Currently submitted to: Journal of Medical Internet Research
Date Submitted: Jul 22, 2026
Open Peer Review Period: Jul 23, 2026 - Sep 17, 2026
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Operational Scaling of Telemedicine During Prolonged Conflict: The Role of Organizational Readiness
ABSTRACT
Background:
Armed conflicts and prolonged security crises substantially disrupt routine ambulatory healthcare delivery. Telemedicine has increasingly been recognized as an important component of healthcare system resilience during emergencies, yet evidence regarding sustained large-scale telemedicine implementation during prolonged armed conflicts remains limited.
Objective:
To evaluate large-scale telemedicine implementation during a prolonged regional armed conflict and identify the organizational determinants of successful telemedicine scalability within a tertiary healthcare system.
Methods:
This retrospective observational study evaluated ambulatory telemedicine implementation at Sheba Medical Center, Israel's largest tertiary academic medical center, during the regional conflict beginning on February 28, 2026. Outpatient encounters performed between February and April 2026 were analyzed, including both in-person and telemedicine visits. Imaging and laboratory services were excluded because they are inherently unsuitable for telemedicine delivery. Primary analyses focused on March 2026, the only complete month during the conflict period. Telemedicine utilization, implementation patterns, and temporal trends were analyzed longitudinally.
Results:
Despite prolonged emergency conditions and repeated missile alerts, overall institutional ambulatory activity remained at approximately 85% of pre-conflict baseline activity during March 2026. Across the study period, 21,454 of 119,632 analyzed ambulatory encounters were conducted via telemedicine, corresponding to an overall telemedicine utilization rate of 17.9% (95% CI 17.7–18.2%), compared with 5.8% (95% CI 5.7–5.9%) before the conflict (relative risk 3.09, 95% CI 3.01–3.16; P < .001). Mean daily telemedicine activity increased from 363 to 933 encounters per day. Telemedicine expansion was heterogeneous across clinical divisions, with the greatest scalability observed in services that had integrated telemedicine into routine practice before the conflict. Large-scale implementation was supported by same-day conversion of scheduled visits, clinician enablement, centralized operational oversight, and continuous monitoring of ambulatory activity.
Conclusions:
Large-scale telemedicine implementation was associated with sustained ambulatory care delivery during a prolonged armed conflict and functioned as a key component of a hybrid continuity-preservation strategy. Successful telemedicine scalability depended less on technology itself than on organizational readiness established before the crisis, including pre-existing clinical integration, operational governance, institutional adaptability, and clinician familiarity with telemedicine delivery. These findings suggest that healthcare systems seeking to strengthen resilience should integrate telemedicine into routine clinical practice before emergencies occur rather than relying on crisis-driven implementation.
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