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
According to the Pew Research Center, as of 2021 only
72% of rural areas have access to high-speed broadband internet. In addition, only 65% of housing units on
rural tribal lands have access to broadband services. The availability of broadband affects the ability
of patients to participate in video consultations, transmit health information, and monitor their health at
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 2020, 80% of rural residents reported owning a
smartphone, compared to 89% of 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. In addition, credentialing and
licensing requirements underwent several changes because of the COVID-19 pandemic and continue to be subject to
new regulations from federal and state legislatures. Some states participate in interstate compacts that make it easier
for rural providers to practice in more than one state and for rural patients to receive care from providers.
Rural organizations with limited resources may also lack the capacity to credential telehealth providers, which
involves verifying licenses and qualifications.
Lack of reimbursement has been a historic 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. During the
COVID-19 pandemic, many states increased reimbursement for telehealth services. The Center for Connected Health
Telehealth Laws and Reimbursement Policies Report reports that all 50 states were providing Medicaid
reimbursement for live video visits, but only 34 were reimbursing for remote patient monitoring.
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
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
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.
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. In 2021, the Centers for Medicare & Medicaid Services
began enforcing some additional
regulations related to interoperability.
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.
Resources to Learn More
Rural Behavioral Health: Telehealth
Challenges and Opportunities
Reviews existing barriers to mental health and substance use disorder treatment. Discusses services in rural
communities, presents ways telehealth can address these barriers, and identifies the challenges in implementing
telehealth in rural areas.
Citation: In Brief, 9(2)
Organization(s): Substance Abuse and Mental Health Services Administration (SAMHSA)
Telehealth in Response to the COVID-19
Pandemic: Implications for Rural Health Disparities
Describes how telehealth initiatives, in response to the pandemic, have developed in rural healthcare, and how
reliance on telehealth in rural areas without adequate broadband may increase rural health disparities. Offers
recommendations for policymakers and researchers supporting telehealth proposals that do not intensify health
disparities in rural communities.
Author(s): Hirko, K.A., Kerver, J.M., Ford, S., et al.
Citation: Journal of the American Medical Informatics Association, 27(11), 1816-1818
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, and
Organization(s): Center for Connected Health Policy: The National Telehealth Policy Resource Center
The Time Is Now: A Guide to Sustainable
Telemedicine During COVID-19 and Beyond
Outlines several important concepts, terminologies, and resources to help physicians stay abreast of
telemedicine. Discusses barriers to utilization, billing procedures, platform selection, and changes in policies
for telemedicine services during COVID-19.
Author(s): Shah, E.D., Amann, S.T. & Karlitz, J.J.
Location: American Journal of Gastroenterology, 115(9), 1371-1375