Telehealth Use in Rural Healthcare
Telehealth can assist healthcare systems, organizations, and providers expand access to and improve the quality of rural healthcare. Using telehealth in rural areas to deliver and assist with the delivery of healthcare services can reduce or minimize challenges and burdens patients encounter, such as transportation issues related to traveling for specialty care. Telehealth can also improve monitoring, timeliness, and communications within the healthcare system.
Telehealth uses telecommunications technology and other electronic data to assist with clinical healthcare services provided at a distance, which can also include providing education, administrative functions, and peer meetings. While one of the most common images of telehealth is that of a patient speaking by videoconference with a healthcare provider who is located remotely, telehealth can take other forms, including:
- Remote patient monitoring (RPM)
- Store and forward transmission of medical information
- Mobile health communication (mHealth)
This guide provides an overview of telehealth in rural America to help healthcare providers find information related to providing telehealth services and highlights funding opportunities and other initiatives to implement telehealth services. The guide includes examples of telehealth projects to serve as models for rural hospitals and clinics to develop and implement telehealth programs. Challenges for providing telehealth services in rural areas are also discussed, such as workforce issues, quality of care concerns, reimbursement, licensure, and access to broadband services.
Frequently Asked Questions
- How does telehealth improve healthcare access in rural communities, and what types of services have proven to be effective?
- What is the difference between telemedicine and telehealth?
- How do Telehealth Resource Centers (TRCs) help rural healthcare facilities develop telehealth services within their organization?
- What are some telehealth funding programs for rural providers?
- What are the challenges related to telehealth services in rural communities?
- What facilities, technology, and staffing would our facility need to implement telehealth services?
- How can telehealth be used to reach patients in their homes?
- How does the use of telehealth impact rural healthcare providers?
- What financial impact could the addition of telehealth services have on a rural facility and community?
- Is telehealth usage widespread in rural facilities?
How does telehealth improve healthcare access in rural communities, and what types of services have proven to be effective?
The National Academies of Science, Engineering, and Medicine 2012 workshop summary, The Role of Telehealth in an Evolving Health Care Environment, discusses how telehealth can drive volume, increase the quality of healthcare, and reduce overall costs by reducing readmissions and avoidable emergency department visits for rural communities. Telehealth allows small rural hospitals to provide quality healthcare services at lower costs and in the local healthcare facility which benefits rural patients, since they are no longer required to travel long distances to access specialty care. Avoiding patient transfers when care can be provided locally is critical for both small hospital and provider viability in rural areas. It also helps tertiary care centers keep beds open for patients in need of critical care.
Using telehealth to provide specialty services is more feasible for rural healthcare facilities than staffing those rural facilities with specialty and subspecialty providers. Telehealth allows specialists and subspecialists to visit rural patients virtually, improving access as well as making a wider range of healthcare services available to rural communities via telemedicine, including:
Often, rural primary care providers and subspecialist providers are able to work as a team to share knowledge and manage patient care through the e-consult model or other successful programs, such as Project ECHO® – Extension for Community Healthcare Outcomes. Effective healthcare services and programs administered through telehealth technology in rural communities include:
- Chronic care management interventions using telehealth to provide patients with access to integrated care during their primary care visits. The TeleTEAM Care for Diabetes Program offers integrated healthcare services for diabetes patients during primary care visits using telehealth to connect with behavioral therapists, dietitians, clinical pharmacists, and a medical diabetologist.
- Access to emergency care providers in real time for evaluations and consults to local providers. Avera eCARE Emergency provides emergency consultations and a variety of emergency services via telehealth to rural emergency rooms.
- Home monitoring can engage patients in their homes between medical visits by helping them effectively manage their conditions. Bridges to Care Transitions-Remote Home Monitoring and Chronic Disease Self-Management is an example of a telehealth remote monitoring program that assists patients with chronic disease management and behavioral health conditions in their homes.
- Intensive care units (ICUs) provide around-the-clock critical care patient monitoring by a team of subspecialists and critical care nurses. Avera eCARE ICU provides 24/7 intensive care monitoring of critically ill patients via telehealth.
- Long-term care services offered through telehealth can bring specialized care to elderly populations who reside in long-term care facilities in rural areas. Telehealth technology, implemented in the SD eResidential Facilities Healthcare Services Access Project, allows specialists located in urban areas to connect with residents in rural long-term care facilities with chronic health problems.
- Online therapy and remote counseling link rural residents with urban behavioral health and mental health counseling services. In Texas, the Madison Outreach and Services through Telehealth (MOST) Network offers counseling services by video and phone to Spanish-speaking residents.
- Telepharmacy extends access to pharmacy services, including medications and medication counseling, at rural healthcare facilities and community pharmacies.
- Electronic communications connect providers working in isolated areas to create virtual professional communities that can assist with patient care.
- Healthcare providers' use of mobile devices, such as tablets and smartphones, can improve communications with patients and other providers.
- Interpreter services can be transmitted on-demand through audio and/or visual technology for patients who speak limited or no English.
Programs supported by telehealth offer new methods for improving healthcare access and quality by extending the reach of healthcare services, improving the ability of rural providers to address a broader range of medical conditions, and facilitating collaboration between professionals with limited access to their colleagues. For more project examples, see RHIhub's listing of telehealth rural health models and innovations.
What is the difference between telemedicine and telehealth?
The Health Resources and Services Administration's (HRSA) Office for the Advancement of Telehealth (OAT) defines telehealth as:
using electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health and health administration.
The Office of the National Coordinator for Health Information Technology's (ONC) Health IT Playbook Section 5.3 defines
remote clinical services with
interactive health communications with clinicians on
both ends of the exchange.
Telehealth can include remote non-clinical services, such as training, Project ECHO®, administrative meetings, and continuing medical education, in addition to clinical services. Although telehealth is broader in scope, the American Telemedicine Association and many other organizations use the terms telemedicine and telehealth interchangeably.
How do Telehealth Resource Centers (TRCs) help rural healthcare facilities develop telehealth services within their organization?
The 12 regional and 2 national TRCs make up the National Consortium of Telehealth Resource Centers (NCTRC) and are funded by Office for the Advancement of Telehealth (OAT) to assist healthcare organizations, networks, and providers with implementing and answering ongoing questions related to cost-effective telehealth programs to serve rural and medically underserved areas and populations. The national TRCs are:
- Center for Connected Health Policy: The National Telehealth Policy Resource Center (CCHP)
- National Telehealth Technology Assessment Resource Center (TTAC)
The regional TRCs consist of:
- California Telehealth Resource Center (CTRC)
- Great Plains Telehealth Resource and Assistance Center (gpTRAC)
- Heartland Telehealth Resource Center (HTRC)
- Mid-Atlantic Telehealth Resource Center (MATRC)
- Northeast Telehealth Resource Center (NETRC)
- Northwest Regional Telehealth Resource Center (NRTRC)
- Pacific Basin Telehealth Resource Center (PBTRC)
- South Central Telehealth Resource Center (SCTRC)
- Southeastern Telehealth Resource Center (SETRC)
- Southwest Telehealth Resource Center (SWTRC)
- TexLa Telehealth Resource Center (TexLa)
- Upper Midwest Regional Telehealth Resource Center (UMTRC)
To find the regional TRC that serves your state, see NCTRC's Find Your TRC map and click on your state. NCTRC offers fact sheets; guides, templates, and checklists; research catalogs; news; events; and webinars that cover a wide range of topics including:
- Staffing and recruiting specialists
- Education and training
- Credentialing and licensing
- Medical malpractice and liability
Telehealth Connect is a registry to locate telehealth provider sites in the U.S. that can be searched by medical specialty, location, practice type, and more. NCTRC hosts a national TRC webinar series that offers monthly webinars on telehealth and related topics. Past webinars in the series are also available as resources.
What are some telehealth funding programs for rural providers?
There are several grant programs focused on funding rural telehealth projects:
The U.S. Department of Agriculture (USDA) Rural Development sponsors several programs and opportunities for
- Rural Broadband Access Loan and Loan Guarantee Program provides funds for the costs of construction, improvement, or acquisition of facilities and equipment needed to provide broadband service in eligible rural areas.
- USDA Distance Learning and Telemedicine Loan and Grant Program offers grants to support and improve telemedicine and distance learning services in rural areas.
- USDA Community Facilities Direct Loan and Grant Program awards direct loans and/or grants for essential community facilities in rural areas.
- The Telehealth Network Grant Program (TNGP) is offered by the Federal Office of Rural Health Policy. TNGP provides funding for telehealth networks and programs to improve access to healthcare services in rural, frontier, and underserved areas.
- The Universal Service Administrative Company (USAC) offers the Rural Health Care Telecommunications Program that provides assistance to rural healthcare providers on eligible expenses for broadband and telecommunications access.
Additional funding for rural telehealth programs and opportunities can be found in the Funding and Opportunities section of this guide.
What are the challenges related to telehealth services in rural communities?
Despite the promise telehealth holds for improving access to healthcare services in rural areas, there are often policy barriers and infrastructure inadequacies that must be overcome. Some challenges to telehealth adoption, implementation, and success include:
The issue of Medicare reimbursement is commonly cited as a major challenge for telehealth programs. CCHP's 2019 fact sheet, Telehealth Reimbursement, discusses some criticisms of the current Medicare reimbursement model for telehealth including:
- Geographic and originating site restrictions
- Provider restrictions
- Service restrictions
Individual state Medicaid programs vary in their guidelines regarding reimbursement for telehealth services. CCHP's 2019 report, State Telehealth Laws and Reimbursement Policies, summarizes telehealth-related laws and reimbursement policies for all 50 states and the District of Columbia. The report includes a focus on Medicaid coverage for telehealth. CCHP also maintains two interactive maps, one for current telehealth state laws and reimbursement policies and the other for telehealth legislation and regulation tracking. The National Rural Health Association (NRHA) policy brief, 2017 Telehealth Policy for the National Rural Health Association, elaborates on barriers to telehealth and provides policy recommendations to increase access to telehealth. Reimbursement by private payers for telehealth services can also vary. Some health insurance companies reimburse for telehealth services, while others do not.
The Center for Telehealth and e-Health Law (CTeL) works to address the legal and regulatory barriers to the adoption of telehealth. CTeL provides a Reimbursement Overview of telehealth and covers Medicare Reimbursement and Medicaid Reimbursement more in depth.
The 2013 NRHA policy brief, Streamlining Telemedicine Licensure to Improve Rural America, describes how the current physician licensure system places burdens on physicians wanting to expand their practice to rural areas. Physicians who wish to practice across state lines must be licensed by the professional licensing board in each state where they are delivering care to patients. Telehealth and Licensing Interstate Providers, a National Conference of State Legislatures 2016 briefing paper, explores actions states have taken to ease licensure barriers and the associated burden, such as:
- Offering specific licenses for telehealth
- Reciprocity and endorsement with other states
- Creating interstate compacts
The Interstate Medical Licensure Compact (IMLC) is an agreement between 29 states, the District of Columbia, and the territory of Guam, and 43 osteopathic and medical boards within those states and territory that offers an expedited process for qualified physicians to be licensed to practice in multiple states. For more information on the process, qualifications, and the agreement see IMLC's frequently asked questions. The U.S. Department of Veterans Affairs (VA) is an exception; VA physicians have license portability that allows them to practice across state lines to wherever the patient is receiving care.
There are many other licensure compacts involved in the delivery of healthcare services to rural populations using telehealth, including:
- Psychology Interjurisdictional Compact (PSYPACT)
- Nurse Licensure Compact (NLC)
- Advanced Practice Registered Nurse Compact (APRN Compact)
- Physical Therapy Licensure Compact
A 2015 report from the American Hospital Association (AHA), Realizing the Promise of Telehealth: Understanding the Legal and Regulatory Challenges, covers challenges providers encounter when providing patient care using telehealth, such as coverage and payment issues, licensure, credentialing, privileging, online prescribing, privacy and security concerns, malpractice and liability insurance, and more. The report offers policy considerations to address telehealth barriers, including:
- Comprehensive payment policies
- Setting standards for the development of clinical guidelines and protocols
- Coordinating state laws to support shared goals regarding physician licensure portability
Affordable broadband is required to support telehealth programs, health information technology (HIT), and health information exchanges (HIEs), all of which increase access to and the quality of healthcare. Many rural communities do not currently have access to internet connection speeds which support the effective and efficient transmission of data to provide telehealth services.
Additional challenges restricting the adoption of telehealth in rural areas including malpractice, HIPAA and privacy, security, prescribing, and credentialing are discussed in CCHP's 2019 Telehealth Policy Barriers fact sheet. Rural broadband access and its importance is explained further in RHIhub's Health Information Technology in Rural Healthcare topic guide question Why is broadband important for HIT? How can we tell if broadband is available in our community?
What facilities, technology, and staffing would our facility need to implement telehealth services?
While technology issues, such as baseline connectivity and interoperability, can impact telehealth implementation, successful programs realize that the technology has to be implemented in the right processes to get the best outcomes.
Some considerations include:
- Services to be supported and enhanced through telehealth
- Payment models and reimbursement
- Equipment needed, which can vary and is dependent on type of services to be provided
- Appropriate accommodations for technology where services are to be provided
- Data management services for handling, storing, printing, and transmitting medical information
- Training of providers and staff
- Provider and staff buy-in
- Support staff to implement telehealth programs
- Privacy and security concerns
California Telehealth Resource Center (CTRC) developed a Telehealth Coordinator Online Training that covers major concepts and resources needed to build a knowledge base and the skills necessary for a telehealth coordinator. If you would like assistance with new or existing telehealth services or if you have specific questions regarding your facility, contact your regional TRC. To learn more about how TRCs can assist you with the implementation of telehealth programs, see How do Telehealth Resource Centers (TRCs) help healthcare facilities develop telehealth services within their rural communities?
How can telehealth be used to reach patients in their homes?
Remote patient monitoring (RPM) can be used to reach patients in their homes. RPM is the collection of personal health and medical data from patients in their home. After data collection, the data are transmitted to a healthcare provider in a different location to be used in healthcare decision-making. Some RPM program examples include:
- Bridges to Care Transitions-Remote Home Monitoring and Chronic Disease Self-Management is a collaboration between three healthcare organizations that works to identify and enroll at-risk patients in a RPM program and a chronic disease education and coaching program after an inpatient hospitalization or emergency room visit.
- Intermountain Healthcare Connect Care Pro®, offers access to healthcare for rural communities through 35 telehealth services in three ways: clinician-to-clinician, direct-to-consumer, and RPM. Connect Care Pro® has existing programs for hypertension and diabetes but is developing RPM programs for chronic obstructive pulmonary disease (COPD), motion, and wellness.
Mobile health can be used by providers and public health units to communicate with patients and citizens in their homes. mHealth is the use of mobile devices to provide health-related information, which can include general education, special notifications, or communication through a health application. mHealth can also be used for remote monitoring, where personal health and medical data are collected from a patient in his home. The Becker's Health IT & CIO Report article, The Rise of mHealth: 10 Trends, reports that mobile devices, applications, tablets, and other smart devices are becoming an integral part of mHealth. National Telehealth Technology Assessment Resource Center (TTAC) offers an overview of mHealth technology and other resources related to product information and product assessment.
Telecare is a term for offering remote monitoring to people who are elderly or have disabilities. Telecare provides care and monitoring to allow these patients to live independently in their homes.
How does the use of telehealth impact rural healthcare providers?
A 2015 National Advisory Committee on Rural Health and Human Services policy brief, Telehealth in Rural America, discusses how telehealth use in rural areas can reduce a provider's feelings of isolation and burn-out, and subsequently improve provider retention at rural hospitals.
The article, Telemedicine: Changing the Landscape of Rural Physician Practice, highlights testimonials from healthcare providers practicing in rural areas throughout the U.S. Dr. Wilbur Hitt discusses his experiences of how telehealth reduces rural practice isolation:
Telemedicine fosters a collaboration that reduces the feelings of isolation that physicians may experience when they go to practice in a small town. With telemedicine, it's like having one foot in the city but being able to live and practice out in a rural area. It's also reassuring to know that you're on the right track with the treatment plan and are staying current.
Healthcare systems with the infrastructure and staffing to support telehealth services impact how rural providers are able to provide patient care by giving them access to:
- Team-based care
- Other specialists and subspecialists for consults in real time
- Virtual networks with peers
- Outsourced diagnostic analyses
- In-home monitoring of patients for follow-up care
- Continuing education and training, reducing travel and out-of-practice time
Implementing telehealth requires staff training and changes in workflows, policies, and procedures. NCTRC offers telehealth resources and tools for physicians and other healthcare staff.
To learn more about how telehealth impacts the recruitment of rural providers, see How can telehealth and other technology be used to make rural practice more attractive to candidates? on RHIhub's Recruitment and Retention for Rural Health Facilities topic guide.
What financial impact could the addition of telehealth services have on a rural facility and community?
The financial impact of implementing telehealth services in a community can vary, depending on the type of healthcare service or services to be offered using telehealth and the patient population. The 2017 NTCA: The Rural Broadband Association report, Anticipating Economic Returns of Rural Telehealth, describes telehealth potential benefits including the following quantifiable benefits:
- Transportation costs
- Lost wages
- Hospital staffing costs
- Local lab and pharmacy profits
The report also lists nonquantifiable benefits:
- Access to specialists
- Timely care
- Benefits to the provider
- Improved patient outcomes
Additionally, more states have started to consider legislation such as telehealth parity laws, which would require insurers to cover services provided via telehealth technology at the same rate as for services delivered in person. A map on the American Telemedicine Association's website shows which states have parity laws, partial parity laws, and proposed parity law legislation for private insurance coverage of telemedicine.
Hospitals that use teleconsultation and telementoring services can retain revenue when providers at those hospitals are able to treat patients in a local healthcare facility, instead of transferring to another healthcare facility for specialty care.
A 2011 report, Estimating the Economic Impact of Telemedicine in a Rural Community, describes a study of 24 hospitals in four Midwestern states with large rural populations: Kansas, Oklahoma, Arkansas, and Texas. All hospitals within these communities practice some form of telemedicine. The results of the study determined:
- Each community identified an annual savings or other economic opportunity of $20,000 or more.
- The average annual financial impact for a community was estimated at $522,000, with a maximum impact of more than $1,300,000.
- The majority of the savings demonstrated came from locally performed lab and pharmacy services.
A 2017 Journal of Telemedicine and Telecare article, Using Tele-Emergency to Avoid Patient Transfers in Rural Emergency Departments: An Assessment of Costs and Benefits, discusses the financial and other benefits of a tele-emergency program in rural hospitals resulting in a cost savings of approximately $3,800 per patient who avoided transfer.
January 1, 2019 marked the first time Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) could receive payments for virtual communication services. For more information on virtual communication reimbursement and payment codes, see the November 23, 2018 Federal Register notice.
Is telehealth usage widespread in rural facilities?
A 2019 American Hospital Association (AHA) publication, Fact Sheet: Telehealth, found a consistent positive trend in the number of hospitals using telehealth services. In 2010, 35% of hospitals reported full or partial implementation that grew to 76% of hospitals reporting telehealth usage in 2017. A 2016 JAMA article, Utilization of Telemedicine among Rural Medicare Beneficiaries, found telemedicine visits for rural Medicare beneficiaries increased from 2004 to 2013 at an annual growth rate of 28%. The article reports nearly 80% of rural beneficiary telehealth visits were for mental health conditions.
A 2014 RUPRI Center for Rural Health Policy Analysis report, Extent of Telehealth Use in Rural and Urban Hospitals, discusses key findings from an analysis of hospital-based telehealth usage and found:
- Only one-third of rural hospitals in the study provided some telehealth services. The other two-thirds of the rural hospitals either did not provide telehealth services or were in the beginning stages of implementing telehealth services.
- Hospitals identified as academic medical centers, not-for-profits, or hospitals affiliated with a larger healthcare system were more likely to have some form of telehealth.
- Rural and urban hospitals implemented telehealth at similar rates.
- Rural hospitals were more likely to use telehealth to assist with providing radiology, emergency, and trauma healthcare services.
- Urban hospitals were more likely to use telehealth for many specialties and subspecialties including: cardiology, stroke and heart attack care, neurology, obstetrics, gynecology, neonatal intensive care unit (NICU), and pediatrics.
Last Reviewed: 3/26/2019