Table 2 Characteristics of the included studies*

Anjana et al. [18]

(July 2020)

India

Diabetes Technology and Therapeutics

Cross-sectional

Video, audio, SMS, apps, blogs, TV channels

● Poor telephone connection

● Telemedicine is hard for older patients

● Sensitization and training of providers

● Physical exam may not be appropriate for emergencies

● Not able to check blood pressure

● Telemedicine cannot provide one of the main prerequisites of a successful doctor-patient relationship, namely the human touch

● It will likely be a hybrid method going forward

Anthony Jnr et al. [19]

(June 2020)

Norway

Journal of Medical Systems

Systematic review

Telemedicine in general

● Need to provide training to physicians in using telemedicine

● Need to educate patients so that they can be aware of healthcare solutions

● Need to provide laws and upgrade technological infrastructure

● Guidelines to address ethical and legal barriers

● Patient consent

● Physician must notify if any third-party application is being used during a virtual consultation

● Setting of the meeting

● Lack of legislation in developing countries

● The physician must dress professionally, make eye contact with the patient, should try to be friendly and warm, make the patient comfortable

● Verify payment coverage

● Physical exam lacks needed elements of dynamic testing and diagnosis

● Some diagnoses may be difficult to perform virtually

● Preparation for an optimal consultation

● Older patients are least likely to use telemedicine

● Most developing countries may not be able to adopt telemedicine

● Connection problems

● Phone preference over video due to connection

● Funds and support to the healthcare systems to establish telemedicine

●Interstate licensure

Biswas et al. [38]

(June 2020)

India

Indian Journal of Palliative Care

Qualitative review

Phone, text messages, smartphone-based applications (WhatsApp, Skype)

● Major limitation of the use of these mobile-based applications is the safety of the patient's data

● Store-forward-delete system

● Lack of multidisciplinary approach over a single call

● Lack of satisfaction among patients

Caetano et al. [39]

(June 2020)

Brazil

Cadernos de Saúde Pública

Qualitative review

Telemedicine in general

● Rural populations have difficulties in accessing telemedicine services

● May not be appropriate for certain disorders that impair the patient's ability to use the technology

● Lack of regulation on the use of telemedicine

● Malpractice insurance applied to telemedicine

● Data confidentiality and security

● Establishment of protocols for managing laboratory tests, prescriptions, and scheduling

● No telehealth app can conclusively say whether the patient is infected and require testing in person

● Physical exam and ancillary diagnostic methods cannot be performed remotely

De Simone et al. [20]

(June 2020)

Italy

American Journal of Cardiovascular Disease

Qualitative review

Remote monitoring

● Low adherence and cooperation of patients

● Lack of a well-structured organization to manage clinical data

● Some issues concerning the device cannot be managed by remote monitoring

● Need for adequate organization through protocols and guidelines

● Data privacy

●Telemedicine services not uniformly reimbursed across Italy

● Informed consent

● Need for adequate training and updating in the use of systems for all personnel involved

● Not dedicated to the management of emergencies

●Periodic verification of the quality of data and diagnostic tools

Eichberg et al. [21]

(July 2020)

USA

Neurosurgery

Systematic review

Telemedicine in general

● Limited access to technology

● Verbal consent

● Providers should have a low threshold to convert to a telephone call

● Telemedicine neurological exam should be considered a screening exam

Ekong et al. [40]

(April 2020)

Nigeria

JMIR mHealth and uHealth

Qualitative review

Mobile positioning data

● Balance between deploying technology and maintaining data safety and patient privacy

● Informed consent

● Protect and safeguard individuals' data by law

● A third-party agreement should be formally signed between parties interfacing patient data to protect it

Gao et al. [43]

(May 2020)

China

Annals of Translational Medicine

Systematic review and meta-analysis

Telemedicine in general

● People were not followed up for outcomes and hotline data were not collected systematically

● If the operators do not have enough professional knowledge, they may provide wrong information or provide inappropriate medical advice, leading to a treatment delay or missed diagnoses

Jiménez-Rodríguez et al. [22]

(July 2020)

Spain

International Journal of

Environmental Research and Public Health

Qualitative review

Video consultations

● Lack of access to the required resources and technological difficulties for both professionals and patients (especially for the elderly)

● Some medical procedures are impossible

● Lack of technical skills among professionals and patients

● Need for training regarding both nontechnical and social-emotional skills

● Healthcare professionals were concerned that relationships with their patients may deteriorate

● Problems may arise among patients of advanced age, who may have reduced cognitive abilities

Kalu et al .[23]

(August 2020)

UK

Journal of Plastic, Reconstructive, and Aesthetic Surgery

Literature review

Online video consultation platforms and store-and-forward telemedicine

● Time lag and poor audio-visual quality due to insufficient bandwidth

● Transparency over the cost, privacy settings, and relative usage of different systems is limited

● Patient's identity should first be confirmed

● Consent should be gained and recorded

● Ensure that internet connection is secure

● Reassure patients that their privacy is to be respected

● Urgent or serious conditions where physical exam conducted over video consultations may not be appropriate

● It is contraindicated to use video consultations when the provider is unsure of the patient's capacity

Kaplan et al. [24]

(July 2020)

USA

International Journal of Medical Informatics

Literature review

Telemedicine in general

● Technological infrastructure

● Access problems (especially the elderly, disabled, or those who have compromised hearing, vision, manual dexterity…)

● Confidentiality, privacy, and security require more scrutiny

● Informed consent

● Ethical concerns

● Regulatory issues

● Doctor-patient relationship

● Patients and clinicians needed to learn how to select and use the technologies

● “a whole-system strategy” is suggested to embed telehealth into routine service and other information system functions

Khilnani et al .[25]

(June 2020)

USA

Journal of Information, Communication, and Ethics in Society

Case study

Telemedicine in general

● Older adults and those with economic disadvantage are also more likely to experience digital inequality

● Long-standing challenges that may impact eHealth adoption, including education, income, broadband access, information-seeking skills, and rural residence

● eHealth requires a battery of resources and skills on the part of patient and practitioner

● Older adult patients as more likely to struggle with skill deficits than younger patients

●Digitally disadvantaged are less likely to use eHealth services and thereby bear greater risks during the pandemic to meet ongoing medical care needs during the pandemic

Lawrence et al. [26]

(July 2020)

USA

Journal of General Internal Medicine

Case study

Virtual OSCE*

●Technical challenges can result in significant barriers to communication

●Adaptation of traditional components of the medical history and physical exam into the virtual space

● Providers may be unable to acquire basic information from remote patients

● The diagnostic accuracy of the physical exam maneuvers that are self-executed by patients is not yet known

● Residents may not be adequately prepared to provide high-quality care via telemedicine

● Needs for both technical proficiency and care delivery quality assurance at both trainee and practitioner levels

● Many traditionally employed nonverbal cues may be difficult to deploy and/or interpret, both by patients and providers, in a virtual context

● Medical associations recommend at least basic training in technical elements

Moss et al. [27]

(July 2020)

USA

Journal of Neuro-Ophthalmology

Cross-sectional

Synchronous (video visits) and asynchronous (Store-forward: remote interpretation of tests, second-opinion review, and e-consults) telehealth

● Data quality was selected as the most perceived barrier

● Video does not offer much more than phone for ophthalmology

● Variable reliability of live video technologies

● Video telemedicine visits may take extra time, resulting in decreased clinic volumes

● Patient dissatisfaction with billing

● Decreased precision and comprehensiveness of examination

● More physically draining than face-to-face to maintain engagement with patients

● Adoption was greatest in the younger respondents

● Provider dissatisfaction

● Privacy

● Protocols, strategies, and scheduling to optimize both efficiency and outcomes and train trainees and providers

Mostafa et al. [28]

(July 2020)

Egypt

Journal of Dermatological Treatment

Cross-sectional

Synchronous (video visits) and store-forward

● Lack of teledermatology consultations in the public hospital because of difficult internet connection

● No private insurance coverage for teledermatological services

● Face-to-face visits are still needed for some conditions like skin cancer check and its surgeries

● Showing one part of the body with a skin lesion can be misleading in diagnosis

● Simulated teledermatology visits may miss some diagnoses and complications of medications

● Legislation is needed

Murphy et al. [41]

(June 2020)

Ireland

Clinical Orthopedics and Related Research

Systematic Review

Virtual clinic model (video and telephone consultations)

● Administrative error regarding the appointment being issued

● Adverse outcomes encompass complications, further surgeries, deviations from protocols and re-referrals back to the clinic, inappropriate referrals, mismanagement/misdiagnosis, and poorly applied splinting in a specialist hand clinic

● Informed consent and agreement with the treatment plan

● There must be a way for the patient to contact the service if difficulties arise

Ohlstein et al. [29]

(August 2020)

USA

The Laryngoscope

Cross-sectional study

Video consultations

● An association between age, technical difficulties, and hesitation in the adoption of virtual medicine

●Increased complaints of logistic and technical difficulties, especially in older populations

● The average age of those declining visits due to technical difficulties was 80 years

● Limitation of virtual otoscopic evaluations

● Lack of physical exam

● Otology patients were less likely to accept a telehealth visit

Puro et al .[30]

(June 2020)

USA

The Journal of Rural Health

Cross-sectional study

Telehealth and eICU capabilities

● Internet connectivity

● Technological restrictions

●State reimbursement, regulatory, insurance restrictions play a role in limiting adoptions

● Clinician acceptance barriers, in general, can pose a threat to successful telehealth implementation

● Geographic restrictions

●The concentrations of rural hospitals possessing these capabilities varied widely by state

● Coastal areas lacked to a great extent the capability to provide e-services in rural areas

Rametta et al. [31]

(June 2020)

USA

Neurology

Qualitative review

Audio-visual telemedicine encounters and scheduled telephone encounters using phones

● The technical quality was impaired, and the most frequent single causes affecting quality were poor audio, poor video, and interruption of the encounter

● Patients who lacked access to a smartphone or computer application required to enable telemedicine encounters were scheduled for structured (audio-only) telephone encounters

● Access to telemedicine encounters compared to telephone encounters was lower in racial and ethnic minority groups

Serper et al .[32]

(August 2020)

USA

Hepatology

Case study

Video consultations

●Technical issues were faced due to software upgrades, resulting in one delayed visit on the same day and one visit requiring rescheduling

● Payer reimbursement policies are highly variable, and most payers do not provide telemedicine parity with in-person visits

● Regulatory and financial barriers

Sorensen et al. [33]

(June 2020)

USA

Annals of Surgery

Cross-sectional study

Video consultation and phone calls

● Preference for in-person versus virtual surgical consultation reflected access to care, with a preference for telemedicine decreasing from 72 to 33% when COVID-related social distancing ends

● Telemedicine visits are less appropriate for surgical consultation

●Concerns about technology related to telemedicine: both functionality and data security

● Practical considerations around reimbursement for services and health care utilization will need to be resolved

● Physical exam and establishing trust and comfort could best be done in person

● Initiating/completing a diagnostic workup would also be better in person

● Concern for the depersonalization of care with telemedicine and the ability to establish rapport virtually

Tashkandi et al. [34]

(June 2020)

Saudi Arabia

Journal of Medical Internet Research

Qualitative cross-sectional study

Virtual visits

● Lack of physical exam

● Patients’ awareness and access

● IT support and resources were not available

● Lack of physical attendance of the patient

● Lack of a direct doctor-patient encounter

● Medicolegal aspects and privacy

● Only 36.0% will continue virtual management after the pandemic

Tenforde et al. [35]

(May 2020)

USA

PM&R: The Journal of Injury, Function and Rehabilitation

Cross-sectional study

Audiovisual consults

● Limitations in technology and ability to perform a physical examination

● Insurance payment models

● Access to telehealth technology

● Physician knowledge

● Malpractice insurance

● Concern regarding the development of patient rapport

● Telehealth visits worked best for follow-up encounters where a more limited physical examination was adequate for management recommendations

● Barriers in healthcare delivery

● Systemic barriers to patients with sensory disabilities, cognitive deficits, those challenged in using technology or without necessary electronic devices, as well as those who require the use of a medical interpreter

Triantafillou et al. [36]

(July 2020)

USA

Otolaryngology-Head and Neck Surgery

Qualitative cross-sectional

Video-based consultations

● Technical challenges, including issues with connectivity and audio

● Various aspects of the doctor-patient relationship were studied, including the video aspect, intimacy of telemedicine, the element of ‘‘human touch,’’ and the physical examination

● Anxiety about the logistics of the visit and skepticism regarding telemedicine

● Patients preferred in-person visits and did not think that telemedicine visits could replace in-person ones

● Remote visits hampered the doctor-patient relationship

● The physician could not perform flexible laryngoscopy

Wamsley et al. [42]

(July 2020)

USA

Aesthetic Surgery Journal

Case Study

Telephone and Video consultations

● Telehealth utilization is lower among 80 + years individuals this may be due to unfamiliarity and lack of comfort with electronic devices and cognitive decline

● Reasons for the decline of telehealth services included lack of comfort and familiarity with the technology, concerns over privacy and confidentiality, and the preference to schedule an in-person office visit when available

● The legal system currently lags the available technology

● Lack of control over the collection, utilization, and sharing of data over the telehealth systems

● Informed consent

● Malpractice

● The practitioner-patient relationship will inevitably be affected

● The physical nature of many conventional clinical tests is simply impossible to perform

Yoon et al. [37]

(June 2020)

USA

International Journal of Spine Surgery,

Qualitative review

Video consultations

● The loss of direct physical examination

● The potential for not detecting subtle neurologic deficits

● Technical software or hardware difficulties

● By no means can telemedicine replace all in-person visits

● There is no standard method to perform a spine examination accurately, reliably, and consistently through telemedicine

● Data privacy is a huge concern

● The breach of personal health information can occur despite multiple layers of security

● These technical shortfalls may be ameliorated by improving network speed, accessibility, and upgrading software usability

Holtz et al. [11]

(July 2020)

USA

Telemedicine journal and e-health

Cross-sectional study

Telemedicine in general

● New users of telemedicine perceived more problems hearing the provider through telemedicine more than past users

● Difficulty hearing and seeing the health care provider over the computer/mobile system

● Privacy

● When an unexperienced provider utilizes telemedicine, they might not have the same technical expertise and experience communicating over technology as other telemedicine-only providers

● The health care provider spent little time taking medical history

● Less communication with the provider

● Worries about the accuracy of the information from the telemedicine health care provider

● Worries about the continuity of care