A comprehensive checklist was developed by closely aligning the findings from the review of relevant literature on telemedicine practice with the outcomes derived from the Delphi analysis. Following the structure of the Delphi questionnaire, the checklist included factors that facilitate and hinder the implementation of telemedicine. The SWOT analysis is presented in Table 1 (5, 6, 9).

Substantial evidence now supports the strengths and opportunities associated with telemedicine. Telemedicine has been shown to reduce consultation time (10), eliminate unnecessary travel for both patients and healthcare professionals (11), facilitate healthcare delivery in remote areas (12), and contribute to cost savings (13). Integrating telemedicine into a well-coordinated care process has been demonstrated to improve health outcomes (14). In fact, patient-provider collaboration (“co-care”) and patient self-management (“self-care”) are not only an expression of patient-centeredness, they will also increase the cost-effectiveness of healthcare due to improved clinical outcomes and increased patient responsibilities and inputs.

Conversely, there is evidence highlighting the weaknesses and risks associated with telemedicine. Although the process of digitalization impacts approximately 90% of the healthcare sector, digital health extends beyond technological implementation and involves profound substantial cultural and social implications. It fundamentally alters the role of physicians and patients and the dynamics of their relationship. Patients now play an active role in the treatment process, fostering a patient-centric model where technology serves as a key tool for encouraging patient engagement and responsibility (15).

It is crucial to meticulously examine ethical issues in the delivery of telemedicine to ensure the confidentiality and security of patient information, address inefficiencies among physicians, and improve the overall quality of healthcare services. Ethical concerns related to telemedicine can be viewed from various perspectives, including technology, physician-patient relationships, data confidentiality and security, informed consent, and satisfaction of patients and their families with telemedicine services. Prioritizing ethical considerations in telemedicine is an essential aspect of ensuring the delivery of high-quality healthcare services (16, 17).

The physical examination performed by healthcare professionals, including medical doctors, has been a fundamental aspect of medical practice for centuries. This examination, involving sensory engagement, has been instrumental in enabling healthcare practitioners to assess the health status of their patients (18). Notably, research indicates that patients place high value on the physical examination not only for its perceived higher accuracy but also for its emotional attributes (19). Moreover, the diagnostic process is not solely based on a single episode of rational decision-making, instead, it involves continuous monitoring of the patient’s condition and subsequent adjustment of care (20). Telemedicine should be recognized as an alternative form of healthcare delivery that is distinct from traditional medical care. In this context, the interaction between technology and the local context holds significant importance (21).

In addition to the information presented in Table 1, there remains unexplored territory regarding the ethical dimensions of telemedicine. These include aspects related to the physician-patient relationship, data confidentiality and security, informed consent, and the satisfaction of both patients and caregivers.

Following the completion of the process, four scenarios were generated, considering various potential future developments.

During the SARS-CoV-2 coronavirus pandemic, telemedicine emerged as a natural and necessary solution to address global emergency healthcare needs (22–24). Telemedicine consultations, or teleconsultations (25–28), are valuable in diverse clinical scenarios, allowing for accurate differential diagnoses and appropriate treatment recommendations (29–31). Importantly, after such consultations, patients not only received medical advice but also benefited from e-prescriptions, e-referrals for further examinations (such as laboratory tests), and e-sick notes. This procedure significantly reduces the risk of infection for patients who would otherwise have to physically visit a healthcare center and wait in traditional waiting rooms for their appointments with doctors.

Examples of use-cases of evidence-based telemedicine applications in Internal Medicine include:

The process of digitalization requires digital health literacy, which is an extension of health literacy and uses an equivalent operational definition in the context of technology. Digital health literacy, or electronic health (e-health) literacy, focuses on an individual’s ability to access, understand, and engage with digital healthcare materials and technologies to contribute to quality of life (38). Technology solutions have the potential to promote health literacy. However, to be effective, health technology solutions must focus on functional and critical skills rather than building literacy and numeracy skills. Effective examples of functional and critical skills include operating the healthcare system, communicating with healthcare professionals, and sharing decision-making (37).

Stakeholders involved in telemedicine should also have adequate digital literacy and e-health literacy. Specifically, healthcare professionals need to develop specific competencies to effectively apply telemedicine to their routine practices. As digital health resources become more prevalent, the individual ability to interact with technology is to be assessed to ensure that the technology is appropriate for the intended audience (38–40).

Training of health care professionals should include (1):

At a society level, educational campaigns should promote and support increased access to digital literacy and infrastructure necessary for successful eHealth solutions (43).

Interprofessional medical care or network medicine across healthcare settings can benefit from the development of eHealth competencies in physicians (44), advanced practice nurses, specialty nurses, physician assistants, and additional affiliated health professionals.

However, healthcare professionals also need to evaluate additional factors in telemedicine application, such as deployment costs at the point of care and high-speed Internet access for patients. Digital health inequity is defined as a systemic inequality that results from infrastructure disparities between countries and regions (45–49).

To establish common definitions for the different typologies of telemedicine, Internal Medicine specialist physicians may distinguish them according to the methods of interaction employed, as following shown:

The methodologies in patient-physician interactions in telemedicine can be categorized into two main modalities: synchronous live and asynchronous interactions (32). However, academic studies comparing outcomes of asynchronous and synchronous care are still limited (50, 51).

In the European region, harmonized guidance on the usage of telemedicine among specialist physicians is lacking. A telemedicine sharing protocol for European specialists does not exist at the time of this writing. Numerous countries, concentrated in particular in Southern Europe, had insufficient operational and legislative tools to rapidly introduce telemedicine services in outpatient specialist care (68).

Telemedicine can significantly reduce readmissions when monitoring patients with chronic diseases (60). However, the inability to conduct a complete physical examination during a teleconsultation is potentially a major barrier to the development of remote consultation services (69, 70). The application of telemedicine devices, such as e-stethoscopes or video cameras, and artificial intelligence algorithms will increase the possibilities of telemedicine in the future. Such development leverages existing experience from fields such as teledermatology, which has successfully integrated digitally enabled clinical examination of the skin (71). Additionally, expressions of empathy can support trust during a patient-physician encounter, and the frontier of digital empathy may be paramount in sustaining such constructs in telemedicine visits (72).

A hybrid model could be considered for long-term care in both primary care and specialist care and would also need evaluation over the long term. This model allows alternating in-person appointments at the health facilities and teleconsultation appointments (73, 74). A similar model employing telephone follow-up visits has been used in many clinical trial protocols, significantly reducing the number of health center visits and hospitalizations (71).

Health Information Technologies (HIT) have the potential to improve the quality of interprofessional and team care coordination, benefiting patients as well as healthcare. Specifically, HIT can support shared decision-making, access to care information (such as open notes) and care services (such as synchronous remote telehealth services), and health education. HIT enhances team care similar to that of another member of the healthcare team, automating routine or tedious tasks so that human agents can focus on providing humanized healthcare. Beyond routine tasks such as scheduling or administrative aspects of care, HIT can further evolve to enable previously unfeasible models of care, such as hospital-at-home care or intensive remote monitoring in selected conditions. Augmented intelligence provides humans with actionable data and information, enhancing human intelligence and decision-making (15).

When planning for novel care models, it is essential to engage HIT developers and clinical informaticians with healthcare training, such as physicians, pharmacists, nurses, and other relevant professionals. In addition, the involvement in the design process of patients and their advocates can also be beneficial. This inclusive approach guarantees the ethical and equitable design of healthcare systems (92, 93).

Despite growing political support for telemedicine systems, their standardization within clinical practice has been hampered by concerns about their effectiveness, cost-effectiveness, and user acceptance (70, 94).

Telemedicine makes it possible to provide healthcare services regardless of geographical constraints. Telemedicine and its associated technologies enable us to switch from the movement of individuals to the flow of information (16).

Telemedicine possesses several positive attributes, such as reduced entry barriers, established health services, integration of primary and specialty care, delivery of care through smart devices in patient homes, patient preference, and convenience. These factors are particularly significant for fragile and vulnerable populations (95). In addition, telemedicine favors the integration of local health systems and hospitals by facilitating communication between internal specialists and general practitioners.

Telemedicine offers benefits in various cases by easing the load on healthcare infrastructure and personnel and ensuring timely and adequate care to patients who face mobility issues and are geographically distant from appropriate medical facilities (96). However, additional telemedicine dimensions requiring evaluation concern the ethical and social aspects of telemedicine such as the patient-physician relationship, data confidentiality and security, informed consent, and patient and caregiver satisfaction. Most suitable telemedicine devices should be carefully selected, procured, and connected with medical professionals for evaluation. While technology has the potential to improve patient access and health outcomes, not all technological innovations can achieve their intended purposes (97, 98). Thus, the investigation of different telemedicine technologies is necessary to prioritize the ones that are efficient and impactful. The Health Technology Assessment (HTA) process (99–103) plays a crucial role in evaluating the adequacy of telemedicine technologies. The HTA carries out a systematic assessment to determine the suitability and effectiveness of various telemedicine approaches (99).

Various types of regulations are touched upon in the jurisdiction of European Law, including primary and secondary regulations, as well as soft law in the form of guidelines and communications issued by the European Commission. With reference to primary law, the Treaty on the Functioning of the European Union (TFEU) plays a central role (104). Article 56 of the TFEU prohibits any restrictions on the freedom to provide services, while Article 57 of the TFEU defines the very notion of service. Medical care falls within the scope of the Treaty as it regulates the free movement of services. As for secondary law, Regulation (EU) 2016/679 and Directive 95/46/EC, known as General Data Protection Regulation (GDPR), are the main reference regulations. Regulation (EU) 2016/679 concerns the protection of personal data and their free movement, while Directive 95/46/EC pertains to health data and genetic data and emphasizes the rights of patients in cross-border healthcare (105, 106). Furthermore, this Directive aims to provide clear regulation for the phenomenon known as “medical tourism.”

Recitals 19 and 20 of the preambles already impose an obligation to inform patients receiving cross-border healthcare about the applicable rules. Upon request, healthcare professionals are also required to provide specific information about the healthcare benefits they offer and the treatment options available. Directive 2011/24/EU further clarifies the information obligations of healthcare professionals under Article 4 (107). According to this directive, healthcare professionals should offer relevant information to support individual patients in making informed decisions, including details on treatment options, availability, quality, and safety of healthcare services, as well as prices for specific benefits. At the same time, Article 4 of Directive 2011/24/EU requires Member States to ensure that healthcare professionals on their territory apply the same fee structure for patients from other Member States as for domestic patients in comparable medical situations. If no comparable prices exist for domestic patients, healthcare professionals should charge a price based on objective and non-discriminatory criteria. This approach is explained by the need to establish standards for telemedicine services to preserve patient’s and medical personnel’s safety and protection.

In summary, this approach is consistent with solutions planned at the EU level. In 2018, the European Commission announced ongoing efforts to provide citizens with secure access to high-quality digital health and welfare services. A communication on the digital transformation of health and social care has been published, outlining three key areas for further action. The first area focuses on actions to ensure secure access and sharing of health data for citizens. The European Commission plans to establish an e-health digital service infrastructure that allows for the exchange of e-prescriptions and patient data between healthcare professionals in order to facilitate access to cross-border healthcare. Development is underway to establish a European electronic health record exchange format accessible to all EU citizens. The second area stresses the importance of better data for research, disease prevention, and personalized healthcare. The third area highlights the use of digital tools to empower citizens and provide person-centered care. Digital services should be scaled up to enable individuals to manage their health effectively. Consequently, the proposed telemedicine standards align perfectly with these adopted assumptions (108).

Specific limitations may prevent the adoption, implementation, and expansion of telemedicine and its supporting technologies. Extensive training is required to familiarize patients with video teleconsultations and the use of assistive technologies. Physicians also require targeted technical, clinical, and communication training tailored to their specific subspecialty needs. Limited access to broadband and internet facilities is a significant barrier, especially in remote areas and under-resourced settings (11). Reliable broadband access is essential for telemedicine services, but its quality is often inadequate in rural clinics and for patients residing in such areas.

Legal restrictions and ambiguity in permissible practices in telemedicine have created a cautious attitude among telemedicine professionals. In addition, certain medical conditions are not adequately addressed within existing healthcare legislation. The pricing structure for virtual consultations and video surveillance in hospitals remains unclear, leaving questions as to whether they will be fully reimbursed or classified as shorter visits at a discounted rate. Physician licensing and telemedicine infrastructures pose additional concerns, especially in resource-scarce settings.

Telemedicine cannot replace many essential medical procedures and is not universally accessible to all patients. Various patient groups may be further marginalized by healthcare technologies, for example, people whose language(s) are not concordant with those of the telemedicine clinician, people with disabilities (109, 110), may be excluded or face challenges in using telemedicine. The effectiveness of telemedicine depends on its successful integration into the existing hospital and healthcare system within a local context, adequate preparation and training of medical professionals, and patient awareness and acceptance of telemedicine tools.

To speculate on the future of telemedicine, various future scenarios emerge from the EFIM Telemedicine Working Group’s overview of academic literature (111). The most probable scenario implies the emergence of a hybrid system where telemedicine augments traditional healthcare services, enhancing efficiency and adaptability to evolving patient care needs in a local context. The goals and measured outcomes of such hybrid models would be to ensure high-quality, accessible, equitable, efficient care, which holds the entire pathway of care services to a similar standard of health outcomes, regardless of the level of technology integration into healthcare services.

Four possible scenarios are expected to emerge within the hybrid system by considering the evolving behavior of different stakeholders.

Built on the scenario analysis, the EFIM Working Group proposes the following recommendations for telemedicine implementation: