Barriers to Telehealth in Rural Areas

This section provides an overview of barriers to establishing, expanding, and sustaining telehealth programs in rural communities. For more information about considerations for implementing telehealth programs, see Module 4: Implementation Considerations.

Limited Access to High Speed Internet

The Health Information Technology in Rural Healthcare topic guide reviews several factors that may affect the ability of rural programs to maintain and expand access to telehealth in rural areas. For example, according to the 2018 Broadband Deployment Report, only 69.3% of rural areas and 64.6% of tribal areas had access to high-speed broadband internet that met the minimum benchmark set by the Federal Communications Commission (FCC). The availability of broadband affects the ability of patients to participate in video consultations, transmit health information, and monitor their health at home.

Limited Access to Smartphones

Many mobile health and remote patient monitoring systems require access to smartphone applications. However, rural populations are less likely to own smartphones when compared to other populations. In 2019, 71% of rural residents reported owning a smartphone, compared to 83% of suburban and urban residents. Rural programs may have to allocate additional funds in order to purchase equipment for patients participating in mobile health interventions.

Credentialing and Licensing

State requirements for licensing and credentialing of telehealth providers vary widely. States typically require providers to be licensed in the state where the patient receives services. Providers may decline to pursue licensure in different states because of high costs and lack of time. Rural organizations with limited resources may also lack the capacity to credential telehealth providers, which involves verifying licenses and qualifications.

Reimbursement

Lack of reimbursement is a key barrier to use of telehealth services. For example, each state has different rules and regulations about the types of services that can be reimbursed by Medicaid. The National Telehealth Policy Resource Center reports that in 2018, only 9 states reimbursed the 3 key telehealth modalities: live video, store-and-forward, and remote patient monitoring.

In addition, Medicare strictly regulates the types of providers who are reimbursed for providing telehealth services. For example, many states place restrictions on reimbursable “originating sites,” which refer to the location of the patient at the time they receive the telehealth services. These restrictions affect access to telehealth for rural populations. There are 23 states with lists of specific sites that can serve as an originating site for telehealth, with 13 states allowing the home and 15 states allowing schools to serve as originating sites for telehealth. However, many states do not reimburse home-based telehealth services, or only reimburse service provided through home health agencies, creating barriers to using telehealth to reach patients at home.

In addition to limited reimbursement policies, rural programs have also described a lack of clarity about existing regulations. For example, one report describes reduced provider participation in asynchronous telehealth as a result of a lack of clarity about the reimbursement policies.

Sustainability

Rural telehealth programs may face challenges with sustaining services. For example, programs may have issues with monetizing the value generated by telehealth services. Rural programs with very low patient volumes may have issues engaging specialists to provide services when the demand for telehealth is sporadic. In addition, rural programs may have difficulties with maintaining infrequently used telehealth equipment and paying expensive connectivity fees. For strategies to address sustainability, see Module 6: Funding & Sustainability of Rural Telehealth Programs.

Malpractice

The Center for Connected Health Policy fact sheet, Telehealth Policy Barriers, states that some malpractice policies do not cover telehealth services. Providers may decline to participate in telehealth because of liability concerns.

Transportation

Telehealth can address the barriers to care of long travel distances to access healthcare services and lack of reliable transportation that affect people who live in rural areas. For example, receiving home-based services can reduce the need to travel long distances to receive care. However, some telehealth services still require patients to travel to a provider's office or agency to receive live video consultations. Patients who need to travel long distances to receive traditional care may face similar issues when seeking face-to-face telehealth consultations.

Interoperability

Interoperability, which includes the exchange of electronic health information, remains a challenge for many rural healthcare providers. Some rural telehealth programs may face difficulties with ensuring secure and effective methods for providers from different systems to share information and access electronic health records.

Mistrust of Technology and Healthcare

Some patients may lack trust in the quality of telehealth services. In addition, patients may have concerns about the security of information that is transmitted via telehealth.

Lack of Provider Buy-in or Utilization

Some providers may lack interest in providing telehealth if they assume patients will be unwilling to meet with them remotely in lieu of an office visit. Other programs may underutilize telehealth because staff struggle to incorporate telehealth services into their workflow.

Despite the challenges, rural communities are increasingly using telehealth to overcome persistent barriers to accessing care, including:

Rural hospital closures due to declining rural populations and insufficient revenue
Disproportionately high numbers of older adults with limited mobility who are aging in place
Lack of access to healthcare services, especially for specialty care
Shortage of health professionals

The following toolkits include telehealth models that provide additional information about barriers to providing care:

Resources to Learn More

Rural Behavioral Health: Telehealth Challenges and Opportunities
Document
Reviews existing barriers to mental health and substance use disorder treatment. Covers services in rural communities, presents ways telehealth can address these barriers, and discusses the challenges in implementing telehealth services in rural areas.
Organization(s): Substance Abuse and Mental Health Services Administration
Date: 2016

Telehealth Policy Barriers
Document
Discusses existing policy barriers at the federal and state level that inhibit the use of telehealth in rural and urban areas, such as reimbursement, malpractice, licensing, HIPAA/privacy/security, prescribing, credentialing and privileges.
Organization(s): Center for Connected Health Policy: The National Telehealth Policy Resource Center
Date: 2/2018

While Telehealth Workforce Expands, Barriers Slow Availability
Document
Describes barriers to telehealth expansion rural providers encounter, such as physician licensing, reimbursement, and technology challenges.
Author(s): Helseth, C.
Organization(s): Rural Health Information Hub
Citation: The Rural Monitor
Date: 8/2013