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Several systematic reviews evaluating the use of telemedicine by clinicians, patients, and health authorities to improve the delivery of care in the 53 member states of the World Health Organization (WHO) European Region have been conducted in recent years. However, a study summarizing the findings of these reviews has not been conducted.
This overview of systematic reviews aimed to summarize findings regarding the use of telemedicine across the 53 member states and identify the medical fields and levels of care in and at which the effectiveness, feasibility, and applicability of telemedicine have been demonstrated. The barriers to and facilitators of telemedicine use were also evaluated and collated to help with the design and implementation of telemedicine interventions.
Through a comprehensive systematic evaluation of the published and unpublished literature, we extracted clinical, epidemiological, and technology-related data from each review included in the study. We focused on evaluating the barriers to and facilitators of the use of telemedicine apps across the 53 member states considered. We rated the methodological quality of each of the included reviews based on A Measurement Tool to Assess Systematic Review 2 approach and judged the overall certainty of evidence by using the Grading of Recommendations, Assessment, Development, and Evaluations methodology. The entire process was performed by 2 independent authors.
This overview drew on data from >2239 primary studies, with >20,000 enrolled patients in total, within the WHO European Region. On the basis of data from randomized trials, observational studies, and economic evaluations from several countries, the results show a clear benefit of telemedicine technologies in the screening, diagnosis, management, treatment, and long-term follow-up of a series of chronic diseases. However, we were unable to pool the results into a reliable numeric parameter because of the high heterogeneity of intervention methodologies, scheduling, primary study design discrepancies, settings, and geographical locations. In addition to the clinical outcomes of the interventions, the social and economic outcomes are highlighted.
The application of telemedicine is well established across countries in the WHO European Region; however, some countries could still benefit from the many uses of these digital solutions. Barriers related to users, technology, and infrastructure were the largest. Conversely, the provision of health services using technological devices was found to significantly enhance patients’ clinical outcomes, improve the long-term follow-up of patients by medical professionals, and offer logistical benefits for both patients and health workers.
PROSPERO (International Prospective Register of Systematic Reviews) CRD42022309375; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=309375
Telemedicine is an accessible, cost-effective medical system, delivering high-quality care and reducing overall morbidity and mortality [
In the World Health Organization (WHO) European Region, an extensive body of literature has recently been produced, evidencing multiple positive health-related outcomes and the creation of integrated and finely structured remote health counseling programs [
The protocol for this overview of systematic reviews was published on February 17, 2022, in PROSPERO (International Prospective Register of Systematic Reviews; CRD42022309375;
This study relied on secondary data; therefore, no ethics approval or patient consent was required.
Five databases (PubMed, Embase, Web of Science, the Cochrane Library, and Scopus) were searched from their inception to February 14, 2022. The search strategy is presented in
Two investigators independently assessed titles and abstracts and analyzed appropriate studies through full-text evaluation. Cochrane and non-Cochrane systematic reviews with or without meta-analyses were included if they had adequately displayed the status of telemedicine among the 53 member states of the WHO European Region or reported on the barriers to and facilitators of the use of such technologies, regardless of publication data and the primary language. Reviews were considered eligible if >50% of the primary studies originated from the WHO European Region [
Two investigators independently extracted data by using Excel (Microsoft). A third party resolved discrepancies. The data extraction form (
Two investigators independently appraised methodological quality by using A Measurement Tool to Assess Systematic Review 2 (AMSTAR 2). Discrepancies were resolved through consensus. In addition to the systematic reviews of intervention trials, additional types of literature were included. Some AMSTAR 2 ratings were therefore adjusted (
Evidence was synthesized based on the core disease or condition by using the
In total, 944 records were retrieved, including 9 duplicates. In title and abstract screening, 806 publications were excluded. Of the remaining studies, 96 were excluded. Therefore, 33 articles were included in the final analysis. Additional records were found after checking the reference lists of included reviews. The overview flowchart is shown in
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 flow diagram for new systematic reviews that include searches of databases and registers only.
The characteristics of the included reviews are reported in in
A total of 2239 primary studies were characterized as observational, interventional, medical, and economic modeling-based analyses and mixed methods studies. Publication designs were mostly “systematic reviews without meta-analyses” (19/33, 58%), “scoping reviews” (8/33, 24%), “others” (3/33, 9%), and “systematic reviews with meta-analyses” (3/33, 9%). Not all reviews specified the number of patients, but the data suggest that there were 61,589 patients.
The results of the AMSTAR 2 assessment showed that the main methodological weaknesses were a lack of protocol registration, no evaluation of the overall risk of bias by using validated approaches, a lack of disclosure and justification of excluded studies, and the absence of detailed reporting of the critical characteristics of the included reviews (
Reliability of included reviews based on A Measurement Tool to Assess Systematic Review (AMSTAR 2) judgmentsa.
Review ID (reference) | 1b | 2c | 3d | 4e | 5f | 6g | 7h | 8i | 9j | 10k | 11l | 12m | 13n | 14o | 15p | 16q | Overall quality |
Allner et al [ |
Yr | PYs | Nt | PY | Y | Y | N | N | N | N | NMACu | NMAC | N | N | NMAC | Y | Very Lowv |
Brunetti al [ |
Y | N | Y | PY | Y | Y | N | N | Y | N | Y | N | N | N | Y | Y | Very Lowv |
Carbo et al [ |
Y | PY | Y | N | Y | Y | N | PY | Y | Y | Y | N | N | Y | N | Y | Very Lowv |
Cordes et al [ |
Y | N | Y | PY | N | N | N | PY | Y | N | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Cruz et al [ |
Y | N | Y | PY | Y | Y | N | Y | N | N | NMAC | NMAC | N | N | NMAC | Y | Loww |
Elbaz et al [ |
Y | N | Y | PY | Y | N | N | PY | N | N | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Farabi et al [ |
Y | N | Y | PY | Y | Y | N | PY | Y | N | NMAC | NMAC | Y | N | NMAC | Y | Very Lowv |
Gaveikaite et al [ |
Y | N | Y | PY | Y | Y | N | Y | Y | N | NMAC | NMAC | N | Y | NMAC | Y | Very Lowv |
Glinkowski et al [ |
Y | N | Y | PY | Y | Y | N | N | N | N | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Hallensleben et al [ |
Y | N | Y | PY | Y | Y | N | Y | N | N | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Hartasanchez et al [ |
Y | N | Y | PY | Y | Y | N | PY | N | N | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Hrynyschyn et al [ |
Y | N | Y | PY | Y | Y | N | Y | Y | N | NMAC | NMAC | Y | N | NMAC | Y | Very Lowv |
Karamanidou et al [ |
Y | PY | Y | PY | Y | Y | N | PY | N | Y | NMAC | NMAC | N | Y | NMAC | Y | Very Lowv |
Kierkegaard et al [ |
Y | PY | Y | PY | Y | N | N | N | N | N | NMAC | NMAC | N | Y | NMAC | Y | Very Lowv |
Kingsdorf et al [ |
Y | PY | Y | PY | Y | Y | N | PY | N | N | NMAC | NMAC | N | Y | NMAC | Y | Very Lowv |
Labiris et al [ |
Y | N | Y | PY | N | N | N | PY | N | N | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Maresca et al [ |
Y | PY | Y | N | N | N | N | PY | N | N | NMAC | NMAC | N | N | NMAC | N | Very Lowv |
Martin et al [ |
Y | PY | Y | N | Y | Y | N | Y | N | N | NMAC | NMAC | N | Y | NMAC | Y | Very Lowv |
McFarland et al [ |
Y | Y | Y | PY | Y | Y | N | Y | PY | N | Y | Y | Y | Y | Y | Y | Loww |
Mold et al [ |
Y | PY | N | PY | Y | Y | Y | Y | N | N | NMAC | NMAC | N | Y | NMAC | Y | Very Lowv |
Nielsen et al [ |
Y | PY | Y | PY | N | N | N | PY | N | N | NMAC | NMAC | N | Y | NMAC | Y | Very Lowv |
O’Cathail et al [ |
Y | PY | Y | PY | Y | Y | N | PY | N | N | NMAC | NMAC | N | Y | NMAC | Y | Very Lowv |
Ohannessian et al [ |
Y | N | Y | PY | Y | Y | N | PY | N | N | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Pron et al [ |
Y | PY | Y | PY | N | N | N | PY | PY | N | NMAC | NMAC | N | Y | NMAC | Y | Very Lowv |
Raja et al [ |
Y | N | Y | PY | Y | Y | N | PY | N | N | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Simmonds-Buckley et al [ |
Y | PY | Y | Y | Y | Y | N | Y | PY | N | Y | Y | Y | Y | Y | Y | Loww |
Singh et al [ |
Y | N | Y | PY | N | N | N | Y | N | N | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Tokgoz et al [ |
Y | Y | Y | PY | Y | Y | N | PY | Y | Y | NMAC | NMAC | Y | Y | NMAC | Y | Loww |
Trettel et al [ |
Y | N | N | PY | N | N | N | N | N | N | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Udsen et al [ |
Y | PY | Y | PY | Y | Y | N | Y | N | N | NMAC | NMAC | N | Y | NMAC | N | Very Lowv |
Verma et al [ |
Y | N | Y | PY | Y | Y | Y | N | N | Y | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Willard et al [ |
N | PY | N | PY | Y | Y | N | N | N | N | NMAC | NMAC | N | N | NMAC | Y | Very Lowv |
Zanin et al [ |
Y | PY | Y | PY | Y | Y | N | PY | PY | N | NMAC | NMAC | N | Y | NMAC | Y | Very Lowv |
aJudgments were made by 2 overview authors based on AMSTAR 2, a critical appraisal tool for systematic reviews that include randomized or nonrandomized studies of health care interventions or both.
bDomain 1—Did the research questions and inclusion criteria for the review include the components of PICO (Patients, Intervention, Comparator, and Outcomes)
cDomain 2—Did the report of the review contain an explicit statement that the review methods were established before the conduct of the review and did the report justify any significant deviations from the protocol?
dDomain 3—Did the review authors explain their selection of the study designs for inclusion in the review?
eDomain 4—Did the review authors use a comprehensive literature search strategy?
fDomain 5—Did the review authors perform study selection in duplicate?
gDomain 6—Did the review authors perform data extraction in duplicate?
hDomain 7—Did the review authors provide a list of excluded studies and justify the exclusions?
iDomain 8—Did the review authors describe the included studies in adequate detail?
jDomain 9—Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review?
kDomain 10—Did the review authors report on the sources of funding for the studies included in the review?
lDomain 11—If meta-analysis was performed, did the review authors use appropriate methods for statistical combination of results?
mDomain 12—If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?
nDomain 13—Did the review authors account for RoB in individual studies when interpreting or discussing the results of the review?
oDomain 14—Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
pDomain 15—If they performed quantitative synthesis, did the review authors carry out an adequate investigation of publication bias (small-study bias) and discuss its likely impact on the results of the review?
qDomain 16—Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
rY: methodological requirements met.
sPY: methodological requirements partly met.
tN: methodological requirements not met.
uNMAC: no meta-analysis conducted.
vXX: studies rated as “critically low.”
wX: studies rated as “low.”
The identified interventions were mainly telephone- and videoconferencing-based methodologies, although they also included mobile apps and exchanges of medical test results (
Nonsignificant or inconclusive effects were found for other outcomes, such as mortality rates in circulatory and skin diseases (2/33, 6%; Chapter IX of ICD-10; 1/33, 3%; Chapter XII of ICD-10), the number of excisions in skin diseases (1/33, 3%; Chapter XII of ICD-10), and the number of hospital admissions (1/33, 3%; Chapter IX of ICD-10; 2/33, 6%; Chapter X of ICD-10).
A total of 5 studies evaluated the usability and acceptance of telemedicine by medical personnel and patients with multiple morbidities, as well as their satisfaction with it. High acceptability was primarily because of cost reduction compared with standard care, convenience, improved follow-up, adherence to planned treatment, and time-saving. A study reported telehealth’s cost-effectiveness, finding no statistically significant difference between standard care and telehealth care.
The barriers, facilitators, and main challenges associated with the use of telemedicine are reported in
List of barriers to and facilitators of the implementation of telemedicine across the 53 member states of the World Health Organization European Region and the main methodological limitations of the included studies.
Domain | Barriers | Facilitators |
Individual domain |
Shortcomings in technology-related knowledge and skill [ Resistance to change [ Patients’ age [ Lack of motivation or support [ Lack of confidence [ Challenges for individuals with disabilities [ Patients’ preference for face-to-face consultations [ Low satisfaction [ Language barriers [ Lack of acceptance [ Lack of usefulness [ Less personal contact through telemedicine [ Invasiveness [ High attrition rate [ |
Patient empowerment [ Participatory design [ Motivation and engagement [ Convenience [ Patients’ age [ Trust in technology [ Patients feel safe and empowered to discuss personal issues [ Physicians’ training and skills [ Satisfaction [ Adoption of digital culture [ Patients sharing their experiences [ |
Organizational domain |
The lack of integration into clinicians’ workflows [ Socioeconomic aspects (financial limitations) [ Lack of access to a helpful caregiver [ Sociocultural aspects [ Increase in workload [ Scheduling conflicts [ Lack of governance [ No appropriate Health Information Systems framework [ Organizational issues creating barriers to long-term implementation [ |
Reduction in response time [ Integration into clinicians’ workflows [ Decrease in workload [ Access to a helpful caregiver and insights into patient’s home environment [ Pandemic- created acceptance of technology [ Increased adherence [ Coordination between healthcare levels [ Telemedicine champions [ |
Clinical domain |
Limited scientific evidence [ Patient recruitment barriers and low rates of patient participation [ Difficulty in making clinical decisions [ Changes to consultation protocols [ Insufficient consultation time [ Loss of physical and visual assessment of symptoms [ |
Clinical and professional benefits [ Assessment after a specified period with service evaluations, including feedback from key stakeholders [ Multidisciplinary care team interventions [ The establishment of guidelines [ Reduction in the number of visits [ Frequent and multimodal communication between the health care professional and patient [ Greater safety and efficacy [ Better monitoring of cases [ |
Economic domain |
Elevated cost of implementation [ Lack of funding model [ Scarce economic benefits [ |
Financial framework [ Financial benefits [ Cost savings [ |
Technological domain |
Issues with internet access [ Technology needs further development [ Usability factors [ Issues with information technology and systems infrastructure [ Concerns about the reliability of the technology [ Issues surrounding infrastructure [ Conflicts of interoperability [ Difficulties in implementation and follow-up over a longer period [ Difficulties in readability [ Limited accessibility to electronic devices [ |
Usability and user satisfaction factors [ Internet availability [ Possibilities of technology development [ Accessibility support [ Adaptable and self-configurable [ |
Ethics, security, and privacy issues |
Private data security concerns or issues [ Regulatory concerns or issues [ Concerns about patient and staff safety [ Ethical aspects [ |
Legal framework [ |
This overview of systematic reviews shows a substantial and unprecedented collection of findings, as it included relevant data from >2239 primary studies, with >20,000 enrolled patients in total, within the WHO European Region. On the basis of data from observational studies, randomized trials, and economic evaluations from several European countries, the results showed a clear benefit of telemedicine interventions in the screening, diagnosis, management, treatment, and long-term follow-up of a range of clinically and epidemiologically significant diseases.
The telemedicine technological solutions addressed have proven to be valid, reliable, and accurate in providing faster access to expert advice, decreasing the number of unnecessary specialist referrals and in-office consultations, as well as increasing patient satisfaction experience. In a comprehensive literature review of studies from the United States, Canada, Brazil, and Australia, Liddy et al [
Most studies were concentrated in European countries (such as Germany, Italy, Spain, and the United Kingdom), while Eastern Europe (such as Albania, Croatia, and Ukraine) was not evaluated in any study. Countries developing digital health implementation must consider leadership, governance, strategy, investment, infrastructure, legislation, policy, compliance, workforce, services, and apps in their digital health strategies. The 2015 WHO Global Survey on eHealth [
Several studies reported barriers and facilitators that should be considered when planning and implementing telemedicine interventions. The individual domain was found to be the most influential in the use of telemedicine interventions, giving place to a greater number of barriers and facilitators. Shortcoming in technology-related knowledge and skills was the main challenge cited, followed by health care professionals’ resistance to procedural change [
In this overview, health care professionals had heavy workloads that seemed to influence resistance by overshadowing benefits [
Many clinical factors have been shown to influence the success of telemedicine in the WHO European Region, mainly the lack of definitive scientific evidence on its clinical contribution. Others included management, care delivery, and outcomes for a particular pathology. More research was considered necessary to provide evidence of both the clinical benefits of telemedicine and improved case monitoring [
Telemedicine resistance was reported as often being due to patients’ lack of confidence, lack of motivation or support, or sociocultural aspects [
However, patients with disabilities or older patients encountered difficulties when using telemedicine [
Access to funding and the high costs associated with implementation were economic barriers. Similarly, socioeconomic aspects emerged as obstacles to the functional integration of telemedicine apps. The implementation of a financial framework must be considered. However, outcomes were positive when technology was financially beneficial [
Internet access, technology development, usability, infrastructure, and interoperability were the main barriers to telemedicine intervention delivery, usability, and user satisfaction, while the availability of technology development was a mediator and facilitator [
The most common barriers associated with ethics, security, and privacy issues were privacy and data security and data-related regulatory concerns [
Finally, based on the solid effectiveness telemedicine technologies can deliver, policy makers and stakeholders should not only facilitate the implementation of these applications but also recognize and tackle drawbacks to maximize the likelihood of use success. Research is confronted with the challenge of producing such evidence, a prerequisite for the generalized adoption of telemedicine. Nevertheless, none of the included studies reached “moderate” or “high” reporting quality based on the AMSTAR 2 methodology. Studies have rarely reported items considered critical for assessing the methodological quality of systematic reviews. The existence of such reporting inappropriateness significantly affected our results, as the overall quality of the evidence was directly affected by the overall limited reporting quality of the included reviews. Notably, several other evidence makers have emphasized the occurrence of systematic reviews with poor or very poor reporting completeness [
A total of 5 databases were explored, focusing only on systematic reviews, meta-analyses, and bibliometric analyses, thus limiting the exhaustivity of the search. Furthermore, although we initially identified almost 1000 studies for screening, our overview found only 33 reviews meeting our inclusion and exclusion criteria. Consequently, the representativeness of our findings can be questioned considering the number of primarily identified records. However, despite using a highly sensitive search strategy, designed with collaboration between a field specialist and librarian, the “over retrieval” of records might not only associate with wrong selection of identifiers and keywords by systematic review authors but also reflect indexation issues. In addition, this could also reflect the absence of a reliable description of methods used throughout study execution (resulting in the exclusion of shortlisted records) and the scarcity of investigations on this particular subject of study. The information sources were peer-reviewed publications; therefore, some relevant information from other sources (eg, gray literature) may have been missed. Lower quality scores based on AMSTAR 2 may have reflected incomplete reports rather than unqualified review methods, such as some aspects not considered by the authors; for example, a lack of protocol registration or clarity on the characteristics of the included and excluded studies.
The results underscore the need to design dynamic approaches for telemedicine interventions in the WHO European Region. Potential barriers should be identified early in the process. The barriers and facilitators identified in this overview, as well as their influence, should be further investigated because only clear evidence will support the formulation of strategies to avoid resistance to change [
Protocol for this overview of systematic reviews published in PROSPERO (International Prospective Register of Systematic Reviews).
Search strategy.
Data extraction form.
A Measurement Tool to Assess Systematic Review 2 judgment for each included study.
Main characteristics of included reviews.
Summary of findings table for main outcomes.
Main findings from included reviews.
List of barriers, facilitators, limitations, and current challenges.
A Measurement Tool to Assess Systematic Review 2
International Classification of Diseases, 10th edition
Preferred Reporting Items for Systematic Reviews and Meta-analyses
International Prospective Register of Systematic Reviews
World Health Organization
DNO and NA-M are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this paper, and they do not necessarily represent the decisions, policies, or views of the World Health Organization.
None declared.