Değerli, M. and Özkan-Yıldırım, S. (2021). Telemedicine in the Current New Normal: Opportunities and Barriers. Enhanced Telemedicine and e-Health: Advanced IoT Enabled Soft Computing Framework – Springer. 10.1007/978-3-030-70111-6_2 - https://link.springer.com/chapter/10.1007/978-3-030-70111-6_2

1. Telemedicine in the Current New
Normal: Opportunities and Barriers
Mustafa Degerli and Sevgi Ozkan-Yildirim
Abstract The prominence and potentials of telemedicine as an appropriate and effi-
cient instrument for addressing, improving, and sustaining health becomes apparent
in the current new normal. A blended approach comprising both classical and
telemedicine practices is going to be the current new normal in healthcare. Therefore,
the authors explore telemedicine at a glance and the roles of Internet of Things (IoT)
and Artificial Intelligence (AI) in telemedicine. Furthermore, success factors, oppor-
tunities, and barriers concerning telemedicine implementations are discussed in the
chapter. In this context, theoretical and practical inferences are also presented. The
chapter discusses success factors and underlines the promising future empowered by
recent IoT and AI technologies. The current COVID-19 pandemic and characteris-
tics of Generation Y and Z are significant opportunities. Legislation and regulation
issues, inequalities regarding access, and infrastructure costs are seen as the main
barriers. The authors comprehensively reviewed the pertinent literature and applica-
tions and discussed the relevant issues by incorporating their views and judgments.
This chapter contributes to the body of knowledge concerning telemedicine practices
empowered with IoT and AI in the current new normal, success factors, opportuni-
ties, and barriers. This contribution improves the pertinent knowledge and is going to
be valuable for relevant researchers and policymakers in ensuring the effectiveness
and efficiency of telemedicine practices.
Keywords Telemedicine · New normal · Opportunity · Barrier · COVID-19 ·
IoT · AI
M. Degerli (B) · S. Ozkan-Yildirim
Graduate School of Informatics of the Middle East Technical University, 06800 Ankara, Turkey
e-mail: mustafa.degerli@metu.edu.tr
S. Ozkan-Yildirim
e-mail: sevgiozk@metu.edu.tr
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
G. Marques et al. (eds.), Enhanced Telemedicine and e-Health, Studies in Fuzziness and
Soft Computing 410, https://doi.org/10.1007/978-3-030-70111-6_2
27

2. 28 M. Degerli and S. Ozkan-Yildirim
1 Introduction
In consequence of notable medical informatics implementations, opportunities intro-
duced by the Internet, and telemedicine practices, we are going to have more oppor-
tune and superior healthcare [1]. Furthermore, Internet of Things (IoT) and arti-
ficial intelligence (AI) technologies do and are going to transform our contempo-
rary and upcoming healthcare views and experiences. The use of computers headed
for sharing, retrieving, and using medical information can be defined as medical
informatics. Besides, the delivery of health care services, clinical data, and even
medicaleducationoveradistancethroughtelecommunicationtechnologiesisdefined
as telemedicine. Moreover, it is known that telemedicine was there remarkably in
advance of the Internet [1].
Telemedicine practices are available for decades. For about eight decades,
there have been different forms and maturity levels of telemedicine practices [2].
Telemedicine is a concept that precisely means “healing at a distance.” Moreover,
there are more than 100 accepted clarifications and designations for the telemedicine
expression [3].
World Health Organization (WHO) makes a more inclusive and comprehensive
definition for telemedicine. The WHO describes telemedicine [4] as “the delivery of
healthcare services, where distance is a critical factor, by all health care professionals
using information and communication technologies for the exchange of valid infor-
mation for the diagnosis, treatment, and prevention of disease and injuries, research
and evaluation, and for the continuing education of healthcare providers, all in the
interests of advancing the health of individuals and their communities.”
It must be noted that telehealth is the broad nature of current applications,
including telemedicine. American Telemedicine Association prefers using the tele-
health term. In that respect, telehealth means technology-empowered health and
care management and delivery systems, extending both access and capacity. There
are fundamentally three stepladders for telehealth and telemedicine initiatives which
are “assess and define,” “develop and plan,” and “implement and monitor” [5].
In the 1990s, radio communications were utilized to deliver medical services in
Antarctica. However, the relevant technologies and the Internet made telemedicine
notably grow and improve [1]. Principal tools and technologies making telemedicine
possible are the telephones, the Internet, videoconferencing, IoT, and virtual
reality [6]. Generally, telemedicine is utilized to provide an amalgamation of
services. However, frequently characterized telemedicine services are teleradiology,
emergency and trauma telemedicine, telesurgery, and telepathology [7]. Besides,
telemedicine practices have two main types, either synchronous (real-time, live two-
way interaction, and virtual appointments) or asynchronous (store and forward, not
live, respond at a later time) [8]. In a noteworthy survey study, it was suggested that
the majority of telemedicine programs were run at national levels or lower [9].
Research showed the benefits of telemedicine practices concerning remarkable
improvements regarding travel time, travel costs, and environmental pollutants [10].
Additionally, the authors of [11] concluded that telemedicine practices are practical

3. Telemedicine in the Current New Normal … 29
and promising to a certain extent. There need to be further studied to understand
better and elaborate on pertinent success factors, opportunities, and barriers [11].
Besides, when we have a look at the major players’ moves [12], we see that
telemedicine is likely to turn out to be a wide-reaching tendency. The USA imple-
ments and utilizes telemedicine to eliminate the difficulties of extraordinary expen-
ditures and physical spaces of conventional medicine. Japan adopts and continues
telemedicine on account of geographical distances. Additionally, other countries
are exploring and implementing relevant practical developments in telemedicine
[12]. Moreover, regarding cost-benefit analyses, telemedicine operations proved their
advantages in certain places. In Singapore, producing comparable health effects, the
telemedicine-based screenings saved huge costs and provided a substantial financial
justification in the direction of magnifying telemedicine implementations [13].
It is relevant to primarily invest in e-health applications since they are to come up
with improvements regarding service provisions [14]. Implementation and utilization
of information and communication technologies to deliver healthcare, both clinical
and preventive, from a distance are defined as telemedicine, and implementation
and utilization of mobile devices for providing or supporting health care is defined
as mobile health (m-Health). To improve people’s access and the health system’s
coverage, telemedicine and m-Health play an essential role [14].
Sustainable development goals of several countries can be tracked with the help
of timeliness and dependability data which can be developed to empowering health
information systems [15]. The recent pandemic (COVID-19) showed that we need
to be proactive regarding crises. Therefore, we ought to put efforts into data and
health information systems in the contexts of attaining, sustaining, and improving
pertinent public health capabilities. Monitoring progress to ensure the proactivity
by way of instantaneous, dependable and meaningful inputs can be achieved thru
improved and integrated health information systems. We need to restructure and
realize robust health care systems with improved access to quality health services,
dropped financial costs, and strengthened health workforces [15].
As the borders of the countries become practically lousier, there may be going to
be other prominent infectious diseases and even pandemics to surface and dissem-
inate. Therefore, it is necessary to implement and improve telemedicine practices
to ensure opportune and economical care to pertinent people. The recent pandemic
as an advantage to invest in, disseminate, and improve telemedicine practices [16].
Moreover, there is a promising future for telemedicine regarding expected growth
rate and market valuation [17].
On the one hand, the main objective of this chapter is to discuss the current
dynamics to understand better success factors, opportunities, and barriers concerning
telemedicine in the current new normal. On the other hand, the main contribution of
this chapter is that it highlights the role of telemedicine in the current new normal,
improves the pertinent knowledge, and is going to be valuable for relevant researchers
and policymakers for taking actions to ensure the effectiveness and efficiency of
telemedicine practices.
This work provides a better understanding of relevant success factors and under-
lines the promising future enabled by IoT and AI. Moreover, this chapter discusses

4. 30 M. Degerli and S. Ozkan-Yildirim
the COVID-19 pandemic and characteristics of Generation Y and Z as significant
opportunities. Legislation and regulation issues, inequalities regarding access, and
infrastructure costs are noted as central obstructions.
The following parts of this chapter include information about success factors
(Sect. 2) and the roles of IoT and AI (Sect. 3). Besides, opportunities (Sect. 4) and
barriers (Sect. 5) regarding telemedicine are elaborated in the subsequent parts. The
chapter ends with the relevant discussions (Sect. 6) and conclusion (Sect. 7).
2 Success Factors
Telemedicine practices are multi-faceted. Consequently, there are several perspec-
tives and cases to be handled for the success of telemedicine. Countries might
establish and appoint nationwide organizations to synchronize initiatives regarding
telemedicine. These organizations must ensure appositeness to native perspectives,
lucrativeness, dependable assessments, and sufficient funds [3]. Additionally, the
main facilitators for telemedicine are itemized as governance, policy and strategy,
and scientific development and evaluation [3].
Integration, and telecommunications are the critical facets to be addressed for the
successful implementation of telemedicine. Additionally, addressing cultural phys-
iognomies and adherence to legal and privacy concerns are imperative for accom-
plishment [2]. Equitable access, timely reimbursement, and seeing telemedicine as
one of the relentless main actors are critical for the future of promising telemedicine.
In this context, groundwork, perseverance, and exercise will truly help [18].
Several open issues in the implementation of telemedicine practices are contextual
features, sustainability elements, cultural aspects, and legal issues [7]. Telemedicine
implementations are being increased to improve stakeholders’ satisfaction, to deliver
capable and excellent care, and to reduce costs. However, there are still opportunities
for improvements concerning regulatory, legal, and reimbursement issues [19].
Training for doctors and nurses, well-refined standards and instructions, and high-
quality infrastructures comprising proficient internet systems increase the acceptance
and adoption of telemedicine [20]. The future of telemedicine can be supported and
accomplished via ensuring equity regarding access and use [21].
The authors of [22, 23] concluded that specific dynamics influence people’s
telemedicine services usage intention. These are resistance to technology, perceived
risk, facilitating conditions, trust, perceived usefulness, social influence, technolog-
ical anxiety, and perceived ease of use. Besides, the policy is an instrumental tool to
address relevant main barriers in the context of telemedicine.
Additionally, preparation, sustained examination, and modification of standing
approaches are compulsory to improve and maintain the benefits and advantages of
telemedicine practices which is well-appreciated during the COVID-19 pandemic
[24]. The trust among stakeholders (medical professionals and patients) plays the
central role in the promising future of telemedicine. Notable improvements in distant

5. Telemedicine in the Current New Normal … 31
monitoring of patients, virtual consultations, and amenities for online prescriptions
are increasingly continuing in consequence of the COVID-19 pandemic [25].
The latest telemedicine implementations that will turn out to be usual in upcoming
rehearsals must be fine-tuned and evaluated. The safety, ethical, and law dimensions
of their use must be understood and addressed [26]. During the COVID-19 pandemic,
we have experienced speedy growth of telemedicine usage for health care visits.
Telemedicine transforms ordinary and conventional healthcare and decreases the
number of patients in emergency rooms [27].
Several attempts [28] to handle and ensure the privacy, security, and confiden-
tiality of the sensitive health data processed over the Internet in the context of health
information systems [28]. In [29], it was noted that normalization and regulariza-
tion of telemedicine procedures, platforms, encryption, and data storage are going
to be highly beneficial. Besides, focal contemplations concerning telemedicine prac-
tices were noted as the Internet requirement, legal facets, cybersecurity and data
regulations, incompetence for palpation or physical inspection, and psychological
influences.
The critical success factors extracted and particularized in this part must be firmly
taken into account by the responsible actors in the telemedicine applications and
implementations. The more success factors covered by the pertinent initiatives, the
more successful and beneficial the telemedicine efforts are to be.
3 Roles of IoT, AI, and Other Relevant Technologies
Currently, developments in information and communication technologies make
telemedicine more feasible and useful. The developments and applications in
IoT and AI fields are noteworthy for better and more convenient telemedicine
implementations and practices.
The connectivity of medical devices to ensure dependability and delivery of
health care is imperative and is possible through IoT technology. To accomplish IoT-
based dependable connectivity in health care networks, a dependable and full-bodied
IoT architecture is necessary. This sort of established architecture should incorpo-
rate medical devices, communication networks, storage, and analytics [30]. There
are notable IoT-enabled solutions. The study proposed in [31] aimed to enhance
the experiences of patients in the context of seeing current health parameters and
conditions.
AI combined with virtual health (telehealth/telemedicine) improve the diagnostic
accuracy of doctors, diminish relevant operational costs, lessen employee scarcities,
and take advantage of interactions [32]. With recent developments in the context
of AI concerning language acknowledgements and collaborating with human users,
telemedicine practices can be fairly improved [33]. AI practices such as chat-bots
and recommender systems allow patients to get refined and improved benefits in the
context of telemedicine. By using live talks and video calls along with AI-improved

6. 32 M. Degerli and S. Ozkan-Yildirim
frameworks, telemedicine becomes more convenient and satisfactory for the relevant
stakeholders [33].
The contributions of IoT implementations in the context of telemedicine are
being appreciated. The authors of [34] address novel issues related to IoT services.
The researchers modified certain domains (characteristics of the application, socio-
cultural, safety and ethical, and legal aspects) of the Model for Assessment of
Telemedicine, which originally has seven domains (health problem and characteris-
tics of the application, safety, clinical effectiveness, patient perspectives, economic
aspects, organizational aspects, socio-cultural, ethical and legal aspects).
Wearable sensors equipped with the connectivity of the IoT provide notable oppor-
tunities regarding health data and information. Big data and AI are to revolutionize
healthcare experiences and views [35]. Recent developments and applications in the
context of IoT and AI not only decrease certain costs but also improves depend-
ability and quality of health care practices [35]. The vital contributions of IoT adopt
telemedicine architectures [36]. Technology-empowered remote care comprising
innovative robots, sensors, and communication infrastructure are being enhanced
cost/benefit ratio for health care systems [37].
To support telemedicine practices, it critical to develop innovative health care
methods and technologies and utilize them for opportune and continuous observing
of patients [38]. IoT is empowered with biosensors attached to patients, sensors, a
database,acloudserver,andawebportal[38].Furthermore,thereareproposalstouse
IoT and big data analytics to promote prevention techniques, enhance dependability,
and to use AI and soft computing to improve diagnoses and minimize interruptions
[39].
IoT technologies and big data are being reached in the health care domains.
Furthermore, fog and cloud computing are critical to ensure and improve the acces-
sibility and availability of pertinent data and information. These technologies allow
governments to provide health care and satisfy requests as long as other vital
requirements are met [40].
Still, several open issues such as interoperability and data management regarding
telemedicine practices. Additionally, telemedicine is supportive owing to its cost-
effectiveness and usefulness for prevention, diagnosis, treatment, and rehabilitation.
Consequently, people and organizations have to make use of telemedicine tools and
technologies [41]. These advancements must improve the inspirations and visions
of all relevant stakeholders to plan, implement, and improve better telemedicine
practices for better health care for all.
4 Opportunities
In addition to the advancements in IoT, AI, and other relevant technologies, there are
supplementary opportunities for the successful implementation and dissemination
of telemedicine.

7. Telemedicine in the Current New Normal … 33
Individuals who were born between 1977 and 1994 are defined as Generation Y.
[42]. Those are the first generation to evaluate that technology is not a right, but a
given. They habitually use technology and the Internet. Over 90% of these population
groups are online.
Generation Z people are individuals who were born between 1995 and 2015 [42].
They use high-technology products and services and multiple technological tools to
access information. Their technology use and readiness are very high [42]. Therefore,
it can be predicted that recent generations are willing to use telemedicine services
to a greater extent. Their given readiness levels concerning tech-use will possibly
promote telemedicine implementations [42].
As the responsible governments and relevant regulatory bodies make invest-
ments concerning both the present and future trends, they can confidently assume
that Generation Y and Z will make use of their pertinent investments regarding
telemedicine practices. The given characteristics of these generation are to rationalize
such investments.
Besides, COVID-19 pandemic is a crucial opportunity to establish, improve, and
disseminate telemedicine practices [43]. It is necessary to address telemedicine,
assuming that it will be not a short-term but a permanent instance in the blended
health care system for the current new normal concentrating on policy and regulation.
This will not only help us manage the effects of recent pandemic more easily but
also construct a bright and robust future for new generations [43]. Telemedicine helps
relevant stakeholders to manage the adverse effects of pandemic scenarios [44].
Moreover, a study proposed by [45] identified that usage of telemedicine tools by
primary care pediatricians increased significantly throughout COVID-19 lockdown.
This must be treated as an opportunity to establish and maintain an integrated medical
approach [45]. Several studies are reporting the satisfaction with teleconsultations
and cost-effectiveness of remote care. Technological advances developed during the
COVID-19 pandemic to amplify the current situation regarding remote care practices
[46]. These opportunities must persuade and encourage all the relevant stakeholders
as these will notably increase the anticipated benefits of telemedicine practices.
5 Barriers
Several barriers concerning the implementation and dissemination of telemedicine
still exist. Nonetheless, these obstructions ought to be evaluated as opportunities and
prospects for potential improvements.
Telemedicine modifies most healthcare practices from hospitals to homes and
technology devices, which makes legitimately continuous monitoring possible.
These facts allow identifying barriers to manage health inequalities and transform
the health care needs and expectations of the current new normal [47]. Understanding
and elimination of such barriers cannot be ignored or postponed as this will bring
about the wasting of relevant time, money, and efforts.

8. 34 M. Degerli and S. Ozkan-Yildirim
The main barriers regarding telemedicine are listed as price, infrastructure, and
information requirements [3]. Additionally, the leading obstacles are deficiency of
funding, shortage of infrastructure, contending health system urgencies, and nonex-
istence of enough pertinent legislation or regulations [9]. In low-income regions,
m-Health capabilities and practices are not at expected phases of progress [48]. Reim-
bursement issues and economics facts are relevant barriers regarding the development
and dissemination of telemedicine [49].
A study proposed by [50] states several barriers on the subject of telemedicine
as technically challenged staff, resistance to change, cost, reimbursement, age of the
patient, and level of education of the patient, in order of the importance reported.
Such barriers can be coped with thorough training and change-management tech-
niques. In spite of telling several negatives, benefactors have largely progressive
attitudes toward telemedicine implementations [3]. Open issues can be epitomized
as technological difficulties, enlarged annoyance, and impersonality views. Devel-
oping countries face several barriers to telemedicine, such as high prices, immature
infrastructure, and the absence of practical know-how. On the other hand, developed
countries have legal concerns, challenging urgencies, and perceived expectations as
hurdles for telemedicine enactments [3].
In [51], it was determined that seniors with illnesses and patients having public
insurances are less probable to get telemedicine services, notwithstanding the
enlarged handling for telemedicine services, supplementary groundwork, and work-
force provisions. This shows an improvement area to be addressed in the scope of
sound telemedicine practices.
In the COVID-19 pandemic, although there are significant improvements in
telemedicine in the United States, there are certain notable inequalities and differ-
ences. Moreover, health management teams need to grasp and address such
fluctuations [52].
The obstacles and blockades listed and elaborated must be carefully analyzed
and addressed by the active contribution of all the relevant stakeholders such as
government bodies, investors, regulators, policymakers, pertinent managers, and
product/service developers and managers.
6 Discussion
The current body of knowledge reflects that there are technological advancements
of IoT and AI, success factors, opportunities, and barriers considering telemedicine
implementations and practices. Nevertheless, this field is still open for improvement.
As we experienced during the transition from classical banking to online banking,
telemedicine will help us experience a notable but pleasing shift from hospitals and
clinics to homes and mobile tools [53]. Similar to banking operations that we still
do only in banks, we are going to be experiencing certain medical operations thru
telemedicine and some still in hospitals and clinics. Consequently, a comprehensive
and blended (classical and telemedicine) healthcare system as long as we cope with

9. Telemedicine in the Current New Normal … 35
certain infrastructure and financing [53]. Telemedicine is firmly here and will be here
for a while, which is not shorter than a couple of decades.
COVID-19 has enforced nearly all healthcare organizations and entities to imple-
ment telemedicine operations and services swiftly. People need to accept that irre-
spective of current health care enterprises’ readiness levels. The current actuality
is that virtual care (telemedicine) has arrived and will be here for a couple of
decades until better and more inclusive tools and technologies are invented and imple-
mented [54]. As long as stakeholders experience and appreciate the true benefits and
contributions of telemedicine practices, the acceptance, adoption, and dissemination.
In the course of the COVID-19 pandemic and possible upcoming circumstances
concerning occurrences of infectious diseases, it is estimated that to guarantee the
mental health of the senior population, and telemedicine is an effective solution
[55]. Telemedicine solutions have been implemented in Italy during the COVID-19.
Therefore, the prominent role of telemedicine is an appropriate investment for today
and the future [56]. Policies must be revised to position and promote telemedicine as
an essential part of the whole healthcare system during COVID-19 [57]. Economic
and social activities are being firmly influenced due to COVID-19. Therefore, it
is logical to predict and address future economic and social issues to unexpected
epidemic outbreaks [58].
A blended approach is going to be the current new normal for health care services
and even medical training. Virtual platforms and other technological advance-
ments improve these experiences. Especially for the training, the technology-
empowered approach is going to be the current new normal augmented by the
COVID-19pandemic[59].Regardingcommunicablevirusdiseases,oneoftheessen-
tial stratagems to decrease and moderate the spread is physical distance methods.
Telemedicine plays a game-changing role while ensuring a safe distance. More-
over, telemedicine links the opportuneness, manageable expenses, and approacha-
bility of evidence and message. Consequently, it relevant to disseminate and improve
telemedicine operations [60].
It is necessary to ensure that there are no significant inequalities concerning access
to healthcare. Furthermore, it is necessary to appraise, comprehend, and address
potential fences to pertinent technologies and tools [61]. Experts and professionals
from different disciplines can create and optimize suggestions to ensure successful
implementation of telemedicine practices which can prevent health worker burnouts
and improve blended health care practices [62]. By appreciating the current realities
of the world, we must not disregard or undervalue the relevant efforts in this context.
In summary, recent developments of IoT and AI technologies in telemedicine
and healthcare notably transform and improve our present and upcoming views and
experiences [32, 33]. This is a notably growing field and careful considerations are
a must to establish and maintain satisfactions of stakeholders.

10. 36 M. Degerli and S. Ozkan-Yildirim
7 Conclusions
Telemedicine is promising due to its cost-effectiveness and usefulness in health care
settings. Moreover, telemedicine must not be characterized as a discrete or tempo-
rary endeavor, it rather must be appreciated as a meaningful and contributory part
of the blended and broader provisions family for healthcare purposes. This chapter
presented materials concerning telemedicine and the roles of applicable technologies
(IoT and AI). Furthermore, this chapter discussed dynamics, occasions, and obstruc-
tions for effective and efficient telemedicine implementations and practices. Theo-
retical and practical inferences were also drawn. This chapter improved the body of
knowledge regarding telemedicine practices in the current new normal. As the current
new normal emerge and form, this work provides the latest and comprehensive distil-
lation and discussion on relevant IoT and AI technologies, success factors, opportu-
nities, and barriers regarding telemedicine. These up-to-date and inclusive drawings
will help other researchers and policymakers to implement and improve telemedicine
practices. As a limitation, the current work does not address contextual parameters
concerning success factors, opportunities, and barriers. Contextual elements might
play a central role in effective and efficient telemedicine implementations. Future
studies might address this issue. Extracting and deliberating contextual consider-
ations possibly will improve the current understanding. Additionally, the authors
note that future studies should be conducted on the determination and improvement
of capability and maturity levels of organizations, countries, and regions regarding
telemedicine practices. In this context, the satisfaction of all stakeholders ought to be
continuously monitored and addressed. Besides, future works might also address how
recent IoT and AI technologies transform experiences and satisfactions of relevant
stakeholders such as patients, doctors, nurses, and caregivers.
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