TABLE 1.

Legal regulations, reimbursement and institutional guidelines, telemedicine modalities and software, and barriers for telemedicine, amongst 40 countries just prior to the COVID‐19 pandemic

	Legal regulations?	Reimbursement? Institutional guidelines?	Telemedicine modalities and software	Barriers
Europe
Ireland, UK	No	No, although patients might have private healthcare insurance	Phone calls	Potential capabilities to use other platforms but hindered by lack of experience by patient/carers.
Italy	Yes	Video‐consultation (eg, Besta Institute in Milan) reimbursed by Regional Health Service		Lack of patient training, lack of familiarity with technology. Request written informed consent prior to video‐consultation.
Israel	Yes. Local care requires Israeli license. With global private professional insurance coverage can provide care to most countries.	Yes, in general. Each HMO and insurance has different plans and reimbursement policy.	For telemedicine clinics: Video conferencing, Zoom, email (Foxit). During the pandemic, HMOs without telemedicine infrastructure used phone calls or WhatsApp.	Reimbursement issues. Large populations without smartphone access. Unrealistic expectations for operative and medical solutions.
Netherlands	No	Fully reimbursed	Phone calls. Zaurus for videoconferencing	Potential capabilities to use other platforms but hindered by lack of experience and knowledge by patient/carers. Privacy concerns. Only Zaurus is integrated on Epic
Spain	No	No, although patients might have private healthcare insurance	Phone calls. WhatsApp, Skype Professional	Potential capabilities to use other platforms but hindered by lack of experience by patient/carers.
Pan‐America
Argentina	No	Yes. Some private companies provide specific reimbursement	Phone calls, emails, video visits, Skype, WhatsApp, Zoom, Doctor teleconsultation, Hangouts, specific hospital telemedicine platform	Lack of experience for patient/carers, technical limitations
Canada	Yes. Any licensed physician can perform telemedicine visits. Some variations by province.	Yes. Generally well reimbursed in all provinces, except for Nova Scotia, for video visits and telephone visits.	Patients go to a telemedicine studio that has an experienced coordinator present in Alberta, Manitoba and Ontario. In Ontario, required to use Ontario Telemedicine Network systems platform. In Quebec, telephone or 3 telemedicine software options are allowed (REACTS which is integrated into EMR; Zoom, Microsoft Team).	Barriers vary by province. No major barriers, except for elderly patients using technology reported in Ontario and Quebec. Limited access, time, and poor reimbursement in Nova Scotia.
Chile	Yes	Yes	Video visits; teladoc	Technical limitation
Colombia	Yes	Yes	Phone calls, video visits, Cisco, Microsoft teams	Technical limitation, patient reluctance
Cuba	No	No	Phone calls, video visits. WhatsApp	Technology access and cost.
Dominican Republic	Unknown	No	Text messages	Technical limitations, lack of training
El Salvador	No	Yes	Video visits. Doxy.me	Lack of training
Guatemala	No	It may or may not be reimbursed.	Video visits, phone calls	Patient reluctance, privacy concerns
Honduras	No	No	Text messages	Technical limitations
Mexico	Yes	Yes	Video visits, Webex	Patient reluctance
Paraguay	Unknown	Yes	Video visits, WhatsApp	Technical limitation
Peru	Yes	No	Emails	Technical limitation
Puerto Rico	Yes. Certification that includes specific requirements and payment of a fee.	Limited, with poor reimbursement	Emails, phone calls	Technical limitations, lack of training, patient reluctance, limited internet access, poor reimbursement, cost
Uruguay	No	No	Phone calls, email, WhatsApp. but not regularly used. A few private healthcare services use other platforms.	Privacy concerns, lack of training, technical limitations.
USA	Yes. Varies by state	Yes, varies by state	Video visits, phone calls, emails, asynchronous consults	Reimbursement, technological issues, patient/health worker lack of training
Asia‐Oceania
Australia	Yes. National regulations. Medical indemnity recommends recording patient consent, potential confidentiality breach, and inability to fully examine the patient. https://www.medicalboard.gov.au/Codes‐Guidelines‐Policies/Technology‐based‐consultation‐guidelines.aspx; http://www.ehealth.acrrm.org.au/telehealth‐standards; https://www.racptelehealth.com.au/guidelines/; https://www.racp.edu.au/fellows/resources/rural‐health‐continuing‐education‐program/telehealth‐technology‐workshops/telehealth‐for‐patient‐care	Yes, reimbursement laws. Government rebate funding restricted to rural/ remote patients and nursing home residents, and matched face‐to‐face consults. Medicare requires specific conditions based on patient service and location (fee for service). For remote patients, the Medicare rebate is higher. For metropolitan area patients, bulk‐billing for private or public services. Reimbursement does not cover the cost of the service, but patients in public service do not pay out of pocket. Moving from fee for service reimbursement to activity based funding. Unable to bill in private practice for phone consultations, and most doctors consult with video. No preference for time split.	Phone calls, video conferences, emails, or GP telecare involvement for complex care. Mostly used for remote or nursing home patients. NSW: My virtual care, e‐health, PEXIP, approved by NSW health and academy of clinical innovation. VIC: Public system uses a proprietary platform produced for state government hospitals. For videoconference in private practice (Skype, Zoom)	Technology (patient and health care worker), limited examination; and start‐up operational issues, privacy/ safety issues, patient lack technology or telemedicine training. However, almost all patients have a phone (also back up for video).
China	Yes. Telemedicine only allowed in “Internet Hospital”, specifically approved for telemedicine		WeChat with text message and videoconference	Inadequate insurance coverage, limited number of “Internet Hospitals”
Japan	No. However telemedicine is used in compliance with laws and guidelines (Medical Practitioners' Act, Medical Care Law, Act on the Protection of Personal Information, and Security Guidelines for Medical Information Systems). Telemedicine was first recognized in 1997 by the Health Policy Bureau Director of the Ministry of Health and Welfare. National Telemedicine Guidelines were issued by the Ministry of Health, Labor and Welfare in 2018.	Yes. Since 2018, telemedicine is included in the universal insurance system. Under this system patients pay up to 30% of medical fees and the remainder 70% is paid by insurance. Medical institutions providing telemedicine can charge insurers up to 700 JPY/month. Medical institutions receive payment for medical services, called a ‘national fee schedule’ for permitted medical practices. Most Japanese hospitals still recommend office visits, but more clinics have adopted telemedicine.	One hospital in Tokyo (Juntendo University Hospital) uses telemedicine since 2017. The device is an iPad.	Cost of devices. Patients have a monthly contract with IBM (corroborating company) for iPAD and app. Limited examination, privacy concerns, patients lack devices.
New Zealand	No. (However regulations for established stroke telemedicine)	Yes, reimbursement is provided. Mainly public‐funding and salaried. Similar for private clinics. No specific guidelines and neurologists decide on case‐by‐case basis whether patient requires an office or virtual visit. The general principal is that it needs to be time‐critical and moderate risk of harm to the patient.	Combination of phone calls, emails, text messages, videoconferences. For Telestroke‐ Polycom. For consults‐ phone calls, Zoom, Facetime, WhatsApp.	Reduced quality of communication/exam, limited internet quality in some areas, privacy concerns (avoid by emailing patient from centralized work address), lack of training, challenging for older generation physicians using paper‐based system.
Pakistan	No	No	Personal email, cell phone or personal WhatsApp. Mostly used for remote care.	Lack of reimbursement results in reduced uptake
Saudi Arabia	Yes. Telemedicine Unit of Excellence (STUE) governs telemedicine malpractice insurance. Physicians need to have a license. Telemedicine covered by malpractice insurance.	No	App (Seha). Phone calls, video calls (in tertiary centers).	Cultural reasons, technical limitations, difficulty communicating with demented or elderly patients.
Singapore	Yes. National Telemedicine Guidelines issued by Ministry of Health in 2015. Since 2018, the National Neuroscience Institute implemented PDPA (Personal Data Protection Act) which is wide ranging with significant punishments (jail, hefty fines) for violators, which made research very difficult for using existing patient databases if prior consent has not been obtained.		Telephone and asynchronous consults via emails and text messaging have been in use since at least 2015 in 1 institution. Zoom accounts secured through a contract with the national telecommunications provider to ensure PDPA (data privacy standards).	Slow bandwidth, older population that should benefit most from telemedicine have technology limitations.
South Korea	Illegal as of April 2020. Only telemedicine for research used with approval.	No	Phone calls.	Lack of training for patients, caregivers, and doctors. Lack of visual input with phone calls.
Taiwan	Yes. Ministry of Health and Welfare determined rules for diagnosis and treatment by telecommunications.	Yes. Covered by National Health Insurance System if telemedicine conducted under the regulations of the rules. Innovative models: model testing payments for telemedicine in rural areas such as Integrated Health Care Delivery System. A Telehealth Center in the National Taiwan University Hospital uses five different cash payment methods based on different instrument combinations used.	The modalities and software used depend on patient and medical team convenience.	Technological and internet limitations, especially in geriatric patients and rural areas. Some interactions by face to face communication cannot be achieved by telemedicine.
Thailand	Yes. Legal regulations and requires patient consent.	No fee‐for‐service in government hospital. Recommend video and in‐office visits alternate to extend travel time.	Phone call first and then video call with Zoom or ‘LINE’ (messenger app similar to WhatsApp).	Lack of training for staff, elderly patients with technology limitations, performing medication changes.
Africa
Cameroon	No	No	Phone calls, emails, Skype, WhatsApp, other teleconferences	Lack of training, lack of motivation of doctors
Egypt	No	Private sector pay similar to physical visits	Phone calls, WhatsApp, Zoom, Facebook	Patient lack of interest and awareness, technical difficulties (internet connections, training).
Ethiopia	Yes.	Not reimbursed. Each Hospital/College has a department that oversees the telemedicine service. Healthcare providers can use department computers for free, but pay technical personnel.	Teleneurology teaching program with patient consent.	Lack of infrastructure for telemedicine, lack of dedicated teleneurology room, lack of sustainable internet service.
Ghana	No	No	Phone calls, consult with colleagues for radiology and investigations. WhatsApp	Quality of internet access, privacy/confidentiality, time constraints.
Morocco	No	Yes. Private clinics are reimbursed for telemedicine visits, but not government.	Phone calls, video visits, sending radiology and laboratory results via photos. WhatsApp	Technological limitations, specifically absence of a national telemedicine platform for public services
Nigeria	No	Yes. Individual private practitioners may charge a fee per consultation, although there is no recommendation provided by government institutions.	Phone calls, text (sms) messages, messaging apps (eg, WhatsApp), video conferences, video chat.	Limited technology capacity within hospitals, that is, internet bandwidth, lack of telemedicine infrastructure (computers with encrypted internet/intranet capacity and restricted access); lack of EMR or video‐visit function, cost of data for phones or WhatsApp video calls. Lack of EMR‐enabled prescriptions (some pharmacies will not sell medications without a prescription, and few pharmacies offer delivery). Low political will to drive and sustain a telemedicine hospital policy. From the patient perspective, limited access to technology (smart phones, tablets), poor internet connectivity in remote areas, lack of confidence with virtual visits, prohibitive cost of data, limited bandwidth in some areas.
South Africa	No. However recent recommendations from indemnity insurers (MPS, Health Professions Council)	Yes. Private sector has codes for telephone consults that are reimbursed by medical insurance companies according to their own rules. There are no codes for other forms of telemedicine.	Mostly phone consults, occasional video visits. Skype phone calls, emails, text messages	Consent and identification of patients. Mostly used for established patients for basic follow up (medication, basic DBS adjustments with patient controller at home)
Tanzania	Yes	No	Video conferences to peripheral/remote hospitals. WhatsApp, text messages.	Patient confidentiality, internet availability in remote areas or phones with WhatsApp. Lack of training and materials for video conferencing.
Tunisia	Yes	Yes. Private practitioners charge fees per consultation	Emails, text messages, video conferences. Platforms offered by private companies are used by private practitioners only.	Technological limitations
Zambia	Yes. Legal regulations in the main tertiary hospital in Lusaka.	No	Phone calls, emails, teleconferences, tele‐education with international lectures. Skype, WhatsApp	Lack of organization, lack of training, lack of motivation of doctors

EMT, electronic medical records; HMO, Health maintenance organization.