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

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.

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.

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.

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).

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).

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.

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.

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.

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]).

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.

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.


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[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.


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

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