INTERACTIVE JOURNAL OF MEDICAL RESEARCH

Feng et al

Original Paper

Telemedicine Research Trends in 2001-2022 and Research
Cooperation Between China and Other Countries Before and Afterthe COVID-19 Pandemic: Bibliometric Analysis
Hanlin Feng1, MSc; Karin Kurata2, MSc; Jianfei Cao3, PhD; Kageyama Itsuki4, PhD; Makoto Niwa5, PhD; Atsushi
Aoyama1, PhD; Kota Kodama4, PhD, RPh
1

Graduate School of Technology Management, Ritsumeikan University, Ibaraki, Japan

2

Course of Information Systems Engineering, National Institute of Technology, Tsuruoka College, Tsuruoka, Japan

3

MergeSystem Inc, Fukuoka, Japan

4

Medical Data Science Lab, Hoshi University, Tokyo, Japan

5

Graduate School of Technology, Ritsumeikan University, Ibaraki, Japan

Corresponding Author:
Kota Kodama, PhD, RPh
Medical Data Science Lab
Hoshi University
2-4-41 Ebara
Shinagawa-Ku
Tokyo, 142-8501
Japan
Phone: 81 337861011
Email: kodama.kota@hoshi.ac.jp

Abstract
Background: Advancements in technology have overcome geographical barriers, making telemedicine, which offers remote
emergency services, healthcare, and medication guidance, increasingly popular. COVID-19 restrictions amplified its global
importance by bridging distances.
Objective: This study aimed to analyze Chinese and global literature data, present new global telemedicine research trends,
and clarify the development potential, collaborations, and deficiencies in China's telemedicine research.
Methods: We conducted bibliometrics and network analyses on relevant documents from the Web of Science database from2001 to 2022. Data collection was completed on October 30, 2023. Considering COVID-19’s impact, 2020 was used as a baseline,
dividing the data into 2 periods: 2001-2019 and 2020-2022. The development potential was determined based on publication
trends. An international coauthorship network analysis identified collaboration statuses and potential. Co-occurrence analysis
was conducted for China and the world.
Results: We identified 25,333 telemedicine-related research papers published between 2001 and 2022, with a substantial increaseduring the COVID-19 period (2020-2022), particularly in China (1.93-fold increase), moving its global publication rank fromtenth to sixth. The United States, the United Kingdom, and Australia contributed 62.96% of the literature, far ahead of China’s
3.90%. Globally, telemedicine research increased significantly post-2020. Between 2001 and 2019, the United States and Australia
were central in coauthor networks; post-2020, the United States remained the largest node. Network hubs included the UnitedStates, the United Kingdom, Australia, and Canada. Keyword co-occurrence analysis revealed 5 global clusters from 2001 to
2019 (system technology, health care applications, mobile health, mental health, and electronic health) and 2020 to 2022
(COVID-19, children’s mental health, artificial intelligence, digital health, and rehabilitation of middle-aged and older adults).
In China, the research trends aligned with global patterns, with rapid growth post-2020. From 2001 to 2019, China cooperated
closely with Indonesia, India, Japan, Taiwan, and South Korea. From 2020 to 2022, cooperation expanded to Japan, Singapore,
Malaysia, and South Korea, as well as Saudi Arabia, Egypt, South Africa, Ghana, Lebanon, and other African and Middle Easterncountries. Chinese keyword co-occurrence analysis showed focus areas in system technology, health care applications, mobile
health, big data analysis, and electronic health (2001-2019) and COVID-19, artificial intelligence, digital health, and mental

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health (2020-2022). Although psychology research increased, studies on children’s mental health and middle-aged and older
adults’ rehabilitation were limited.
Conclusions: We identified the latest trends in telemedicine research, demonstrating its significant potential in China andproviding directions for future development and collaborations in telemedicine research.
(Interact J Med Res 2024;13:e40801) doi: 10.2196/40801
KEYWORDS
telemedicine; telehealth; coauthorship analysis; network analysis; bibliometric analysis; co-occurrence analysis

Introduction
Development of personal computers, communication
technology, and professional medical technology have led to
improvements in medical-related technology. Telemedicine
provides health care solutions in difficult-to-access areas. Healthcare organizations worldwide are becoming increasinglyinterested in implementing telemedicine technologies to improve
care and services [1]. Telemedicine is the delivery of healthcare and the exchange of health care information acrossdistances [2]. Telemedicine dates back to the mid-to-late 19th
century [2]. Furthermore, one of the earliest reports was
published in the early 20th century, with electrocardiogram datatransmitted over telephone lines. Currently known telemedicine
was formed in the 1920s to 1960s and was largely driven bymilitary and space technology sectors [2,3]. Moreover, only a
few individuals used off-the-shelf commercial equipment at thetime [4]. Examples of early telemedicine technology include
the use of televisions to facilitate consultations between
specialists in institutions and general practitioners in state
psychiatric hospitals [5]. Furthermore, it was also used toprovide expert medical guidance to airport medical centers frommajor teaching hospitals [6]. Continued development ofinternet-based audio and video communication technologies,
coupled with high demand for a convenient and efficient way
to receive care, enabled the development of telemedicine
applications [7]. With the rapid development of telemedicine
equipment and information communication technology,
telemedicine has developed rapidly and is used widely aroundthe world as a new mode of medical service [8,9]. In particular,
in China, telemedicine has been used as a crucial method by
the government to address the inequality of medical resources
between urban and rural areas [10]. The development oftelemedicine in China began in the 1980s. In 1986, theGuangzhou Ocean Shipping Company conducted a cross-sea
consultation for emergency patients on the oceangoing freighter
through telegraph, which was the earliest telemedicine activity
in China. In 1997, the Jinwei Medical Network in China wasofficially opened to provide remote, off-site, real-time, anddynamic live television consultations for patients with severe
illness. Subsequently, the medical institutions at all levels in
China began to explore and develop telemedicine. After yearsof effort, the development of telemedicine entered its goldenage. In 2017, 22 provinces in China established telemedicine
platforms covering 13,000 medical institutions, providing
teleconsultation, telediagnosis, and remote medical education[10].

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Travel was restricted owing to the COVID-19 pandemic startingin 2019 [11]. However, telemedicine is attracting attention
worldwide as it can overcome the problems caused by distances.
Telemedicine was increasingly used during the COVID-19
pandemic as a tool to reduce the spread of potential diseases
and fill gaps in health care services. Telemedicine emerged asa crucial tool during the COVID-19 pandemic, playing asignificant role in health care delivery and management. The
global health crisis prompted by the pandemic accelerated theadoption of telemedicine, highlighting its importance in ensuring
the continuity of medical services and reducing the risk ofinfection transmission. Studies have shown that telemedicine
was particularly valuable in providing care to patients while
minimizing physical contact, especially in situations wherein-person visits may have posed health risks due to the highly
contagious nature of the virus [12]. Telemedicine could serve
as a public health tool to reduce hospital burden, provide
continuity of care, and support disease surveillance andmanagement. Particularly, China took protective measures andrelied on telemedicine as a response to the pandemic [13,14].
Zhang and Ma [15] quantified the differences between online
and face-to-face delivery of health services during the
COVID-19 pandemic through a discontinuous time series study
in Beijing, China. Moreover, they compared the impact of
COVID-19 on the primary outcomes of face-to-face (outpatient,emergency visits, and discharge) and online (online inquiry)
health care services. The impact of COVID-19 on health carefor different diseases was also analyzed. The average monthly
outpatient and discharge volumes of 22 public hospitals in
Beijing dropped by 36.33% (2020: 1,720,180 cases; 2019:
2,701,790 cases) and 35.75% (2020: 21,600 cases; 2019: 86,770
cases), respectively, compared with those in 2019. In addition,
the average monthly online consultation volume increased by
90.06% (2020: 12,050 cases; 2019: 6340 cases) [15]. After the
COVID-19 lockdown, patients with nonsevere disease opted
for online consultations. Conversely, patients with severe diseasechose hospital care.
Simultaneously, studies are increasingly focusing on the further
development of telemedicine. Although telemedicine technology
has developed rapidly around the world, research on China's
specific development in this field, the challenges it faces, andthe status and potential of international cooperation is still
limited. Therefore, understanding the current trends and hot
spots of publication in telemedicine is necessary. Understanding
the pandemic’s effect on telemedicine research through Chinese
protective measures can play a significant role in promoting thedevelopment of telemedicine.

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In light of this, understanding telemedicine research trends in
China, where demand for telemedicine is high, and research
relationships among China and other countries is of particularinterest. This study aimed to analyze Chinese and global
literature data, present new global trends in telemedicine
research, and clarify the development potential of China's
telemedicine research, potential collaborations, and deficiencies
in its own telemedicine research.
Bibliometric analysis is a research method that quantitatively
analyzes data from scientific literature and publications. Resultsof a bibliometric analysis can guide future research by
identifying the quality of research and major research areas[16,17]. It includes coauthorship analysis to identify the
relationships between institutions and countries [16,17].
Co-occurrence analysis is another methodology used in
bibliometric analysis. It investigates co-occurrence relationships
between keywords in academic literature and reveals theirrelationships and structures [16,17]. Co-occurrence analysis
allows the identification of research hot spots and the main
research directions through keyword clustering. It also allows
researchers to obtain information on topics of interest [17-19].
It helps researchers understand the trends in academic researchand topics, areas of research focus, and evolution of research
fields. Keywords are extracted through co-occurrence analysis[18].
Academically relevant literature on telemedicine bibliometricanalyses to date includes the analysis by Armfield et al [20] of
17,932 articles published between 1970 and 2013 in the PubMed
database. Furthermore, they divided the time period into 1970
to 1995 and 2009 to 2013. The study examined the themes
during the early adoption of telemedicine and compared themwith more recently published reports, which provided anunderstanding of the maturity, scope, and perceptions oftelemedicine. Furthermore, they found that the focus of the field
shifted from technical issues to clinical applications andassessment.
Sikandar et al [1] conducted a bibliometric analysis thatextracted data from 2011 to 2020 from the Scopus database.
This study analyzed 1401 articles to examine primary authors,
journals, research institutions and countries, and articles witha high number of citations. However, this study lacked datafrom 2001 to 2011, which was not conducive to an overview
of the development of telemedicine. They found that the UnitedStates, the Netherlands, and the United Kingdom had many
publications in telemedicine. Furthermore, the 10 most studied
keywords were identified: mobile health (mHealth),telemedicine, internet, eHealth literacy, technology,
self-management, digital health, primary health care, mental
health, and electronic health records. This study enabledresearchers to understand that telemedicine was an emerging
discipline as well as an understudied field. However,telemedicine experienced rapid development after 2020 due tothe COVID-19 pandemic. Therefore, updating our understanding
regarding telemedicine is essential.
Yanga et al [7] used the Web of Science database to obtain dataon telemedicine over a 20-year period, from 1993 to 2012, which
produced 7960 publications. Bibliometric analysis revealed that,https://www.i-jmr.org/2024/1/e40801

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Feng et al
although the total volume of telemedicine literature increased
significantly over the past 20 years, publication activity in eachcountry and region changed over time. The results revealed thatthe number of telemedicine publications per year increased from
10 in 1993 to 996 in 2012. There was annual growth from 1993
to 2000; however, the growth rate declined between 2000 and2008. Despite this, growth in telemedicine publications
continued to decrease and has remained steady since 2009 [7].
Although the United States leads the cumulative number oftelemedicine publications, Norway ranked the highest whenranking countries by publications per capita. The study also
found that the annual increase in the number of publications
was inconsistent between 1993 and 2012. Moreover,neuroscience and nursing were 2 significant subresearch fields
in telemedicine research.
Waqas et al [21] conducted a bibliometric analysis and extracted
data through the Web of Science from 2010 to 2019, with afocus on English publications. They found that academic
research in telemedicine increased significantly over the 10-year
period. Furthermore, research on telemedicine was primarily
conducted by institutions in high-income countries. In addition,
telemedicine research shifted from radiology to specificdisciplines, such as telemedicine, teledermatology, and telecare.
Disciplines that promoted joint research included public
environment and occupational health, psychiatry, pediatrics,
health policy and services, nursing, rehabilitation, radiology,
pharmacology, surgery, respiratory medicine, neuroscience,obstetrics, and geriatrics. However, after the COVID-19
pandemic, telemedicine research fostered telemedicine
development, which implies the need for further analysis.
Lan et al [14] discussed the research direction of telemedicine
during COVID-19, clarified the diseases for which telemedicine
technology was used, and identified the medical services it
provided. As of December 16, 2021, 5224 telemedicine research
papers on COVID-19 were retrieved from the PubMed database.
The United States had the most published articles ontelemedicine. Simultaneously, most research was related to theprovision of health care and mental health services. Although
the study mainly explained the application of telemedicine
during COVID-19, it did not consider the difference in thetimeline before and after the COVID-19 pandemic. Hence, there
is a need to further analyze the changes in telemedicine research
motivated by COVID-19. Telemedicine’s popularity andacceptance, as well as the awareness and recognition of it bypatients and health care professionals, may have changed before
and after the COVID-19 pandemic. Clarifying these changes isimportant when considering the future direction of telemedicine.
Waqas et al [21] also found that Web of Science indexed 6896
papers from 2010 to 2019, with an overall h-index of 87.
Furthermore, each study was cited an average of 10.64 times.
In total, 42,381 papers were cited 73,354 times. In addition,
both the number of published papers and number of citations
showed an increasing trend from 2010 to 2019. Regionally,
publication output (in English) was highest in high-income
countries: the United States, Australia, the United Kingdom,
Canada, and Germany. However, 2 middle-income countries,
India and China, also featured in the top 10 for publication
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telemedicine, even before the COVID-19 pandemic. We
anticipated that the research landscape and implementation oftelemedicine infrastructure would likely advance exponentiallyduring and after the COVID-19 pandemic. This was echoed bya recent report from the American Medical Association, which
predicted that “$250 billion in care could shift to telehealth in
the wake of COVID-19, boosting research and infrastructure”[22].
Through preliminary research in telemedicine, we found thatthe relevant literature increased or decreased every year [1,21].
However, the overall trend was rising. Simultaneously, theUnited States made the largest contribution to the literature [21].
Research hot spots ranged broadly, including early technology,
teleconsultation, telepathology, teleradiology, teledermatology,
chronic disease care, and home care.
This study aimed to analyze Chinese and global literature data,
present new global trends in telemedicine research, and clarify
the development potential of China's telemedicine research,
potential collaborations, and deficiencies in its own telemedicine
research. By identifying and understanding its own opportunities
and shortcomings, China could further develop effective
strategies to promote the innovation and development oftelemedicine technologies and services. Identifying potential
countries with which to collaborate will help China establish
international collaboration in telemedicine, share knowledge

Feng et al
and experience, and jointly respond to global health challenges,
such as COVID-19.

Methods
Data Collection
We conducted a comprehensive literature search fortelemedicine research articles published between 2001 and 2022
in the Web of Science database. A combination of the following
keywords was used, with all relevant keywords in 1 search box:
topic search = (“telemedicine” OR “tele-medicine” OR “telemedicine”) or (“telehealth” OR “tele-health” OR “tele health”).
This means that we searched for articles containing any“telemedicine”-related terms and any “telehealth”-related terms
at once. In this way, we ensured that all results contained
relevant keywords in the fields of telemedicine and telehealth.
Our selection criteria were limited to articles published in
English within a specified time frame. The search was divided
into 2 periods: 2001-2019 and 2020-2022. As illustrated in
Figure 1, the initial search yielded 11,681 and 13,652 articles
in the first and second periods, respectively. Subsequently, we
extracted data that pertained to publications from China, which
resulted in 337 and 652 articles in the first and second periods,
respectively. Data collection was completed on October 30,
2023.

Figure 1. Data collection strategy for the bibliometric analysis of telemedicine research. TS: topic search.

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We selected the Web of Science database to extract data for our
publication analysis. Since the use and definition of“telemedicine” were not uniformly standardized across theliterature and had variations in spelling and terminology, it iscritical to encompass such diversity. The term “telemedicine”
and its synonymous term “telehealth” were usedinterchangeably. A previous study highlighted the importanceof including both “telemedicine” and “telehealth” in searches
for comprehensive representation [7]. This database was chosen
for 2 primary reasons. First, it provided extensive citation
coverage across more than 20,000 peer-reviewed journals indiverse fields, such as health, social sciences, and engineering.
Second, it was the sole database that enabled citation
management across 250 distinct subjects [21]. These features
led numerous researchers to consider the Web of Science as an
optimal resource for conducting bibliometric analyses [23-25].
Before conducting data analysis, it is crucial to ensure the data's
accuracy and reliability. To this end, we performed data cleaning
to check for and remove possible duplicate entries in the
database, ensuring that each article appeared only once.
Databases may list multiple institutions as affiliations for asingle author due to the author's personal profile, which may
not match the affiliation listed in the article. In such cases, wecleaned the entries to retain only the author's valid affiliation
at the time of publication. If the affiliation field for the sameauthor contained multiple institutions, we cleaned the data toreflect only the primary affiliation associated with the
publication. This step is critical to preventing misrepresentationof institutional contributions and collaborations. Through thesedata cleaning steps, we ensured the data set's completeness andaccuracy, avoiding bias in the research results due to duplicate
or erroneous data, including titles, author names, journal names,and publication dates.

Use of SoftwareThis study used Microsoft Excel (version 2019), VOSviewer(version 1.6.18), R studio (version 3.3.0), Bibliometrix package(version 4.1.3), Statnet package (version 2019.6), and CiteSpace(version 6.2.R4).

Data Analysis
We used Microsoft Excel (version 2019) to collect the statistics
and organize the following literature data [26,27]: the annual
number of publications in China and the world, the top 10
countries in the world in total number of publications from 2001
to 2022, the number of publications in these countries from2001 to 2019 and 2020 to 2022, and magnification. We also
used Microsoft Excel (version 2019) to calculate the ratio of
the number of publications in each country to the total numberof publications and determine the contribution of each country
in this field. Magnification is the publication growth ratio in aperiod, that is, comparing the ratio of the number of publicationsin the 2 different time periods, 2001-2019 and 2020-2022. The

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Feng et alcalculation used the following formula: N2/N1, where N is thenumber of publications in each time period [28]. This
comparison can be used to measure how quickly thetelemedicine field or topic is growing or changing over time.
This ratio helps understand whether the field of telemedicine
has experienced significant research growth during and after
the COVID-19 pandemic.
Furthermore, we performed bibliometric analysis with
VOSviewer (version 1.6.18). VOSviewer is a software tool
designed to construct and visualize bibliometric networks [17].
Bibliometric analysis is the application of mathematics andstatistics [16]. We used VOSviewer and generated bibliometricmaps to visualize social networks based on geographical data,
which thereby showed international collaborations within thetelemedicine domain. Additional analyses were performed via
R Studio (version 3.3.0) and incorporated the Bibliometrix andStatnet packages to delineate intercountry relationships intelemedicine research. These packages are tools for bibliometricanalysis and scientific mapping, respectively. Bibliometrix is
an R package specially designed for bibliometric analysis andprovides functions for data import, cleaning, analysis, andbibliometric data visualization [29]. Conversely, Statnet is a
software package used to describe and visualize networks ofrelationships between countries in bibliometric data, with a
special focus on international research collaborations [30]. These
tools are valuable for researchers who conducted bibliometricstudies in various fields. They enable the analysis of publication
trends, citation networks, coauthorship patterns, andinternational collaborations and provide insights into thestructure and dynamics of scientific research. By leveraging
these packages, researchers gain a comprehensive view ofscholarly communications and identify key contributors,
influential publications, and emerging trends. The use of
Bibliometrix and Statnet in R Studio was consistent with the
purpose of conducting bibliometric and network analyses to
describe international collaborations in telemedicine. These
tools facilitated the visualization and interpretation of social
networks for academic collaboration, elucidated the relationships
between countries, and disseminated research in telemedicine.
We established thresholds, setting the minimum numbers of
publications in a country and citations to 10 and 5 times,
respectively, to ensure the relevance and importance of network
analysis. This approach allowed us to identify China’s role andevolution in international telemedicine collaboration [31,32].
Figure 2 presents a network diagram in which each point isshown as a node within the network structure. Connections
between the points, indicative of relationships, are illustrated
as edges. Degree centrality is a key measure within this context
and was defined as the number of direct neighbors of a node.
It was calculated by adding the total number of direct links thata node had with other nodes [33].

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Figure 2. Description of a network diagram.

Betweenness centrality quantified a node's role as anintermediary within a network. It was measured by the frequency
with which a node occurred on the shortest paths between pairsof nodes. In essence, a node with high betweenness centrality
acted as a critical bridge within the network’s shortest pathstructure. The calculation of betweenness centrality was derived
from the aggregate shortest paths that passed through a given
node:

where σst was the total number of shortest paths between nodess and t and σst(υ) was the number of paths passing throughnode υ [33,34].
Betweenness centrality is known as an “intermediary agency”
role in the network. If one node was in the path to other uniquenodes through communicating, connecting, transporting, ortrading, then it could be important and is likely to have a highbetweenness centrality [35].
We conducted co-occurrence analysis using author-provided
keywords in VOSviewer to identify research hot spots intelemedicine. We chose binary counting when using VOSviewer
for analysis. This means that each keyword is counted only
once, no matter how many times it appears in the document.
This is done to ensure that the weight of each keyword in the
network graph is not affected by its frequency of occurrence ina single document but is based on its occurrence in multiple
documents. The minimum number of co-occurrences was set
to 50. This is to ensure that the keywords analyzed are
sufficiently representative in international research. For China’s
data, since the amount of extracted data was lower, the minimum
number of co-occurrences was set to 5. This ensures thatimportant keywords are included even in smaller data sets. Dueto the search strategy, the keywords telemedicine and telehealth(and keywords with similar meanings) appear more frequently
and occupy a larger weight in the co-occurrence network graph.
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Such keywords are considered to affect the distribution of theremaining keywords; therefore, when mapping the co-occurrenceof keywords in China and the world, the keywords used in the
search strategy that appeared in the results are deleted, and theresults are concentrated on valuable research topic buzzwords[36]. Keywords were standardized, and synonyms and different
spellings were merged. For example, we combined synonyms
like “COVID19” and “covid-19” into 1 unified keyword.
To examine the changes in hot spots more comprehensively,
we used CiteSpace (Basic version 6.2. R4) to visualize thechanges over time for international telemedicine research trends[37]. We used CiteSpace (version 6.2. R4) to analyze keyword
bursts. CiteSpace is popular scientometric software to analyze
and visualize trends, patterns, and frontiers in scientific
literature. It includes several key concepts, such as “keyword
burst,” and has 2 important concepts [38]. Keyword explosions
refer to sharp increases in the frequency of the use of certain
keywords within a specific period. An explosion could indicatethat the represented concept, technology, or topic represented
had received widespread attention or become a hot research
topic during that period. CiteSpace’s (version 6.2.R4) keyword
burst analysis helps identify and track research trends and hotareas [38].

Results
Telemedicine Research Publications
The publication patterns in telemedicine revealed a global
upward trajectory, which was particularly significant over the
past 3 years. Although the growth from 2001 to 2019 was
gradual, a marked acceleration in publication volume wasobserved after 2020. The number of telemedicine papers
published by the top 10 countries from 2020 to 2022 surpassed
those published in the preceding 19 years, as shown in Table
1. This was also notably true for China, where the publication
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aggregate for those in 2001 to 2019. Table 1 also shows theglobal ranking of Chinese telemedicine research publications.
China’s global ranking increased from tenth in 2001 to 2019 tosixth in 2020 to 2022. This surge highlighted the escalating
significance of telemedicine, propelled by technologicaladvancements in health care and intensified by the COVID-19
pandemic [20-22]. Figure 3 illustrates the burgeoning global

Feng et alinterest in telemedicine research, a trend expected to persist.
Figure 3 also charts the trajectory of telemedicine publicationsin China, which shows a steady increase from 2001 to 2019,
followed by a sharp increase in the subsequent years. Thispattern mirrored the global trend and highlighted China's
intensified focus on telemedicine research in the face of recent
health challenges.

Table 1. Top 10 countries by publication volume (total number of publications=25,333).
Rank

a

Country

Publications in the country, n (%)

Publications by time period
2001-2019, n

2020-2022, n

Magnificationa

1

United States

12,112 (47.81)

5295

6817

1.29

2

Australia

2035 (8.03)

1002

1033

1.03

3

England1804 (7.12)

873

931

1.07

4

Canada1543 (6.09)

782

761

0.97

5

Italy

1201 (4.74)

485

716

1.48

6

Germany1022 (4.03)

498

524

1.05

7

India

998 (3.93)

362

636

1.76

8

China

989 (3.9)

337

652

1.93

9

Spain

842 (3.32)

401

441

1.10

10

Netherlands

665 (2.62)

352

313

0.89

Number of publications before and after 2020.

Figure 3. Number of international telemedicine publications.

International Coauthorship Network for the
Telemedicine Research Field
Figures 4A and 4B depict the international coauthorship networkin the telemedicine field. The size of each node corresponds tothe number of publications in each country, and larger nodes
indicate a higher volume. Proximity between 2 nodes suggest
the degree of relatedness between the corresponding countries
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regarding research. An interconnecting line represents
collaborative relationships, and thicker lines denote more
frequent or substantial collaborative efforts. The different colors
assigned by VOSviewer signifies different clusters within the
network, where nodes of the same color typically share common
properties or characteristics [39]. The network demonstrates
the global scale of telemedicine research, showcasing various
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care through telemedicine technologies. As shown in Figure
4A, the United States and Australia emerged as central hubs forcoauthor networks between 2001 and 2019, which emphasizes
their critical roles in telemedicine research collaboration.
Although Brazil’s node is relatively small, its proximity to theUnited States and the network’s core suggests an important
collaborative link. China maintained close cooperative relations

Feng et alwith Indonesia, India, Japan, Taiwan, and South Korea. China’s
main cooperation collaboratives were neighboring Asian
countries in the same geographical location. However, network
density was more concentrated in Europe and North America,
which could reflect more intensive collaboration in theseregions.

Figure 4. International co-authorship network in telemedicine: (A) 2001-2019 and (B) 2020-2022.

Figure 4B further illustrates the scale of international
collaboration in telemedicine between 2020 and 2022. The
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United States remained the largest node, which represented themost extensive international collaboration. The countries in theInteract J Med Res 2024 | vol. 13 | e40801 | p. 8
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center of the network included the United States, the United
Kingdom, Australia, and Canada. Importantly, China maintained
close cooperation with countries from Asia including Japan,
Singapore, Malaysia, and South Korea. In addition, China, Saudi
Arabia, Egypt, South Africa, Ghana, Lebanon, and other Africanand Middle Eastern countries unified from the different colored
clusters in Figure 4A to a common red cluster in Figure 4B.
Cooperation with countries in Africa and the Middle East wasalso strengthening. Simultaneously, European countries unified
from the different colored clusters in Figure 4A to a common
green cluster in Figure 4B. Italy is in the central area, and thesize of the nodes is relatively large, which indicates more
contributions to publications.
This study used RStudio (version 3.3.0) to generate the degreeand betweenness centrality for 130 countries in the field of
telemedicine. Matrices of the top 50 countries in degree andbetweenness centrality from 2001 to 2019 (complete list shownin Multimedia Appendix 1) and 2020 to 2022 (complete list
shown in Multimedia Appendix 2) are shown in Figures 5A and
5B, respectively. The central axis divides the matrix into 4
quadrants, with the degree centrality increasing along the X axis
from left to right and the betweenness centrality increasingalong the Y axis from bottom to top. The X axis quantifies thedegree centrality, which reflects the number of connections a

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Feng et al
country has within the network. In contrast, the Y axis quantifies
betweenness centrality, which indicates a country's role as anintermediary within the network.
In Figure 5, the span of the X and Y axes ranged from 0 to 140
and 0 and 4.5, respectively. From 2001 to 2019, shown in Figure
5A, to 2020 to 2022, shown in Figure 5B, the countries as awhole moved to the right and downwards, indicating thatcountries within the international telemedicine researchcollaboration network exhibited a general increase in degreeand decrease in betweenness centrality. This trend implies that,
although the number of international collaborations increased,
the role of these countries in the dissemination of research
information diminished.
In Figure 5, the United States consistently occupied the quadrant
characterized by high degree and betweenness centralities, whichindicates its significant role as both a primary collaborator andvital conduit for information flow. In contrast, China wassituated in a quadrant of low degree and betweenness centralities
from 2001 to 2019. However, from 2020 to 2022, China shiftedto the quadrant indicative of high degree centrality but low
betweenness centrality, which aligns with the general trend inwhich international collaborations increased while the centrality
in information dissemination decreased [40,41].

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Feng et al

Figure 5. Matrix of degree and betweenness centrality in telemedicine: (A) 2001-2019 and (B) 2020-2022.

Co-Occurrence Analysis of Author Keywords for
China and International Trends in the Telemedicine
Research Field

and 2020 to 2022, respectively. Figures 6C and 6D represent
trends in China from 2001 to 2021 and 2020 to 2022,
respectively.

Figure 6 presents the keyword co-occurrence network. Figures
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Figure 6. Keyword co-occurrence network in telemedicine in (A) the world in 2001-2019, (B) the world in 2020-2022, (C) China in 2001-2019, and(D) China in 2020-2022.

In Figures 6A and 6C (2001-2019), the keyword analysis
revealed that “care” and “health” were the predominant nodes,
which signifies their foundational role in telemedicine research.
The prominence of “technology” underscores its criticalinfluence, while the association with terms, such as “mobile
health” and “eHealth,” reflects the importance of digital
innovation in telemedicine service provision. The emergenceof “user acceptance” and “self-management” as notable
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keywords denotes the sector's focus on consumer engagement
and empowerment of patients in managing their health. The
keyword “outcomes” highlights the significance of research
results and evaluation of service efficacy in telemedicine.
Moreover, the keyword “mobile” suggests an intensive researchinterest in the application of mobile technologies to telemedicine
services. “Health information” and “data” highlight theimportance of information management and data analysis, andInteract J Med Res 2024 | vol. 13 | e40801 | p. 11(page number not for citation purposes)

INTERACTIVE JOURNAL OF MEDICAL RESEARCH
the emergence of “quality of care” underscores a commitment
to service excellence.
The focus on “security” and “privacy” in Chinese research
indicates a growing awareness of the need for data protection
measures in telemedicine services. Comparison of Figures 6A
and 6C shows that, although international studies were inclined
toward nursing and health, China had a unique focus on
fundamental technology and systems management, with a
special emphasis on health data collection and analysis. Thisdifference could stem from specific telemedicine policies
implemented in China [41]. However, compared with Figure
6A, which shows global keyword co-occurrence, Figure 6C
shows that China’s telemedicine research had fewer keywords
in mental health.
As seen in Figures 6B and 6D, the keyword landscape from2020 to 2022 was significantly reshaped by the emergence of
the COVID-19 pandemic, with the importance of “COVID-19”
and “pandemic.” This was demonstrated in research discourse.
These terms underscored the significant impact of health crises
on telemedicine research and implementation. The increase in“mental health” keywords may have relationships with thewidespread use of telemedicine in mental health services andpsychotherapy. In addition, the mental health issues caused by
the pandemic may have provided potential opportunities fortelemedicine to implement psychological assistance. The
prominent appearance of “data,” “analytics,” and “artificial
intelligence” demonstrates an accelerated convergence of data
analytics and artificial intelligence in telemedicine, which points
to technological changes triggered by the pandemic.
Additionally, consistent references to “telemedicine,”“technology,” and “digital” reaffirm the centrality oftechnological innovation in telemedicine services. The
emergence of “children” as a keyword highlights the importanceof telemedicine for pediatric care. “Patient engagement” and“self-management” suggest that patient autonomy wasincreasing, which could have been influenced by increased
health awareness and limited access to physical care during the
pandemic.
Consistent with the global pattern, the term “COVID-19”
became the focus of telemedicine research in China during the
pandemic. This reflects the significant impact of the pandemic
on the health care system and the resulting shift in researchhttps://www.i-jmr.org/2024/1/e40801

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Feng et alfocus toward telemedicine. The clustering of terms, such as“eHealth,” “mHealth,” and “digitalization,” highlight the criticalrole that digital and mobile technologies played in health caredelivery in China. The observed increases in the keywords“mental health” and “depression” may indicate an increasing
focus in telemedicine research on mental health services andpsychotherapy. In addition, the emergence of keywords suchas “children” and “rehabilitation” in telemedicine researchhighlights the growing interest in specialist telemedicine
applications. This may reflect an increased awareness of diverse
health care needs, including those for the older adult population,
pediatric care, and rehabilitation services. These needs may be
impacted by the pandemic’s broader impact on health carepriorities and service delivery models.
Figure 7 shows the bursts of the top 50 global telemedicine
keywords between 2001 and 2022. International trends intelemedicine have generally undergone 3 stages oftransformation: early focus, mid-term evolution, near-term
focus.
Keywords such as “system,” “telepsychiatry,” and “technology”
experienced citation explosions between 2001 and 2012, whichreflect the early days of telemedicine, system building, andtechnology applications in specific fields (eg, telemental health).
From 2013 to 2017, there was a rapid increase in citations withkeywords such as “telecare,” “self-management,” and “mobile
health,” which indicates that telemedicine was beginning tobecome more personalized as mobile technology became popularand self-management tools developed. This was an indication
toward development in the direction of globalization andmobility. Beginning from 2018, there was an explosion ofcitations for keywords such as “social media,” “disparity,” and“emergency medicine,” possibly due to the increased role ofsocial media in health communication, which heightened
concerns of inequalities in medical services and increased
demand for remote emergency medical services. Beginningfrom 2020, pandemic-related keywords, such as “COVID-19,”“coronavirus disease,” and “emergency department,” showedsignificant citation explosions, which highlights the profound
impact of the new coronavirus pandemic on telemedicine
research and practice. Telemedicine’s focus underwent drasticchanges from the initial technical foundation and systemconstruction to the integration of mobile and self-management
tools and application of social media during the pandemic.

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Figure 7. Top 50 international trends with keywords from the co-occurrence network in telemedicine.

Discussion
Principal Findings
This study revealed significant insights into the evolution andstatus of telemedicine research globally, with a special focus
on China. The primary findings indicate a substantial increasein telemedicine-related publications over the years, particularly
noting a surge from 2020 to 2022, which aligns with the
COVID-19 pandemic. This increase reflects the growing global
and regional recognition of telemedicine as a critical componentof health care systems, especially during times of crisis. We
identified a total of 25,333 telemedicine-related research papers
published between 2001 and 2022, with the United States, theUnited Kingdom, and Australia leading in publication numbers.
However, China's contribution and global ranking intelemedicine research significantly improved after 2020,
showcasing the country's rapidly growing interest and efforts
in this field.

COVID-19 and Telemedicine Research
Overall, the development of communication and professional
medical technologies made it easier for many people to accessmedical services [42]. Both international and Chinese trends
steadily increased from 2001, according to literature on
telemedicine. However, after 2010, the rapid development ofsmartphones and mobile technologies enabled the further
development of telemedicine research [43]. The COVID-19
pandemic significantly influenced and increased the amount oftelemedicine research and number of publications from 2020
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to 2022. The COVID-19 pandemic resulted in a significant
increase in telemedicine use across medical specialties andgeographic locations [44]. Telehealth services expanded rapidly,with a significant shift toward virtual care. This shift was wellreceived by patients and health care providers and had highpatient satisfaction scores [45]. Additionally, the pandemic
accelerated the adoption of telemedicine in clinical practiceacross various medical disciplines, such as dentistry, pediatriccare, endocrinology, rheumatology, and sports medicine [46].
The widespread adoption of telemedicine facilitated continuityof care for patients and highlighted the potential for telemedicine
to be integrated into health care services long after the pandemic[47]. In addition, telemedicine led to positive outcomes, suchas reduced hospitalizations and emergency department visits,
which demonstrated its effectiveness in remotely managing
various medical conditions [48].

Potential Possibilities in Telemedicine Research
China’s top researchers in telemedicine were actively engaged
in research in various medical fields. Specifically, research
conducted in western China demonstrated the feasibility,
acceptability, and effectiveness of telemedicine during the
COVID-19 pandemic. This highlighted the significant
contribution of researchers in this region toward theadvancement of telemedicine [49]. In addition, pilot studies
focused on the evaluation of the utilization rate andcost-effectiveness of telemedicine programs in western China,
which indicated that researchers were actively involved in theimplementation and evaluation of telemedicine programs [50].
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INTERACTIVE JOURNAL OF MEDICAL RESEARCH
Gansu Province, China, emphasized that developed cities, suchas Beijing, Shanghai, and Guangzhou, had telemedicine
consultation centers and successfully managed diseases, suchas hypertension and diabetes [51]. Xu et al [52] examinedregional heterogeneity in the application and effect oftelemedicine in rural primary care centers in China and revealed
the diverse implementation and impacts of telemedicine indifferent regions.
Overall, research by Chinese scholars in telemedicine spanned
across many regions, which included western China, Gansu
Province, and rural areas. This demonstrated comprehensive
and extensive participation in advancing telemedicine practices
and technologies.
From a Chinese perspective, Figure 3 shows a significant
increase in the number of Chinese publications in telemedicine
research over time, especially after 2020, which was consistent
with global trends. This growth trend demonstrates China's
increasing interest and investment in telemedicine research,which reflects active research activities and potential research
momentum. Simultaneously, Table 1 shows China’s global
ranking in telemedicine research publications. China’s global
ranking is rising, which shows that its research is valued both
domestically and internationally. Moreover, among themultiplier effects of publications in the top 10 countries in Table
1, China’s multiplier effect was greater than that of the othercountries, which further emphasizes its research potential.

International Coauthorship in Telemedicine
From 2001 to 2022, the United States was a central node intelemedicine research and had extensive cooperative
relationships with other countries. During this period, China
gradually developed from a lower degree centrality and lower
betweenness centrality to a lower degree centrality and higher
betweenness centrality. This indicates that its role as an
information dissemination medium in the international
collaboration network was small; however, the number ofcooperating countries increased. International influence was
improved to a certain extent. South American countries (mainly
Brazil), western European countries (mainly Italy), and Africancountries (mainly Egypt and countries in west Africa) all grewin influence. China is currently conducting relatively close
cooperative research with Asian and African countries, led by
Egypt and countries in west Africa. However, joint researchwith South American countries (mainly Brazil) and western
European countries (mainly Italy) remains relatively slow. These
countries are potential research collaborators. Simultaneously,
the United States, Australia, the United Kingdom, and Canada
were the most influential countries and maintained close
cooperation.

Research Hot Spots in Telemedicine
Between 2001 and 2019, “care” and “health” became the largest
research nodes in telemedicine literature, which reflected that
health care was the core of telemedicine research. Technology
played a significant role in telemedicine, particularly in mHealthand eHealth applications. Telemedicine research in China
focused on the management and application of technology. User
acceptance, mobile technology, health information, and data
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Feng et al
analytics were key points in Chinese studies, which reflects
China's special emphasis on telemedicine policy and data
management. From 2020 to 2022, “COVID-19” and “pandemic”
become prominent keywords in global telemedicine research,which indicates that the pandemic greatly affected telemedicine
research and practice. This forced researchers to focus on various
areas, such as pandemic management, public health, medical
disparities, and digital health. Mental health, urgent care, anddata analytics were also areas of focus, which indicates theimpact of the pandemic on the demand for telehealth services
and technology. Simultaneously, the emergence of keywords
shown in Figure 7 reflects the forefront of the research field.
The emergence of some keywords, such as “big data” and“artificial intelligence,” indicates that telemedicine research
was beginning to integrate advanced technologies, which could
potentially completely change the field.
Simultaneously, the world is working on telemedicine for all
ages. However, as far as Chinese keywords were concerned,
relatively few studies focused on telerehabilitation for children
and older adults. In addition, few studies examined telemental
health for children. China should also consider strengthening
telemedicine research across all age groups. The world's latest
telemedicine research direction is toward the development ofartificial intelligence, digital medicine, and individualization.
China has also conducted extensive research in these fields. In
the future, we will continue to deepen research on artificial
intelligence and digital medicine in telemedicine.

Future Prospects for Research in Telemedicine
This study demonstrated China’s significant development in
the research field of telemedicine. However, betweenness
centrality remained low, which indicates the need for Chinese
researchers to seek opportunities that allow them to be themediators while bonding in smaller subnetworks.
Through this analysis, we found that telemedicine research islikely to focus on improving service efficiency and quality withthe advancement of technology, especially in artificial
intelligence and mHealth. Future telemedicine research should
explore the application and integration of these technologies in
the medical field. Personalized medicine and increased patientengagement are expected to be crucial. As international
collaboration increases, future telemedicine research should
place greater emphasis on knowledge sharing and collaborationinternationally. Special keywords, such as “lockdown” and“tracing,” were revealed in the co-occurrence analysis for China,
which suggests that telemedicine research also targeted specificregional, social, and cultural factors. This demonstrates thatsolutions must be identified for each culture, region, and country
when it comes to mitigating social problems and healthchallenges through telemedicine development. Policy andregulation will remain an important topic in telemedicine
research, particularly regarding data security and privacy
protection.
Simultaneously, the impact of the COVID-19 pandemic ontelemedicine will be reflected in future research, including the
exploration of public health emergency management,
vaccination, pandemic monitoring, and remote patientmanagement. Future research is expected to explore how
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INTERACTIVE JOURNAL OF MEDICAL RESEARCH
telemedicine technology can help respond to global health crises.
Different cultural and social contexts may bring different
acceptance and needs for telemedicine. Considering how toprovide medical services that are more adaptable to different
cultural and social environments will be a direction for future
research.

Limitations
This study has 4 limitations. First, we only collected bibliometricdata from the Web of Science database and excluded othersearch engines, such as Scopus, PubMed, IEEE, and Google
Scholar. Second, we extracted only articles published in English.
Third, although we aimed to identify research trends intelemedicine in China, we obtained limited articles ontelemedicine, as we only used those published in Web of
Science. Fourth, some data in the literature data collected
through Web of Science could be changed due to electronic

Feng et al
publishing or document editing and publication time. Hence,
this may impact the data analysis results.

Conclusions
This study provides the latest trends in telemedicine research,demonstrates that telemedicine research has considerable
potential in China, and provides directions for future
development. Simultaneously, China’s future remote medical
research collaboratives and research areas are also of reference
value. Although this study shows significant growth intelemedicine research in China, it points out that China's status
as a center for international collaboration is still low. In the
future, telemedicine research is likely to focus on improving
service efficiency and quality, particularly by leveraging
technological advances in artificial intelligence and mHealth.
In addition, personalized medicine and increased patientengagement will be important trends in the future.

Acknowledgments
We would like to express our gratitude to Ritsumeikan University for providing access to the Web of Science database. We also
thank all the study participants for their constructive suggestions and guidance. This work was supported by the Japan-Ritsumeikan
University Ritsumeikan Advanced Research Academy (RARA) Student Fukuro Scholarship. The authors sincerely thank theJapan-Ritsumeikan University RARA Student Fukuro Scholarship for its generous support and assistance.

Conflicts of Interest
KK has received research donations for Ritsumeikan University from Kumagaya Gumi, Sumitomo Life Insurance, Merge system,
and Pasona. All other authors declare no conflicts of interest.

Multimedia Appendix 1
List of degree and betweenness centrality by country from 2001 to 2019.
[XLSX File (Microsoft Excel File), 13 KB-Multimedia Appendix 1]

Multimedia Appendix 2
List of degree and betweenness centrality by country from 2020 to 2022.
[XLSX File (Microsoft Excel File), 13 KB-Multimedia Appendix 2]

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Abbreviations
mHealth: mobile healthhttps://www.i-jmr.org/2024/1/e40801

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INTERACTIVE JOURNAL OF MEDICAL RESEARCH

Feng et al

Edited by T de Azevedo Cardoso; submitted 29.01.24; peer-reviewed by H Guo, I Maniu; comments to author 09.03.24; revised version
received 23.03.24; accepted 19.06.24; published 30.08.24
Please cite as:Feng H, Kurata K, Cao J, Itsuki K, Niwa M, Aoyama A, Kodama K
Telemedicine Research Trends in 2001-2022 and Research Cooperation Between China and Other Countries Before and After the
COVID-19 Pandemic: Bibliometric Analysis
Interact J Med Res 2024;13:e40801
URL: https://www.i-jmr.org/2024/1/e40801
doi: 10.2196/40801
PMID:©Hanlin Feng, Karin Kurata, Jianfei Cao, Kageyama Itsuki, Makoto Niwa, Atsushi Aoyama, Kota Kodama. Originally publishedin the Interactive Journal of Medical Research (https://www.i-jmr.org/), 30.08.2024. This is an open-access article distributed
under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Interactive
Journal of Medical Research, is properly cited. The complete bibliographic information, a link to the original publication on
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