Research Brief | No. 22 | November 2017

Telemedicine: Decreasing Barriers and Increasing Access to Healthcare

Telemedicine includes a variety of technologies and tactics to deliver virtual healthcare.¹ Telemedicine is considered a subset of telehealth, which includes more general health services, like public health and medical education.² Telemedicine is a specific kind of telehealth that involves clinicians providing medical services.

Telemedicine can enhance interactions among providers to improve patient care, support provider-to-provider training, enhance service capacity and quality (such as in small rural hospital emergency departments and pharmacy services), manage patients with multiple chronic conditions from a distance, and remotely monitor patient health and activities.³

Four Types of Telemedicine

Telehealth has four main types of technology: live video, store-and-forward, remote patient monitoring, and mobile health.⁴

• Live video (synchronous): Live, two-way interaction between a person (patient, caregiver, or provider) and a provider using audiovisual telecommunications technology. This type of service can serve as a substitute for in-person visits for consultative, diagnostic and treatment services. For example, if a patient suspects they have an infection and needs quick treatment but cannot easily see a doctor, they could use real-time telemedicine to consult a doctor remotely and get treatment advice, referral or a necessary prescription. Video devices can include videoconferencing units or web cameras. Display devices include computer monitors, TVs, LCD projectors, tablets and smartphones.⁵
• Store-and-forward (asynchronous): Transmission of recorded health history (for example, pre-recorded videos and digital images such as x-rays and photos) through a secure electronic communications system to a practitioner, who uses the information to evaluate the case or render a service outside of a real-time or live interaction. As compared to a real-time visit, this service provides access to data after it has been collected, and involves communication tools such as secure email. 
• Remote patient monitoring: Electronic collection of personal health and medical data  from a patient in one location and transmitted to a provider (sometimes via a data processing service) in a different location for use in care and related support. This type of service enables a provider to track a patient’s healthcare data after discharge to home or a care facility, reducing hospital readmission rates. 
• Mobile health (mHealth): Refers to patient engagement, patient education, and public health programs offered via mobile communication devices such as cell phones, tablets, and PDAs. Applications include targeted text messages that promote healthy behavior wide-scale alerts about disease outbreaks, apps to help patients self-diagnose illnesses, to name a few examples. As far as telehealth solutions go, mHealth is growing quickly due to the rise in smartphones.⁶

Telemedicine Benefits

This review of the evidence focuses on the first three types of technology as they are pertinent to telemedicine: synchronous and asynchronous data transmissions and remote patient monitoring. These uses of telemedicine have been shown to offer numerous benefits, including:⁷

• Timeliness: Telemedicine enables patients to get certain types of care when they need it instead of having to travel to a facility or waiting to get an appointment. Of course, different health problems require different approaches. Persistent fevers, chest pain, unrelenting belly pain, and low blood pressure should never be handled with telemedicine, but a sore throat or a rash can be easily handled through telemedicine.⁸ Telemedicine can provide immediate assistance until the patient can get to a facility, if needed. A study found that telemedicine use tends to rise on weekends and holidays since many physicians’ offices are closed.⁹
• Comfort: Telemedicine has increased in demand because it allows patients to remain in their homes or community as they receive care. Traveling to a hospital could be more uncomfortable or even painful for patients as they recover, and being in a supportive, known environment may foster quicker recovery.
• Transportation: Patients in rural settings or suburban settings might not have the necessary resources to travel to a provider. Even for patients in an urban environment, public transportation can be tedious and grueling. Older or less mobile patients might also not have family or friends who can be their caretaker and take them to clinics. Telemedicine can help a patient feel more independent. One study found that the use of a specific home-telemedicine strategy for care coordination improved functional independence in non-institutionalized veterans with chronic disease.¹⁰
• Improved Outcomes: Telemedicine increases collaboration and productivity of medical staff which improves the quality of care patients receive. A study that surveyed intensive care unit nurses found that 79 percent agreed tele-ICU systems enable nurses to improve patient care, and approximately 75 percent agreed it improves job performance.¹¹ Evidence suggests that the use of telemedicine results in fewer follow-up visits, making it more cost-effective. One study found that 6 percent of patients using telemedicine required a follow up for a similar condition, compared to 13 percent of those visiting a physician’s office and 20 percent of those visiting an emergency department.¹²
• Provider Benefits: There are benefits to providers as well. Telemedicine increases the collaboration between providers, and for those serving in a rural environment this can reduce the isolation they may face. Telemedicine brings together numerous specialties, thus allowing healthcare providers to informally continue their education and training through collaboration.
• Cost Savings: Telemedicine has been shown to reduce the cost of healthcare and increase efficiency through improved management of chronic diseases. Telemedicine also reduces hospital costs by providing remote access to specialists that rural hospitals cannot usually attract to serve as a local provider.¹³ In one example, a rural hospital reduced its use of a full-time radiologist from five days a week to one. Using rural specialists’ salaries from the Physician Compensation and Production Survey, the estimated annual cost savings was $101,600.¹⁴ The same study examined 24 rural hospitals in various communities to quantify potential cost savings. Patients who use telemedicine services do not incur travel expenses that they otherwise would to visit a far-off treatment site. The study measured average distance traveled, the average cost per mile, and the number of encounters per year—taking into account the percentage of encounters that required immediate attention, as opposed to those who could wait until a specialist was available locally.¹⁵

Telemedicine Barriers and Limitations

While many benefits of telemedicine have been identified, there are still barriers to states adopting or expanding this method of healthcare:¹⁶ 

• Broadband Access: The main barrier to telemedicine is access to reliable broadband or satellite since live video (synchronous) requires high-speed, high-quality connections on all devices. These electronics allow physicians to keep in contact with their patients through video and apps that transmit vital data and results, as well as with other healthcare professionals.¹⁷ According to the Federal Communications Commission, in 2016, 10 percent of all Americans—34 million people—lacked access to 25 Mbps downstream/3 Mbps upstream service, a speed that would make consultations viable.¹⁸ This is particularly true in rural areas, where 39 percent—23 million people—lack access to 25 Mbps/3 Mbps service.¹⁹ Rural areas are more expensive to serve with broadband, due to smaller populations being served over greater distances.
• Reimbursement: In the 2017 legislative session, forty-four states introduced more than 200 telemedicine legislative bills, most of which focused on reimbursement policies in regards to private payers and Medicaid or licensing requirements for providers.²⁰ Telemedicine regulations and reimbursements differ by state, but there has been an increase in the number of states that provide reimbursements for telemedicine services to providers. The issue is that even though these policies might be in statute they might not have taken effect.²¹
  • Forty-eight states and Washington, D.C., provide reimbursement for live video (synchronous) in their Medicaid program.
  • Thirteen state Medicaid programs reimburse for store and forward.
  • Twenty-two state Medicaid programs reimburse for remote patient monitoring.
  • Nine states reimburse for all three.

Medicare offers the most limited coverage of telemedicine; they only cover a narrow set of services and only in rural areas.²² Healthcare providers have to meet a number of provisions to qualify for telemedicine and telemedicine reimbursement under Medicare. They must be one of 10 qualifying distant site practitioners in a federally designated rural zone; the patient must be in a federally designated rural zone; and they must be using a real-time audio-visual platform.²³ These restrictions have become a barrier to many providers, especially if they were to broaden their telemedicine practice. Regardless, telemedicine use among Medicare beneficiaries increased by almost a third in 2016, with much of that increase occurring within the rigid boundaries of CMS reimbursement guidelines.²⁴ Private payers are more willing to embrace telemedicine as a covered service for beneficiaries as part of a broader move to increase the quality of care—and avoid costly readmissions and other adverse outcomes.²⁵

• Medical Errors and Patient Safety: The overall impact of telemedicine on safety is less studied, and some have raised concerns.²⁶ One study reviewed 32 cases that ended with catastrophic outcomes, including deaths and malpractice settlements amounting to more than $12 million.²⁷ Without the ability to physically touch a patient, the doctor is limited in the care they can provide. However, telemedicine is a tool meant to complement existing healthcare methods, not replace them. Telemedicine will not replace traditional in-person visits; only expand the range of care providers are able to offer. While an in-person exam is important in many scenarios, there are still conditions that do not require one, like the common cold. However, for a set of other conditions, the absence of the traditional face-to-face encounter may increase the risk of medical errors.²⁸
• Patient Privacy: Telemedicine complies with HIPAA laws, which aim to prevent private or secure medical documents from being leaked. However, there is no guarantee that routine data transmissions from an app or medical device, such as an insulin pump, may be shared with third-party advertisers or others.²⁹
• Licensing: States have varying licensing regulations, which can be a challenge for many telemedicine providers. While virtually all physicians must be licensed in the state in which they physically practice, a number of states require that physicians must also have a valid license in the state where the patient is located.³⁰ For this reason, states are introducing legislation to join the Interstate Medical Licensure Compact, which offers an expedited pathway to licensure for qualified physicians who wish to practice in multiple states.³¹ In recent years, numerous telemedicine bills have been focusing on scope of practice and licensing for nurse practitioners and physical therapists as well.³²

How Does Telemedicine Help with Value?

State health policy leaders are faced with the challenge of making sure all residents have adequate access to care. In support of this goal, the use of telemedicine has gained traction, especially in rural areas. Advancements in high-speed broadband and wireless communications have made these services more reliable and affordable.

Consumers support these advances. According to a 2015 American Well Telemedicine Consumer Survey, 64 percent of Americans would be willing to have a video visit with their doctor.³³ Consumers want telemedicine because it is convenient and it reduces travel time and related stresses for the patient.

Live video, in particular, has a higher appeal among consumers.³⁴ Patients do not need to be in a clinical setting to receive basic care to address minor concerns; they can stay in their home and video conference their physician through a computer, tablet or smartphone. Providers can then assess physical symptoms and ailments, such as skin rashes, post-operative stitches.

Telemedicine can be particularly valuable for patients in rural communities. They are more likely than their urban counterparts to have trouble either physically or financially getting to a health clinic, especially because rural hospital closures continue to climb at an alarming rate.³⁵ According to the National Rural Health Association, more than 70 rural hospitals have closed since 2010.³⁶ Rural communities are more likely to have older residents who might have more risk factors and chronic conditions. Telemedicine has some of the highest adoption in some of the nation's most remote areas: The three states with the highest telemedicine use are Alaska (75%), Arkansas (71%) and South Dakota (70%).³⁷ 

As noted above, telemedicine can increase the quality of care and potentially provide cost savings. Patients have better access to a variety of specialists through telemedicine including psychiatry, which has increased the number of people receiving appropriate care for behavioral health issues.³⁸ Even in situations where a patient’s condition requires transfer to a hospital, telemedicine services can provide a live audio and visual consultation from a specialist to where the patient is physically receiving care, possibly alleviating the need for a second transport.³⁹

Recommendations

Telemedicine has revolutionized medicine by increasing access and quality of care while decreasing costs. Telemedicine also reduces the inconveniences, cost and health effects of traveling to a provider or healthcare facility.

To leverage these benefits, many states still need to adapt or expand telemedicine regulations. Some recommendations include:

• Including telemedicine in all payment models, with research to ensure the outcomes and cost-effectiveness of reimbursement levels. 
• Easing regulations on licensing and geographic areas where telemedicine can be utilized, in order to reach a broader patient population—while keeping an eye on patient safety.
• Pair telemedicine legislation with appropriately expanded scope of practice rules (physician assistants and nurse practitioners, for example)⁴⁰ to increase the number of providers who can assist the patient.
• Continue to pursue national efforts to provide broadband internet access in rural areas.
• Be vigilant about patient privacy regulations and data breaches to protect the privacy of telemedicine data transmissions and storage.

 Notes

1. Center for Connected Health Policy, What is Telemedicine, http://www.cchpca.org/what-is-telemedicine (accessed Oct. 1, 2017).
2. eVisit, Telemedicine Guide, https://evisit.com/what-is-telemedicine/ (accessed Oct. 25, 2017).
3. National Quality Forum, Creating a Framework to Support Measure Development for Telemedicine, Washington, D.C. (2017).
4. Center for Connected Health Policy, What is Telemedicine, http://www.cchpca.org/what-is-telemedicine (accessed Oct. 1, 2017).
5. Center for Connected Health Policy, Video Conferencing, http://www.cchpca.org/what-is-telemedicine/video-conferencing (accessed Sept. 27, 2017).
6. eVisit, Telemedicine Solutions, https://evisit.com/telemedicine-solutions/ (accessed Sept. 27, 2017).
7. Rural Broadband Association, Anticipating Economic Returns of Rural Telemedicine, Arlington, VA (2017).
8. Alkon, Cheryl, “Using Telemedicine to Advance Value-Based Care,” Modern Healthcare (Jan. 11, 2017).
9. Uscher-Pines, Lori, and Ateev Mehrotra, “Analysis of Teledoc Use Seems to Indicate Access to Care for Patients Without Prior Connection to a Provider,” Health Affairs (February 2014).
10. Chumbler, Neale, et al., Early Outcomes of a Care Coordination-Enhanced Telehome Care Program for Elderly Veterans with Chronic Heart Failure, Telemedicine Journal and e-Health (January 2005).
11. Davis, Jessica, “Telemedicine Improves Patient Care, Outcomes in ICU, Nurses Say,” Healthcare IT News (Jan. 7, 2016).
12. Uscher-Pines and Mehrotra (February 2014).
13. Healthcare Value Hub, Improving Healthcare Value in Rural America, Research Brief No. 19 (October 2017).
14. Schadelbauer, Rick, Anticipating Economic Returns of Rural Telemedicine, Rural Broadband Association, Arlington, VA (March 2017).
15. Ibid.
16. Ibid.
17. Ibid.
18. Federal Communications Commission, “2016 Broadband Progress Report,” FCC 16-6 (Jan. 29, 2016).
19. Ibid.
20. Center for Connected Health Policy, State Telemedicine Laws and Reimbursement Policies, Sacramento, CA (Fall 2017).
21. Ibid.
22. American Hospital Association, Telemedicine: Helping Hospitals Deliver Cost-Effective Care, Washington, D.C. (2016).
23. Wicklund, Eric, “Medicare Spending on Telemedicine Increases but Barriers Remain,” Mhealth Intelligence (Aug. 28, 2017).
24. Ibid.
25. American Hospital Association, Telemedicine: Helping Hospitals Deliver Cost-Effective Care, Washington, D.C. (2016).
26. Agboola, Stephen, and Joseph Kvedar, “Telemedicine and Patient Safety,” Patient Safety Network (September 2016).
27. Katz, Harvey P., et al., “Patient Safety and Telephone Medicine: Some Lessons from Closed Claim Case Review,” Journal of General Internal Medicine (May 2008).
28. Ibid.
29. Hall, Joseph L., and Deven McGraw, “For Telemedicine to Succeed, Privacy and Security Risks Must be Identified and Addressed,” Health Affairs (February 2014).
30. Schadelbauer (March 2017).
31. Interstate Medical Licensure Compact, The IMLC, http://www.imlcc.org/ (accessed Oct. 25, 2017).
32. National Quality Forum, Creating a Framework to Support Measure Development for Telemedicine, Washington, D.C. (August 2017).
33. Alkon (Jan. 11, 2017).
34. Ibid.
35. Schadelbauer (March 2017).
36. Ibid.
37. Alkon (Jan. 11, 2017).
38. American Hospital Association, Telemedicine: Helping Hospitals Deliver Cost-Effective Care, Washington, D.C. (April 22, 2016).
39. Ibid.
40. Healthcare Value Hub, Provider Scope of Practice: Expanding Non-Physician Providers’ Responsibilities Can Benefit Consumers, Research Brief No. 21, Washington, D.C. (November 2017).