Research Anthology: Telehealth and Telemedicine

Overview of telehealth

What telehealth is

Telehealth is "the use of electronic information and telecommunication technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration."A Often, telehealth is interchangeable with the terms telemedicineB or eHealth. Telemedicine and eHealth are distinct areas within the broader telehealth.C

What telemedicine and eHealth are

The Federation of State Medical Boards defines telemedicine as "the practice of medicine using electronic communication, information technology, or other means between a physician in one location, and a patient in another location, with or without an intervening health care provider."D The World Health Organization defines eHealth as "the use of information and communication technologies (ICT) for health."E

The benefits of telehealth

Telehealth is a promising public health tool because:

• It has the potential to significantly increase access to healthcare for the medically underserved.
• There is a widespread belief that it can reduce healthcare costs and improve overall health outcomes.
• It is an efficient way for people to receive care in rural areas facing federal legislative demands for medical services in short supply.

The challenges of telehealth

Despite recent popularity growth, telehealth faces barriers hindering its widespread adoption. Gaps exist in state statutes and regulations governing telehealth for the following areas:

• Information security
• Patient privacy
• Licensing
• Insurance reimbursement
• Liability concerns

Learn more about the policy and legal considerations for implementing and governing telehealth in the resources provided below.

Telehealth adoption barriers

The following resources identify and discuss barriers limiting the implementation and expansion of telehealth.

• Utilization of Outpatient Telehealth Services in Parity and Nonparity States 2010–2015, Jillian B. Harvey et al., Telemedicine Journal and e-Health (2018), http://doi.org/10.1089/tmj.2017.0265.
  • Compares private insurance reimbursement rates for outpatient healthcare telehealth in states with and without laws requiring such reimbursement.

• Telehealth and Remote Patient Monitoring Use in Medicare and Selected Federal Programs, United States Government Accountability Office (2017).
  • Highlights views of provider, payer, and patient associations about the potential benefits of and barriers to telehealth in government healthcare programs.
  • Provides data on the use of telehealth in services offered by the Centers for Medicare & Medicaid Services, the Department of Defense, and the Department of Veterans Affairs.

• Telehealth, Reed V. Tuckson et al., 377 New England Journal of Medicine 1585 (2017), doi: 10.1056/NEJMsr1503323.
  • Reviews several reports and studies that inform the authors' policy recommendations.
  • Devotes much of the article to the disconnect between electronic health records, patient and provider interaction with software and devices.
  • Prioritizes a technological platform for telehealth that would serve as a sort of one-stop-shop for healthcare providers and consumers.

• Legal Considerations in Telehealth and Telemedicine, Edie Brous, 116 American Journal of Nursing 64 (2016), doi:10.1097/01.NAJ.0000494700.78616.d3. Subscription required.
  • Highlights many of the provider barriers surrounding telehealth and telemedicine, including lack of evidence for positive outcomes, liability concerns, technological barriers, and especially licensing requirements.
  • Provides a unique perspective, articulating barriers for nurses, who require their own state licensures, when much of the literature deals only with physicians.

• State of Telehealth, E. Ray Dorsey & Eric J. Topol, 375 New England Journal of Medicine 154 (2016), doi: 10.1056/NEJMra1601705. Subscription required.
  • Examines the exponential rise in the investment in, and adoption of telehealth.
  • Focuses on promising future applications, as well as limitations of the technology and healthcare industry.
  • Highlights social reasons that might limit expansion, including the high percentage of chronically ill patients over age 65 and the lower rates of internet usage by older and rural populations.

• Telehealth Policy Trends and Considerations, National Conference of State Legislatures (2015).
  • Reviews state telehealth legislation and policies in 2015.
  • Analyzes many peer-reviewed studies indicating substantial cost savings and suggesting improved health outcomes.
  • Highlights the expansion of licensing compacts among states, as well as the proliferation of private payer reimbursement of telehealth services.

• Private Payer Telehealth Reimbursement in the United States, Nina M. Antoniotti et al., 20 Telemedicine Journal and e-Health 539 (2014), doi: 10.1089/tmj.2013.0256.
  • Meta-analysis of the difficulties healthcare providers have navigating insurance codes and reimbursement.
  • Identifies government payers' influence over private payer insurance providers.

• For Telehealth to Succeed, Privacy and Security Risks Must be Identified and Addressed, Joseph L. Hall & Deven McGraw, 33 Health Affairs (Millwood) 216 (2014), doi: 10.1377/hlthaff.2013.0997.
  • Examines possible barriers to telehealth from privacy and security perspectives.
  • Addresses privacy regulation beyond the Health Insurance Portability and Accountability Act (HIPAA) for information supplied and received by the patient.
  • Contemplates the rights of patients when they are forced to accept terms and licensing in order to use an app or device.

Telehealth cost and health outcomes

Proponents of telehealth believe it will expand access, reduce costs, and improve health outcomes. The following resources discuss attempts made by researchers to empirically evaluate claims that telehealth improves health outcomes, reduces healthcare costs, or both.

• What is the Economic Evidence for mHealth? A Systematic Review of Economic Evaluations of mHealth Solutions, Sarah J. Iribarren et al., 12 Plos One (2017), doi:10.1371/journal.pone.0170581.
  • Summarizes and assesses the body of evidence related to economic evaluations of mobile health (mHealth) interventions.
  • Takes a conservative approach by limiting cost savings to primary outcomes.
  • Notes that most studies claiming cost benefits lack sufficient supporting evidence but supports an overall cost-effectiveness for mHealth interventions.
  • Warns against generalizing to all interventions.

• Urban Telemedicine Enables Equity in Access to Acute Illness Care, Sarah D. Ronis et al., 23 Telemedicine Journal and e-Health 1 (2017), doi: 10.1089/tmj.2016.0098.
  • Studies urban telemedicine use for acute care compared to suburban populations without telehealth use.
  • Finds an overall cost savings, due largely to reductions in visits to the emergency department.
  • Reports that the use of telemedicine increased healthcare access substantially in the urban population.
  • Indicates providers reported that a majority of office visits could have taken place via telemedicine.

• Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study, Lucas Van Oeveren et al., 23 Telemedicine Journal and e-Health 1 (2017), doi: 10.1089/tmj.2016.0140.
  • Studies rural, Midwestern hospitals' use of telemedicine to assist nonemergency-trained physicians when they intubate patients.
  • Finds that health outcomes improved through use of the technology.

• The Empirical Foundations of Telemedicine Interventions in Primary Care, Rashid Bashshur et al., 22 Telemedicine Journal and e-Health 342 (2016), doi: 10.1089/tmj.2016.0045.
  • Reviews nearly three dozen studies of telemedicine intervention in primary care.
  • Finds that the studies commonly affirmed the feasibility and acceptance of telemedicine in primary care, and telemedicine typically resulted in care quality improvements and cost savings.

• Cost-Utility and Cost-Effectiveness Studies of Telemedicine, Electronic, and Mobile Health Systems in the Literature: A Systematic Review, Isabel de la Torre-Díez et al. 21 Telemedicine Journal and e-Health 81 (2015), doi: 10.1089/tmj.2014.0053.
  • Reviews thirty-five studies dealing with costs of various forms of telehealth.
  • Reports discrepancies in methods, aims, and results, prompting the authors to declare that current studies are inconclusive on the matters of cost-utility and cost-effectiveness of telehealth.

• Interactive Telemedicine: Effects on Professional Practice and Health Care Outcomes, Gerd Flodgren et al., Cochrane Database of Systematic Reviews (2015), doi: 10.1002/14651858.CD002098.pub2.
  • Meta-analyzes more than 90 studies evaluating telemedicine use and effectiveness across many medical conditions.
  • Looks at remote monitoring and real-time teleconferencing interventions.
  • Finds that cost-savings claims in telemedicine are inconclusive across studies, but a reduction in the number of hospitalizations for patients with chronic conditions is indicated.
  • Calls for further study.

• Telepsychiatry Integration of Mental Health Services into Rural Primary Care Settings, John C. Fortney et al., 27 International Review of Psychiatry 525 (2015), doi: 10.3109/09540261.2015.1085838. Subscription required, link to abstract provided.
  • Compares several models that combine telepsychiatry with in-person care.
  • Concludes that telepsychiatry has the potential to significantly improve access to care, based on the results of implementation by the US Department of Veterans Affairs.

• High-Intensity Telemedicine Decreases Emergency Department Use by Senior Living Community Residents, Manish N. Shah et al., 22 Telemedicine Journal and e-Health 251 (2015), doi: 10.1089/tmj.2015.0103.
  • Studies the effectiveness and acceptance of telemedicine in senior living communities.
  • Finds that more than 80 percent of residents surveyed would prefer a community with telemedicine capabilities for acute illness.
  • In terms of cost savings, finds an 18 percent reduction in emergency department visits annually, which the authors indicate is a conservative number based on study limitations.

Telehealth statutes and regulations

Federal regulations generally pertain to use of telehealth in government-supported health care through the Department of Veterans Affairs and Medicare. State laws govern use of telehealth in Medicaid programs, licensing requirements for practicing telehealth within the state, and private insurance reimbursement for telehealth services. The following resources discuss state and federal statutes and regulations governing the use of telehealth.

• State Telehealth Laws and Reimbursement Policies Report, Center for Connected Health Policy (2018).
  • Surveys 50 states and the District of Columbia on telehealth-related statutes, regulations, and Medicaid provider manuals.
  • Covers areas of telehealth and telemedicine definitions, insurance reimbursement, prescribing, consent, and location of services provided.

• 50-State Survey: Establishment of a Patient-Physician Relationship via Telemedicine, American Medical Association (2017).
  • Compiles a collection of laws demonstrating that all states allow physicians to establish new patient relationships via telemedicine, noting that state laws vary.
  • Provides a table of existing state laws with citations and the relevant language of each statute.

• State Telemedicine Gap Analysis, American Telemedicine Association (2017).
  • Reports on coverage and reimbursement gaps in state laws related to provision of telehealth services.

• Legal Mapping Analysis of State Telehealth Reimbursement Policies, Kate E. Trout et al., 23 Telemedicine Journal and e-Health 1 (2017), doi: 10.1089/tmj.2017.0016.
  • Surveys 50 states on state laws and policies relating to telehealth reimbursement implemented since 1997.
  • Identifies where policies exist, the types of telehealth covered or restricted by state, and the form of telehealth.
  • Provides a separate analysis of state Medicaid reimbursement.

• Telehealth: Applications from a Legal and Regulatory Perspective, Rita M. Marcoux & F. Randy Vogenberg, 41 Pharmacology & Therapeutics 567 (2016).
  • Assesses policies and regulations, identifying which agencies have the ability to regulate telehealth and the scope of those regulatory authorities.
  • Points to successful government implementations of telehealth, but also acknowledges the lack of consistency across policies and the murky status of the law around telehealth.

• U.S. and Territory Telemedicine Policies: Identifying Gaps in Perinatal Care, Ekwutosi M. Okorohet et al., 215 American Journal of Obstetrics & Gynecology 1 (2016), doi: http://dx.doi.org/10.1016/j.ajog.2016.08.020. Subscription required, link to abstract provided.
  • Surveys state telemedicine policies focused on three aspects of maternal and neonatal care: consultation, diagnosis, and treatment.
  • Notes only three states specifically mention maternal or neonatal concerns, while looking at 50 states, the District of Columbia, and eight territories for applicable, broad telemedicine policies.

• HIPAA and Telehealth, Center for Connected Health Policy (2014).
  • Provides a concise guide to HIPAA compliance for covered entities using telehealth technologies for providing health care.
  • Specifically talks about the role of conduits, a narrowly defined role in information delivery, such as Skype and FaceTime.

Recent telehealth policy recommendations

Telehealth faces regulation at multiple levels. Each state sets its own rules for practicing telehealth within its borders. Additionally, many federal agencies have the authority to regulate various aspects of telehealth. The following resources identify the existing reach and gaps in the web of state and federal regulations and statutory provisions.

• An Emergent Research and Policy Framework for Telehealth, Margo Edmunds et al., 5 Journal of Electronic Health Data and Methods (2017), doi: http://doi.org/10.13063/2327-9214.1303.
  • Proposes a framework for moving forward with telehealth, including standardization of terms and policies for both consistent outcomes in research and practice, and implementation of policies.

• Health Policy Brief: Telehealth Parity Laws, Tony Yang, Health Affairs (2016), doi: 10.1377/hpb2016.12.
  • Provides a brief overview of the debate surrounding reimbursement parity.
  • Summarizes the concerns of the opponents to parity and offers support for parity through studies and other reports.
  • Briefly discusses state parity laws on the books in 2016.

• Going Online With Telemedicine: What Barriers Exist and How Might They Be Resolved, Pierron Tackes, 11 Oklahoma Journal of Law & Technology 80 (2015).
  • Identifies obstacles to telemedicine policy as politically based rather than science based.
  • Contrasts the attempts at telemedicine expansion by the federal government with the hindering effects of state regulation of medical practice.
  • Proposes a solution of mandating arbitration for claims arising out of interstate telemedicine use.

• Patient Safety Risks Associated with Telecare: A Systematic Review and Narrative Synthesis of the Literature, Veslemøy Guise et al., 14 BMC Health Services Research 588 (2014), doi: http://doi.org.ezproxy.library.tamu.edu/10.1186/s12913-014-0588-z.
  • Analyzes several patient safety studies concerning telecare, identifying gaps in the research and potential areas for study.
  • Suggests a human factors framework to study patient safety risks of home telecare.

• Interstate Licensure for Telemedicine: The Time Has Come, Mei Wa Kwong et al., 16 American Medical Association Journal of Ethics 1010 (2014), doi: 10.1001/virtualmentor.2014.16.12.pfor2-1412.
  • Addresses the need for uniform regulation of interstate medical licensing to better implement telemedicine and expand access.

Telehealth in rural areas

A chief benefit of telehealth is the ability to provide access to medically underserved populations. The following resources discuss attempts to broaden healthcare access through telehealth interventions, including successes and opportunities for expanding telehealth.

• The Promise of Telehealth: Strategies to Increase Access to Quality Healthcare in Rural America, Center for Health Law and Policy Innovation, Harvard Law School (2018).
  • Identifies legal and administrative barriers and strategies for broadening the use of telehealth to increase healthcare access in rural communities.

• Rural and Urban/Suburban Families' Use of a Web-Based Mental Health Intervention, Brian E. Bunnell et al., 23 Telemedicine Journal and e-Health 1 (2017), doi: 10.1089/tmj.2016.0153.
  • Investigates the applicability of web-based approaches to mental health care.
  • Finds that geographic differences did not affect the likelihood of patients or caregivers using the technology, suggesting that advancements in telehealth will lead to improved access to historically underserved rural areas.

• Rural Family Physicians Are Twice as Likely to Use Telehealth as Urban Family Physicians, Anuradha Jetty et al., 24 Telemedicine Journal and e-Health 1 (2017), doi: 10.1089/tmj.2017.0161.
  • Studies the perceptions of family physicians in both rural and urban settings, comparing attitudes toward telehealth and likelihood of future use and controlling for a number of variables.

• Rapid Growth in Mental Health Telemedicine Use Among Rural Medicare Beneficiares, Wide Variation Across States, Ateev Mehrotra et al., 36 Health Affairs (Millwood) 909 (2017), doi: 10.1377/hlthaff.2016.1461. Subscription required, link to abstract provided.
  • Studies telemedicine use from 2004 through 2014 among rural Medicare beneficiaries.
  • Finds that despite an annual growth rate of 28% over a decade, fewer than 1% of rural beneficiaries received any telemedicine care.
  • Focuses on how parity laws affect use of telemedicine.

• Utilization of Telemedicine Among Rural Medicare Beneficiaries, Ateev Mehrotra et al., 315 Journal of the American Medical Association 2015 (2016), doi: 10.1001/jama.2016.2186.
  • Reviews use of telehealth services in rural populations with mental illness and coverage under Medicare.
  • Finds that telehealth use is concentrated geographically and used by an extremely small percentage of mental health care recipients under Medicare.

• Telehealth in Rural America, National Advisory Committee on Rural Health and Human Services (2015).
  • Provides a policy brief on the current state of telehealth in rural areas at the federal level.
  • Indicates committee recommendations regarding expansion of telehealth to traditionally underserved areas, mostly concerning barriers caused by current Medicare reimbursement policies.

• Transforming Rural Health Care: High-Quality, Sustainable Access to Specialty Care, Kavita Patel et al., Health Affairs Blog (2014).
  • Comments on the slow US adoption of telehealth, specifically the opportunities of expansion into rural areas.

Acknowledgments & disclaimers

Jack Brackney, JD, MS, intern with the Public Health Law Program (PHLP) within CDC's National Center for State, Tribal, Local, and Territorial Public Health Infrastructure and Workforce; Rachel Hulkower, JD, MSPH, and Dawn Pepin, JD, MPH, Cherokee Nation Assurance contractors with PHLP; and Russell McCord, JD, Oak Ridge Institute for Science and Education fellow with CDC's National Center on Birth Defects and Developmental Disabilities developed this document.

PHLP used online databases to create this resource. PHLP searched in Google, PubMed, and WestLawNext for the terms “telemedicine,” “telehealth,” “ehealth,” and “mhealth,” along with “policy” and “law.” Searches were completed between August 2017 and September 2018. PHLP used WestlawNext to conduct searches for legal publications and Google and PubMed for additional resources.

For further technical assistance with this inventory, please contact phlawprogram@cdc.gov. PHLP provides technical assistance and public health law resources to advance the use of law as a public health tool. PHLP cannot provide legal advice on any issue and cannot represent any individual or entity in any matter. PHLP recommends seeking the advice of an attorney or other qualified professional with questions regarding the application of law to a specific circumstance.

Support for this research came in part by an appointment to the Research Participation Program at CDC administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the US Department of Energy and CDC. The findings and conclusions in this summary are those of the authors and do not necessarily represent the official position of CDC.