via ICTs (e.g. tele‑education or e‑learning) are not included in the definition of telemedicine used in this report. Mobile applications that do not involve any transfer of data or any patient-to-provider communication, such as self-care and wellness mobile applications, are also not included. Any intervention that does not involve clinical services, such as public health awareness campaigns, is not included. All applications matching the definition of telemedicine in this report are included, whether they involve public or private providers, and regardless of the specific technology used (e‑mail, video, fixed or mobile phone).

Note: see Oliveira Hashiguchi (2020[15]), “Bringing health care to the patient: An overview of the use of telemedicine in OECD countries”, https://doi.org/10.1787/8e56ede7-en; Sood et al. (2007[19]), “What is telemedicine? A collection of 104 peer-reviewed perspectives and theoretical underpinnings” https://doi.org/10.1089/TMJ.2006.0073; and Rural Telehealth Evaluation Center (RTEC) (2022[20]) for more on definitions, Telehealth: Current Definitions and Future Trends, https://idhi.uams.edu/rtec/wp-content/uploads/sites/4/2022/05/Telehealth-Definitions-Paper-06MAY2022-1.pdf

1.2.2. The COVID‑19 pandemic greatly accelerated the use of telemedicine

Then, in early 2020, in response to the unfolding COVID‑19 pandemic, governments and health care providers moved quickly to simplify and promote the adoption and use of remote care services. According to the OECD Survey on Telemedicine and COVID‑19 (see Box 1.2), before March 2020, nine countries1 only allowed medical consultations to be performed in the physical presence of the patient (see Figure 1.2). After March 2020, all but Korea dropped this requirement (still, Korea made it possible to temporarily use telemedicine services at the highest alert level of COVID‑19).

Figure 1.2. Pre‑pandemic restrictions to the use of telemedicine were relaxed in early 2020

Note: * Only applicable for General Practitioners and other Medical Officers practicing in general practice, with limited exceptions. Agreement with statements is shown for both before March 2020 (i.e. before the start of the pandemic) and after March 2020 (i.e. after the start of the pandemic). For the United States, medical consultations were already allowed prior to the pandemic, but only for certain payers; for example, state Medicaid programs could allow telehealth services, but for certain populations only (e.g. rural).

Source: OECD Survey on Telemedicine and COVID‑19 (2022).

Box 1.2. The OECD Survey on Telemedicine and COVID‑19, 2021‑22

The OECD designed a survey to understand how COVID‑19 has changed the telemedicine and remote care landscape, and to inform policy directions for the use of remote care services in the near future. The survey has four thematic focuses, with information requested for two periods: before and after the start of the COVID‑19 pandemic (for simplicity, these periods are considered to be before and after March 2020). The four thematic focuses are utilisation; legislation, policies and guidelines; financing, pricing and provider payment; and impact on health system performance (e.g. access, quality and equity). The questionnaire was sent to OECD countries in December 2021, and responses were accepted until the end of April 2022. A total of 31 OECD countries participated in the survey. More details on participation in the survey provided in Annex A.

After the start of the COVID‑19 pandemic, Austria, Türkiye, and the United States dropped requirements that prescriptions could only be written in the physical presence of the patient, and seven countries relaxed a prerequisite that patients were only allowed to have teleconsultations with physicians with whom they had already consulted in-person before (see Figure 1.2). Estonia and Türkiye introduced new legislation, or revised existing laws, to authorise or regulate the use of telemedicine after the start of the pandemic. In the United States, through the CARES Act provisions, Medicare telehealth restrictions that previously only allowed rural providers to offer telehealth were waived during the pandemic. These findings are in line with responses to the OECD Resilience of Health Systems Questionnaire showing that Australia, Austria, Canada, Costa Rica, Czech Republic, Finland, Ireland, Israel, Italy, Latvia, Lithuania, Portugal, Spain, the United Kingdom, and the United States all scaled up telehealth to maintain access to primary health care services and improve care co‑ordination.

Governments also promoted the use of telemedicine through financing and provider payment. After the start of the COVID‑19 pandemic, eight countries began covering real-time (synchronous) teleconsultations through government/compulsory schemes (see Figure 1.3). In Mexico, while there are no specific financial schemes for payment of remote care services, remote care can be covered through employer and employee contributions or provided for free by the Instituto de Salud para el Bienestar (Health Institute for Welfare). In Belgium, while there were no significant legislative changes, in March 2020 a new legal base was adopted allowing reimbursement of telemedicine. In England, the financing of telemedicine has only changed in the context of secondary care since telemedicine services in primary care were and are covered by government financing schemes. In secondary care, before the pandemic, telemedicine services were mostly financed through voluntary schemes and out-of-pocket payments, and only changed to government/compulsory financing afterwards. In the United States, for the first time, audio‑only telehealth services were allowed in fee‑for-service Medicare during the pandemic. While there have been limited changes to the financing of asynchronous store‑and-forward telemedicine services during the pandemic, eight countries (Belgium, England, Estonia, Germany, Hungary, Ireland, Latvia and Switzerland) began covering remote patient monitoring services after the start of the pandemic (see Figure 1.3).

Figure 1.3. Public financial coverage of telemedicine services increased in early 2020

Note: Agreement with statements is shown for both before March 2020 (i.e. before the start of the pandemic) and after March 2020 (i.e. after the start of the pandemic). Austria did not respond to this section of the survey. Answers for England are for Secondary Care only, and for General Practice the answers are “yes” as these services are provided by GPs that are funded by the government.

Source: OECD Survey on Telemedicine and COVID‑19 (2022).

1.3. The use of telemedicine has skyrocketed during the COVID‑19 pandemic, partly compensating for the disruptions to in-person care services

Reductions in the number of in-person health care services provided in OECD countries were partly offset by an unprecedented scale‑up of telemedicine services, following the adoption by governments of policies to promote remote care. The number of teleconsultations skyrocketed in the early months of the pandemic, offsetting, to some extent, the reduction in in-person health care services, as illustrated in Figure 1.4. Due to differences in definitions (see Box 1.1), most data on the use of telemedicine services are not fully comparable across countries.

Figure 1.4. Reductions in the number of in-person consultations were partly offset by increases in the number of teleconsultations, in selected OECD countries from January to December 2020

Note: Numbers of consultations (in thousands) may not be directly comparable across countries due to different definitions. In England, teleconsultations include telephone and video consultations; in Finland, teleconsultations include telephone connections, electronic services, and real-time remote transactions, while in-person consultations include customer visit to reception and hospital visit; in Belgium, in-person consultations include general practitioner appointments and specialist appointments.

Source: Belgian National Institute for Health and Disability Insurance, Finish National Institute for Health and Welfare, Norwegian Directorate of Health, and NHS Digital for England.

In Belgium, there were no teleconsultations at all in January and February of 2020; then there were over 1.2 million teleconsultations performed just in March 2020 alone. In Norway, the number of teleconsultations increased more than 10 times, from around 43 000 in January 2020 to over 470 000 in March of 2020. In England, the number of teleconsultations almost doubled from February to March 2020 and grew further in the months after March to almost three times the number of teleconsultations in January 2020. In Finland, the number of teleconsultations increased in March of 2020 as well but not as markedly as in other countries. While time‑series of the number of telemedicine services are not available for all OECD countries, Table 1.1 provides some illustrative examples of the astounding growth in the use of telemedicine during the pandemic. Numbers of in-person and telemedicine services may not be directly comparable across countries due to differences in definitions.

Table 1.1. The use of telemedicine grew exponentially in many OECD countries in 2020

Examples of the growth in volume of, and spending on, telemedicine services after the start of COVID‑19

	Before the start of the COVID‑19 pandemic	After the start of the COVID‑19 pandemic
Australia	The volume of telemedicine services funded by the Medicare Benefits Schedule (MBS) had been steadily growing from 101 741 in 2013 to 188 369 telemedicine services in 2017 (Oliveira Hashiguchi, 2020[15]).	In the quarter ending September 2020, 13.3% of all MBS services, 15.5 million, were telehealth consultations (AIHW, 2021[21]). Between 16 March 2020 and 27 September 2020, 2.5 million Medicare‑subsidised mental health related services were delivered via telehealth nationally (out of 7.2 million), with AUD 791 million paid in benefits (AIHW, 2022[22]). A 10% drop in in-person antenatal care between January and September 2020, compared to 2019, was almost entirely offset by an uptake of 91 000 telehealth services (AIHW, 2021[23]).
Belgium	There was no reimbursement of telemedicine services before March 2020; no telemedicine services were provided in January and February of 2020 (see note).	Of the over 72 million appointments performed in 2020, over 10.5 million were delivered using telemedicine. In April 2020, 44.4% of all appointments were done via telemedicine. A total of EUR 238 million were paid in benefits (INAMI, 2021[24]).
Canada	Between 2012 and 2014, the number of interactive real-time clinical sessions grew by 46%, from 282 529 to 411 778 appointments, representing about CAD 405 000 of billable services (Oliveira Hashiguchi, 2020[15]; CMA, 2019[25]). In Ontario, virtual care use increased from 0.2% in the first quarter of 2012 to 1.8% of total ambulatory visits in the fourth quarter of 2019 (Bhatia et al., 2021[26])	In April 2020, telemedicine accounted for 77% (3 194 107 of 4 161 582) of all ambulatory visits among people in Ontario (Mehrotra, Bhatia and Snoswell, 2021[27]). Almost three‑quarters (73.7%) of all primary care visits and 63.9% of specialty care visits were delivered virtually in the second quarter of 2020 in Ontario (Bhatia et al., 2021[26]). National poll data from 14‑17 May 2020 shows almost half of all Canadians had accessed a physician using virtual care (CMA, CFPC and RCPSC, 2022[28]). In May 2020, the federal government announced an investment of CAD 240.5 million to accelerate the use of virtual tools and digital approaches (CMA, CFPC and RCPSC, 2022[28]).
France	There were 1 500 teleconsultations in 2017, 5 985 in 2018, and 136 882 in 2019, according to data from the Caisse Nationale de l’Assurance Maladie (CNAM; see note).	In the first half of 2020, the number of teleconsultations invoiced to l’Assurance Maladie rose from 40 000 acts per month to 4.5 million in April. During the first lockdown, one in four consultations was a teleconsultation (L’Assurance Maladie, 2020[29]). 10.9 million teleconsultations were performed between January and September 2021 (see note).
Germany	There were almost 3 000 video consultations nationwide in 2019 (KBV, 2021[30]).	There were almost 1.4 million video consultations in the first half of 2020. Almost 1.2 million times patients consulted a doctor or psychotherapist via video in the second quarter of 2020 (KBV, 2021[30]).
Iceland	In May and April 2018/19, telephone consultations accounted for around 43% and web-based services for more than 10% of all consultations provided in primary health care centres (Sigurdsson et al., 2020[31]). In 2019, the platform Heilsuvera, which offers health information online, allows appointments to be scheduled, and offers telephone calls and online chat with health professionals, was accessed 1.2 million times (Möller, 2021[32]).	In March and April 2020, the use of telephone consultations delivered at primary health care centres increased by 69% compared to that period in 2018/19. The use of web-based consultations increased by 213%, while office visits decreased by 41%. Remote services made up more than 80% of the consultations delivered at that time (Sigurdsson et al., 2020[31]). The use of the online platform Heilsuvera almost tripled since 2019. The number of users rose to 194 180, so that almost 70% of the Icelandic population is registered (Möller, 2021[32]).
Lithuania	While telemedicine services were implemented already in 2018, they played a small role in the Lithuanian health care system before the pandemic: 57% of all outpatient consultations were with family physicians and 98% through direct consultations (Liseckiene, 2021[33])	The numbers of remote services delivered in 2020 were more than 25 times as high as in 2019, jumping from 260 568 to 6 676 110, which is an increase of 2 462%. The numbers for the first 11 months of 2021 surpassed those of 2020, showing that remote consultations continue be widely used (see note).
Netherlands	In 2018, there were more than 20 million telephone consultations in outpatient care. The number of consultations via e‑mail doubled between 2015 and 2018, with more 400 000 provided in 2018 (Rompelberg, Suijkerbuijk and Wouters, 2020[34]). In 2019, about 10% of all consultations in outpatient care have been delivered remotely with about 1 900 video consultations per year. Only 51% of Dutch hospitals offered video calling in 2019 (Nederlandse Vereniging van Ziekenhuizen (NVZ), 2022[35])	In 2021, 99% of hospitals in the Netherlands offered video consultations, compared to only 51% in 2019. While in 2019, there were 1 900 video consultation in outpatient care per year, in 2020 there were around 44 000, a 23‑fold increase. In 2021, the numbers rose again to roughly 66 000 video calls (Nederlandse Vereniging van Ziekenhuizen (NVZ), 2022[35]). In total, 28.3% of outpatient care consultations were delivered remotely in 2021, which includes telephone and video consultations, teledermatology and written consultations (ibid).
Poland	While telemedicine was available before the pandemic in Poland it made up only a fraction of the overall health care services. However, use was on the rise, with 4 335 teleconsultations delivered in 2017, 9 249 in 2018 and 14 930 in 2019 (see note).	The number of teleconsultations skyrocketed, accounting for up to 80% of all consultations at times (National Health Fund, Department of Patient Services (Departament Obsługi Pacjenta, Narodowy Fundusz Zdrowia), 2020[36]). In 2020, 56.8 million medical consultations in primary care were carried out remotely and 16.3 million in specialised care. There were 116 500 appointments for dental advice provided remotely (see note).
Portugal	85% of surveyed physicians had not participated in teleconsultations (O’Neill et al., 2022[37]). Between January and December of 2019, 29 778 teleconsultations were performed (ACSS, 2022[38]).	During the first wave of the pandemic, 94% of physicians used teleconsultations (O’Neill et al., 2022[37]). Between January and December of 2020, a total of 44 475 teleconsultations were performed, and between January and December 2021 a total of 354 634 teleconsultations had been performed (ACSS, 2022[38]).
Sweden	From 2016 to 2019, the number of video visits rose remarkably from 20 149 to 1 159 377, which is and increase of 5 654% (Swedish Agency for Health and Social Care Analysis, 2022[39]). This still only accounted for a fraction of the health care services provided in total. In 2018, the costs for teleconsultations constituted roughly 1% of Swedish health care spending in primary care (Vårdanalys, 2020[40]).	With the pandemic, the numbers of video teleconsultations increased yet again from 1 159 377 in 2019 to 2 308 089 in 2020, a growth of 99% (Swedish Agency for Health and Social Care Analysis, 2022[39]). While video consultations only accounted for about 3% of all physical visits in 2019, this number rose to 7% in 2020. Although these numbers do not include the digital visits scheduled instead of physical visits due to the pandemic, they still signify a shift towards remote care (Swedish Agency for Health and Social Care Analysis, 2022[39]). In 2020, the costs of video visits amounted to 2% of the net cost in Swedish primary care, compared to 0.5% in 2018 (Swedish Agency for Health and Social Care Analysis, 2022[39]).
United States	The number of Medicare fee‑for-service beneficiary telehealth visits was approximately 840 000 in 2019. Prior to the pandemic, telehealth made up less than 1% of visits across all visit specialties (Samson et al., 2021[41]).	The number of Medicare fee‑for-service beneficiary telehealth visits increased 63‑fold in 2020, to nearly 52.7 million. Telehealth increased to 8% of primary care visits. Telehealth comprised a third of total visits to behavioural health specialists (Samson et al., 2021[41]).

Note: Numbers of services may not be directly comparable across countries due to differences in definitions. The data in this table are not meant to be exhaustive. Telehealth and virtual care are used interchangeably with telemedicine. The source for statistics without citations is the OECD Survey of Telemedicine and COVID‑19 (2022).

Source: OECD analysis of multiple sources (see citations in table), including the OECD Survey on Telemedicine and COVID‑19 (2022).

Figure 1.5 shows the number of doctor teleconsultations per capita, and the share of total doctor consultations that are teleconsultations, since 2020. In nine OECD countries for which data are available from the 2022 OECD Health Statistics and an ad-hoc data collection on teleconsultations, doctor teleconsultations represented 21% of all doctor consultations in 2020, compared to 11% in 2019.

Figure 1.5. Doctor teleconsultations in OECD countries, in 2020

Note: All values are provisional; * Norway excludes teleconsultations by medical specialists, Spain covers consultations to generalist and paediatricians who work in primary health care centres of the National Health System; values for the Czech Republic are estimates. Data for Portugal are from the “Portal da transparência”, a data website of the National Health Service.

Source: OECD Health Statistics (2022); OECD ad-hoc data collection on teleconsultations (2022).

Survey data also provide insights into how many patients used teleconsultations during the pandemic. In the 22 OECD countries that are also Member States of the European Union, an average of 32.9% of adults surveyed by Eurofound in June/July of 2020 reported they had a medical consultation online or by phone since the start of the pandemic (Eurofound, 2020[42]). In February/March of 2021, an average of 45.3% of adults surveyed by Eurofound reported they had a medical consultation online or by phone since the start of the pandemic. The shares in February/March of 2021 ranged from 23.2% in France to 71.6% in Spain. In Canada, 47% of respondents reported using telehealth services to receive advice from a doctor since the start of the pandemic in May 2020 (CMA and Abacus Data, 2020[43]). In Australia, one in seven adults had used a telehealth service (including making online bookings, e‑Prescriptions, and consulting health information online) over the four weeks preceding April 2021 (Australian Bureau of Statistics, 2021[44]). In Costa Rica, one‑third of consultations in 2020 took place via teleconsultation, with a similar proportion (34%) reported for the first eight months of 2021 (OECD, 2021[2]).

1.4. Data on telemedicine services are very limited, with almost half of OECD countries having no breakdowns by demographic and socio‑economic factors

Despite growing interest in telemedicine before the start of the COVID‑19 pandemic and significant growth in telemedicine use during the pandemic, data on remote care services, including data on the number of teleconsultations (i.e. phone and video calls) provided, are scarce. While only four countries (Austria, Iceland, Japan and Switzerland) reported that they could not currently provide any data on the number of teleconsultations, only 17 out of 38 OECD countries reported data on the number of doctor teleconsultations performed since 2020 in the 2022 OECD ad-hoc data collection on teleconsultations (see Figure 1.5). Based on the OECD Survey on Telemedicine and COVID‑19, at least 10 out of the 27 countries that are able to report data on teleconsultations can only do so starting in March 2020. For example, in Hungary, Korea and Türkiye, the use of telemedicine only became a significant part of the delivery of health care during the pandemic, so no data are available pre‑COVID. Estonia, Iceland and Mexico reported they will be able to collect better and more detailed data soon.

One challenge is that central governments have no visibility of remote care services provided by public authorities at subnational level or by private providers that are not paid through government/compulsory financing schemes. In Austria, inpatient care is the responsibility of the nine provinces, while outpatient care (provided by doctors in private practice) is the responsibility of the social security institutions, with data on teleconsultations dispersed across multiple actors. In New Zealand, the central government only has data on teleconsultations provided by the National Telehealth Service, which is a free telephone service that provides episodic care across the country. Teleconsultations taking place outside the National Telehealth Service are difficult to track due to the devolved nature of New Zealand’s health care system. Canada, Israel, Sweden and Switzerland also reported that data collection on teleconsultations takes place primarily at a subnational level (see Chapter  2, Box 2.1) for a more detailed discussion of how devolution of responsibilities in health affects the provision of telemedicine services).

The collection and reporting of data on teleconsultations are often associated with financing schemes. In the United States, there are extensive data on the teleconsultations provided to patients that are insured via Medicare and Medicaid, while no data are available for those using private insurance. In Latvia, data are only available for teleconsultations financed through government/compulsory schemes, starting from March 2020 when financing was introduced. In France, only data on video teleconsultations are available, since this is the only type of telemedicine that can be reimbursed.

1.4.1. Fewer than half of OECD countries have data on patient characteristics, type of telemedicine service, reasons for telemedicine use, and subsequent care

While over half of 31 reporting countries can stratify the number of teleconsultations by patient age (18 countries) and gender (17 countries), breakdowns by income, education, employment status, ethnicity and nationality are only possible in at most five OECD countries. Only seven countries can quantify the number of teleconsultations provided to rural and urban patients. Although many countries do not actively collect data on whether a teleconsultation took place in an urban or rural area, the Czech Republic and England note that such information can be estimated based on the location of the patient or provider. The exact measures of socio‑economic indicators differ across countries. Luxembourg can provide data on whether the patient is employed in the private sector, self-employed, or is a civil servant, as well as the patient’s monthly wage (including base wage, overtime, and other additional income). New Zealand only has data on patients’ Social Deprivation Index, which is partly based on income. Canada and Costa Rica and the United States are the countries with the most comprehensive data on patients receiving teleconsultations, collecting data on at least six socio‑economic indicators. As with the total number of teleconsultations performed, often data on socio‑economic and demographic characteristics of patients using teleconsultations are not collected or reported by central governments.

Data on the number of telemedicine services provided by type of communication technology used are also limited. Fewer than half of countries can provide a breakdown for real-time audio (11 countries) and video consultations (14 countries). Iceland and the Netherlands are the only countries able to provide data on telemedicine delivered via email. Iceland specified that, since 2021, it collects data on the number of messages exchanged between health care professionals and patients, the number of electronic requests for drug prescription renewals, and electronic bookings for a medical appointment. All messaging takes place through a secure communication channel via the medical records systems and health portals.

In England, data for general practice differentiates between telephone and online/video medical appointments, the latter of which includes both synchronous and asynchronous consultations, whereas data for secondary care only covers video consultations. In Ireland, there are data on audio and video consultations combined, but only for appointments provided by acute care hospitals. In Norway, there are no data collected on the type of teleconsultation, but there are population surveys that provide some information on the types of digital consultations that patients use. In countries with case‑based provider payment systems, such as the Czech Republic and the United States, it may be possible to determine what type of communication technology was used in a teleconsultation. This may also be possible in Belgium, however there are only some codes which require a specific type of communication technology, and most telemedicine codes allow the use of both audio‑only and video communication.

Regarding the type of telemedicine service provided, 11 countries have data on the use of remote monitoring and only five countries have data on store‑and-forward telemedicine. Moreover, the data that are available are often focused on specific health conditions or care settings. In Türkiye, for instance, there are national data only for some procedures such as remote monitoring of patients with a pacemaker, while Belgium only collects data on patient monitoring for COVID‑19. In Norway, there are data on remote monitoring from specialist hospitals that work with rehabilitation patients. There are pilot projects on remote monitoring in Austria and Lithuania, but data from these projects are likely not representative.

Data on the reasons why patients used teleconsultations are available in just over half of reporting countries (17 out of 31 countries). In Belgium, Costa Rica and Lithuania, procedural codes, diagnostic data, and administrative information are used to gain insight into patient’s reasons for using telemedicine. In Belgium, it is possible to differentiate between COVID‑19 triage and psychiatric and psychological consultations. In Costa Rica ICD‑10 codes are used, and Lithuania can differentiate between the following reasons for teleconsulting: evaluation of health status, exam appointments, e‑prescriptions, exam results, and medical leave certificates. In Australia, Norway, Slovenia, Sweden and the United States there are studies or reports on telemedicine that also cover the reasons for telemedicine use. In the United States, for example, there have been various government and academic analyses conducted to assess the reasons for telehealth visits.

Finally, ten countries (out of 31 reporting countries) have data or studies on the subsequent use of health care services following a teleconsultation. In New Zealand, it is possible to collect data on what users of the National Telehealth Service are advised to do after the teleconsultation has taken place, but it is difficult to assess whether patients follow the advice. In Costa Rica, data are collected via the electronic health record, including requests for examination or prescriptions. In Estonia, data are not directly collected but may be generated by linking separate datasets. In the Czech Republic, Luxembourg and the United States, there are research studies on this topic, and in Norway, data are gathered as part of a population survey on eHealth, which also includes questions about whether the use of telemedicine led to a physical follow-up appointment.

References

[38] ACSS (2022), Consultas em Telemedicina, Transparencia SNS, https://www.sns.gov.pt/monitorizacao-do-sns/consultas-em-telemedicina/ (accessed on 6 May 2022).

[22] AIHW (2022), COVID-19: looking back on health in 2020, Australian Institute of Health and Welfare, Canberra, https://www.aihw.gov.au/reports-data/australias-health-performance/covid-19-and-looking-back-on-health-in-2020 (accessed on 5 May 2022).

[21] AIHW (2021), Impacts of COVID-19 on Medicare Benefits Scheme and Pharmaceutical Benefits Scheme: quarterly data, Impact on MBS service utilisation, Australian Institute of Health and Welfare, Canberra, https://www.aihw.gov.au/reports/health-care-quality-performance/impacts-of-covid19-mbs-pbs-quarterly-data/contents/impact-on-mbs-service-utilisation (accessed on 5 May 2022).

[23] AIHW (2021), New report looks at uptake of telehealth in antenatal care during COVID-19 lockdowns, Australian Institute of Health and Welfare, Canberra, https://www.aihw.gov.au/news-media/media-releases/2021-1/february/new-report-looks-at-uptake-of-telehealth-in-antena (accessed on 5 May 2022).

[4] AIHW (2020), How COVID-19 changed the way Australians used health services in 2019-20, Australian Institute of Health and Welfare, Canberra.

[5] Appleby, J. (2020), “What is happening to non-covid deaths?”, BMJ, p. m1607, https://doi.org/10.1136/bmj.m1607.

[44] Australian Bureau of Statistics (2021), Household Impacts of COVID-19 Survey: Insights into the prevalence and nature of impacts from COVID-19 on households in Australia.

[26] Bhatia, R. et al. (2021), “Virtual care use before and during the COVID-19 pandemic: a repeated cross-sectional study”, CMAJ Open, Vol. 9/1, pp. E107-E114, https://doi.org/10.9778/cmajo.20200311.

[17] CDC (2019), Public Health Law Anthologies: Telehealth and Telemedicine, Center for State, Tribal, Local, and Territorial Support, Public Health Law Program, https://www.cdc.gov/phlp/publications/topic/anthologies/anthologies-telehealth.html (accessed on 4 October 2022).

[9] Cicuttini, F. et al. (2022), “Determinants of worse care for non-COVID-19 health or disability needs in Australia in the first month of COVID-19 restrictions: A national survey”, Health & Social Care in the Community, Vol. 00, pp. 1-12, https://doi.org/10.1111/HSC.13699.

[25] CMA (2019), Virtual Care in Canada - Discussion Paper, Canadian Medical Association.

[43] CMA and Abacus Data (2020), What Canadians think about virtual health care: national survey results, Canadian Medical Association.

[28] CMA, CFPC and RCPSC (2022), Virtual care in Canada: Progress and potential - Report of the virtual care task force.

[42] Eurofound (2020), Living, working and COVID-19 dataset, http://eurofound.link/covid19data (accessed on 6 May 2022).

[3] European Cancer Organisation (2021), European Cancer Organisation: Time to act data navigator, https://www.europeancancer.org/data-navigator/#map-time-to-act-interactive-map (accessed on 17 February 2022).

[18] Flodgren, G. et al. (2015), “Interactive telemedicine: effects on professional practice and health care outcomes”, The Cochrane database of systematic reviews, Vol. 9, https://doi.org/10.1002/14651858.CD002098.PUB2.

[24] INAMI (2021), Monitoring COVID-19 - L’impact de la COVID-19 sur le remboursement des soins de santé, Direction actuariat et budget, Service des soins de santé de l’INAMI, https://www.riziv.fgov.be/fr/publications/Pages/rapport-impact-covid19-remboursement-soins-sante.aspx (accessed on 5 May 2022).

[30] KBV (2021), Immer mehr Praxen greifen zur Kamera - Zahl der Videosprechstunden auf über eine Million gestiegen, Kassenärztliche Bundesvereinigung, https://www.kbv.de/html/1150_50419.php (accessed on 5 May 2022).

[29] L’Assurance Maladie (2020), Téléconsultation : une pratique qui s’installe dans la durée, https://assurance-maladie.ameli.fr/presse/2020-09-16-cp-teleconsultation-anniversaire (accessed on 5 May 2022).

[8] Lazzerini, M. et al. (2020), “Delayed access or provision of care in Italy resulting from fear of COVID-19”, The Lancet Child & Adolescent Health, Vol. 4/5, pp. e10-e11, https://doi.org/10.1016/s2352-4642(20)30108-5.

[33] Liseckiene, I. (2021), Lithuania: Multi-disciplinary primary health care during the covid 19 pandemic: improving access through remote consultations (2021), WHO Europe, https://www.euro.who.int/en/health-topics/Health-systems/primary-health-care/country-work/primary-health-care-country-vignettes/lithuania-multi-disciplinary-primary-health-care-during-the-covid-19-pandemic-improving-access-through-remote-consultations-2021 (accessed on 12 May 2022).

[6] Marijon, E. et al. (2020), “Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study”, The Lancet Public Health, Vol. 5/8, pp. e437-e443, https://doi.org/10.1016/s2468-2667(20)30117-1.

[27] Mehrotra, A., R. Bhatia and C. Snoswell (2021), “Paying for Telemedicine After the Pandemic”, JAMA, Vol. 325/5, pp. 431-432, https://doi.org/10.1001/JAMA.2020.25706.

[32] Möller, A. (2021), Ársskýrsla Embættis Landlæknis 2020/ Annual Report of the Office of the Medical Director of Health 2020, The Office of the Medical Director of Health, Reykjavík, http://www.milomanara.it/. (accessed on 16 May 2022).

[36] National Health Fund, Department of Patient Services (Departament Obsługi Pacjenta, Narodowy Fundusz Zdrowia) (2020), Raport z badania satysfakcji pacjentów korzystających z teleporad u lekarza podstawowej opieki zdrowotnej w okresie epidemii COVID-19, Polish Health Ministry/ Ministerstwo Zdrowia.

[35] Nederlandse Vereniging van Ziekenhuizen (NVZ) (2022), NVZ Factsheet digital healthcare, Nederlandse Vereniging van Ziekenhuizen (NVZ).

[2] OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.

[11] OECD (2018), “Spending on Health: Latest Trends”, OECD, Paris, http://www.oecd.org/health/health-systems/Health-Spending-Latest-Trends-Brief.pdf.

[12] OECD (2017), Tackling Wasteful Spending on Health, OECD Publishing, Paris, https://doi.org/10.1787/9789264266414-en.

[14] OECD/WHO/World Bank Group (2018), Delivering Quality Health Services: A Global Imperative, World Health Organization, Geneva 27, https://doi.org/10.1787/9789264300309-en.

[15] Oliveira Hashiguchi, T. (2020), “Bringing health care to the patient: An overview of the use of telemedicine in OECD countries”, OECD Health Working Papers, No. 116, OECD Publishing, Paris, https://doi.org/10.1787/8e56ede7-en.

[37] O’Neill, C. et al. (2022), “Consulta Não Presencial no Serviço Nacional de Saúde Português Durante a Pandemia de COVID-19: Estudo da Opinião dos Médicos e Implicações para o Futuro”, Acta Médica Portuguesa, Vol. 35/13, https://doi.org/10.20344/AMP.16724.

[34] Rompelberg, C., A. Suijkerbuijk and M. Wouters (2020), Stand van zaken e-health in 2020, Rijksinstituut voor Volksgezondheid en Milieu, http://www.rivm.nl/publicaties/verkenning-e-healthmonitor-digitale (accessed on 17 May 2022).

[20] Rural Telehealth Evaluation Center (RTEC) (2022), Telehealth: Current Definitions and Future Trends, https://idhi.uams.edu/rtec/wp-content/uploads/sites/4/2022/05/Telehealth-Definitions-Paper-06MAY2022-1.pdf (accessed on 21 September 2022).

[41] Samson, L. et al. (2021), Medicare Beneficiaries’ Use of Telehealth in 2020: Trends by Beneficiary Characteristics and Location, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet (accessed on 6 May 2022).

[7] Schwarz, V. et al. (2020), “Decline of emergency admissions for cardiovascular and cerebrovascular events after the outbreak of COVID-19”, Clinical Research in Cardiology, Vol. 109/12, pp. 1500-1506, https://doi.org/10.1007/s00392-020-01688-9.

[31] Sigurdsson, E. et al. (2020), “How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic”, BMJ Open, pp. 10:e043151, https://doi.org/10.1136/bmjopen-2020-043151.

[19] Sood, S. et al. (2007), “What is telemedicine? A collection of 104 peer-reviewed perspectives and theoretical underpinnings”, Telemedicine Journal and e-Health, Vol. 13/5, pp. 573-590, https://doi.org/10.1089/TMJ.2006.0073.

[39] Swedish Agency for Health and Social Care Analysis (2022), Visiting online: Resource use and equity linked to digital health visits.

[16] Thomas, L. and G. Capistrant (2017), State Telemedicine Gaps Analysis: Coverage and Reimbursement, American Telemedicine Association.

[40] Vårdanalys (2020), Three perspectives on digital care visits - the perceptions of the population, patients and healthcare, Swedish Agency for Health and Care Analysis, Stockholm.

[1] WHO (2022), Third round of the global pulse survey on continuity of essential health services during the COVID-19 pandemic. Interim report, World Health Organization, Geneva.

[13] WHO (2019), WHO guideline: recommendations on digital interventions for health system strengthening, World Health Organisation, Geneva, https://apps.who.int/iris/handle/10665/311941.

[10] Williams II, R. et al. (2021), The Impact of COVID-19 on Older Adults: Findings from the 2021 International Health Policy Survey of Older Adults, Commonwealth Fund, New York.

Note

← 1.  Estonia, Hungary, Iceland, Ireland, Korea, Luxembourg, Mexico, Türkiye and the United States.