Telehealth can assist healthcare systems, organizations, and providers in expanding 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 became a more prominent mode of providing healthcare during the COVID-19 pandemic, when patients and
providers sought to decrease in-person contact for routine visits. In order to expand access to telehealth from
patients' homes and increase provider flexibility, laws, reimbursement policies, and regulations were
temporarily changed through emergency orders and legislation. Some of these policy changes at the state and
federal level may become permanent.
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
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 and clinics to provide quality
healthcare services locally and at lower costs, 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.
Telemedicine Services During COVID-19:
Considerations for Medically Underserved Populations, a 2020 commentary in The Journal of Rural
Health, examines the potential of telemedicine to increase access to healthcare for underserved
communities. The article notes that telemedicine has grown in usefulness and convenience and that it is becoming
more sustainable for providers, even though barriers remain, such as limited broadband access and patient
technological capability. A COVID-19 Healthcare
Coalition survey conducted between March 2020 and January 2021 explores patient experiences with
telehealth during the COVID-19 pandemic, addressing issues of access, reduced barriers to care, and satisfaction
with telehealth services.
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:
- Psychiatry and behavioral health services
- Medication for Opioid Use Disorder (MOUD)
Effective healthcare services and programs administered through telehealth technology in rural communities
Chronic care management interventions using telehealth to provide patients with access to
integrated care during their primary care visits.
Provider-to-Provider models such as the Project ECHO®
— Extension for Community Healthcare Outcomes allow rural primary care providers and
specialist providers to work as a team to share knowledge and manage patient care.
E-Consults are an asynchronous provider-to-provider model.
Access to emergency care providers in real time for evaluations and consults to local
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
Intensive care units (ICUs) provide around-the-clock critical care patient monitoring by a
team of subspecialists and critical care nurses. The Eastern Oklahoma VA
Health Care System and the Cincinnati VA Medical Center provide 24/7 intensive care monitoring of
rural 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
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.
School-based telehealth can increase access to pediatric care and, in some cases, increase
access to telehealth for the broader community.
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. Provider Bridge, a program funded by HRSA and HHS, and managed by
the Federation of State Medical Boards, is a platform that connects healthcare providers with state agencies and
healthcare organizations to increase patient access to telehealth.
The National Emergency Tele-Critical Care Network (NETCCN) is
another collaborative resource project that has emerged as a result of the COVID-19 pandemic, providing surge
support by virtually connecting providers to a clinical-technical team trained in critical care assistance. 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
The Office of the National Coordinator for Health Information Technology (ONC) offers this distinction:
“Telehealth is different from telemedicine because it refers to a broader scope of remote
healthcare services than telemedicine. While telemedicine refers specifically to remote clinical
services, telehealth can refer to remote non-clinical services, such as provider training, 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 has the COVID-19 pandemic affected telehealth policy?
Following the outbreak of COVID-19 in the United States, the Centers for Medicare & Medicaid Services
geographic restrictions and changed reimbursement requirements to allow providers to expand the use of
telehealth services in the places where patients live. This allowed providers to continue to offer care as many
states implemented physical distancing and other restrictions to curb the spread of the disease. Many providers
either expanded existing telehealth service offerings or were thrust into a situation in which they had to
rapidly develop telehealth programs. According to a
CDC report on trends in telehealth use among HRSA-funded health centers, on average 30.2% of weekly
health center visits between June 26 and November 6, 2020 took place through telehealth. A survey of health
centers completed in July 2020 found that urban health centers were more likely to complete visits using
telehealth than rural health centers, with 55.1% of urban facilities and 29.9% of rural facilities providing
more than 30% of visits via telehealth.
The Center for Connected Health Policy (CCHP) offers a website with up-to-date
information on telehealth coverage policies related to COVID-19 Public Health Emergency orders, with
information on Medicare policies, federal actions, private insurer policies, and state-level policies. CCHP also publishes the Billing for
Telehealth Encounters guide, which provides an overview of billing fee-for-service Medicare and Medicaid
(using California as an example) for telehealth encounters and is regularly updated to reflect COVID-19 related
In a letter
to governors, the office of the Secretary of Health and Human Services noted that the public health
emergency would likely remain in place throughout 2021, raising questions about what temporary changes to
telehealth policy may remain permanent following the pandemic. In a 2020
policy brief, the National Rural Health Association also outlines policy recommendations to support the
adoption of telehealth in rural America. Telehealth supporters see an opportunity to increase healthcare access,
reduce costs, improve quality of care, and reduce health disparities by reducing barriers to offering telehealth
services, as explored in the 2021 policy report Telehealth
after COVID-19: Clarifying Policy Goals for a Way Forward.
How do Telehealth Resource Centers (TRCs) help rural healthcare facilities develop telehealth services within
Twelve regional and 2 national Telehealth Resource Centers (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:
The regional TRCs consist of:
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
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. For more information on the NCTRC and Telehealth
Resource Centers, see this
consortium white paper.
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
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.
The Evidence Based Telehealth Network Program (EHB THNP) is a HRSA program that
supports existing telehealth programs to demonstrate evidence-based effectiveness at increasing access in
rural and remote areas.
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 described in this section pertain to policies before the COVID-19 Public Health
Emergency. It is unclear which of these barriers may remain after the PHE.
The issue of Medicare reimbursement is commonly cited as a major challenge for telehealth programs, including
concerns related to geographic and originating site restrictions, provider restrictions, and service
Individual state Medicaid programs vary in their guidelines regarding reimbursement for telehealth services.
CCHP's biannual 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 telehealth state law and reimbursement policy
guides that are browsable by state and by topic. The 2019 National Rural Health Association (NRHA)
policy brief Telehealth
in Rural America 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.
In response to the COVID-19 pandemic, the U.S. Department of Health and Human Services implemented temporary
policy changes to increase flexibility in offering telehealth services, including reimbursement. These changes
address many of the barriers described above, but those barriers may return if changes in telehealth policy are
rescinded after the public health emergency ends. This healthcare
provider fact sheet and reimbursement
FAQ document provide more detail on HHS temporary regulatory changes.
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 2016 National Conference of State Legislatures 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
In 2021, the Federation of State Medical Boards, with the support of HRSA and HHS, launched Provider Bridge, a platform that facilitates license portability
to allow providers to submit credentials and treat patients in high demand areas via telehealth.
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:
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. Traditionally,
healthcare facilities needed broadband to provide telehealth services, but with modern applications of
telehealth such as remote patient monitoring and e-visits, broadband is also necessary in patients' homes. 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. The broadband gap has the potential to lead to a
new set of health inequities due to disparate access to telehealth.
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. The 2021 report Broadband
Today: Rural America's Critical Connection discusses the importance of broadband access to rural
business, telehealth, and remote work opportunities. 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?
Technology issues, such as baseline connectivity and interoperability, can impact telehealth implementation.
Successful programs implement technology planning and staff training to achieve successful program outcomes.
Some technology and staffing 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
research report from the RAND Corporation on community health centers describes staffing, program, and
process changes related to expanding telemedicine programs as well as challenges and barriers to telemedicine
expansion. The National Telehealth Technology Assessment
Resource Center (TTAC) offers a variety of toolkits that introduce technologies used in telehealth
programs, including video platforms, digital cameras, and digital health equipment. The 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.
Telehealth.hhs.gov offers information on
telehealth implementation for providers, practitioners, and staff, including best practice guides. From
Coverage to Care (C2C), a CMS initiative to support patients and providers as they navigate virtual
care, also offers telehealth resources. The National
Rural Health Resource Center provides information about telehealth
campaigns to promote confidence in telehealth
If you would like assistance with new or existing telehealth services or if you have specific questions
your facility's needs, 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?
E-visits, or electronic visits, are communications that are not in-person with a provider and
that are initiated by the patient, often from the patient's home. This includes direct-to-consumer telehealth, which
occurs when a patient initiates an appointment with a provider on their own device, and can occur synchronously
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. For a
project example, see the Bridges to Care Transitions-Remote Home Monitoring and
Chronic Disease Self-Management, which 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.
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. The National Telehealth Technology Assessment Resource Center (TTAC)
offers an overview of mHealth technology and
other resources related to product
information and product
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. Telecare technology can include fitness trackers and apps, wearable sensors, medication reminders, and
fall detection devices.
Telebehavioral health, also known as telemental health, expands access to mental and behavioral
health services, especially in underserved and rural mental healthcare deserts. This 2020 issue
brief from the Milbank Memorial Fund discusses treatment gaps for individuals with substance use
disorder affecting rural, minority, and vulnerable populations and evidence supporting telehealth as a viable
way to expand mental and behavioral healthcare access. The Mid-Atlantic Telehealth Resource Center (MATRC)
operates the Telebehavioral Health Center of Excellence, which provides
resources to support providers looking to start or enhance a telebehavioral or telemental health program. This
best practice guide from
the Office for the Advancement of Telehealth discusses telebehavioral health implementation.
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.
In July and August 2020, the COVID-19 Healthcare Coalition conducted a telehealth impact study of physicians,
finding that 86.5% of rural physicians had been using telehealth for 6 or fewer months as of mid-2020. According
to the survey, 27% of rural physician respondents felt that telehealth did not improve the satisfaction of their
work, while 28% were neutral and 45% felt satisfied with the care they delivered via telehealth.
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. Anticipating
Economic Returns of Rural Telehealth, a 2017 NTCA—The Rural Broadband Association report,
describes telehealth potential benefits including the following quantifiable benefits:
- Decreased transportation costs
- Minimizing lost wages
- Reduced hospital staffing costs
- Increased local lab and pharmacy profits
The report also lists nonquantifiable benefits:
- Increased access to specialists
- Providing timely care
- Ensuring patient comfort
- Reducing need for transportation
- 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 services delivered in
person. CCHP offers state-by-state
information on current laws and reimbursement policies, including parity
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 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 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 2019 American Hospital Association
(AHA) publication, Fact
Sheet: Telehealth, found a consistent positive trend in the number of hospitals using telehealth
services before the rapid expansion of telehealth services during the COVID-19 pandemic. According to the
report, in 2010 35% of hospitals reported full or partial implementation that grew to 76% of hospitals reporting
telehealth usage in 2017.
The article Evaluating Telehealth Adoption and
Related Barriers Among Hospitals Located in Rural and Urban Areas examines lingering barriers to
telehealth adoption in rural hospitals, including lack of health information exchange capabilities and limited
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 1/3 of rural hospitals in the study provided some telehealth services. The other 2/3 of the rural
hospitals either did not provide telehealth services or were in the beginning stages of implementing
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
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.
The 2021 Kaiser Family Foundation issue brief Medicare
and Telehealth: Coverage and Use During the COVID-19 Pandemic and Options for the Future describes
telehealth utilization by Medicare beneficiaries in summer and fall 2020, finding that 65% of rural telehealth
visits were conducted by telephone only. The study notes that 52% of Medicare beneficiaries said that their
provider currently offered telehealth appointments, though 30% reported not knowing if their provider offers
telehealth. This 2021 American
Journal of Preventive Medicine article examines telemedicine patient demographics based on 2020 data
to find what populations are and are not accessing care through telehealth.
The COVID-19 Healthcare Coalition's physician
survey, which is part of their Telehealth Impact Study, offers rural, urban, and suburban comparisons of the
implementation of telehealth, impacts on access, reduced barriers for patients, and physicians' responses to
providing telehealth services during the pandemic. Telehealth
in Rural America: Disruptive Innovation for the Long Term? describes rural-specific concerns surrounding
telehealth following COVID-19, and the 2020 ATA blog post Leveraging
Telehealth to Drive Health Equity and Expand Access to Care discusses policy approaches to support
telehealth's future impacts on health equity.
The Center for Connected Health Policy maintains a policy finder with current state telehealth laws
and reimbursement policies. They also offer information on COVID-19 temporary actions at the state
level and publish a biannual, comprehensive report
on current state telehealth laws.
Conference of State Legislatures also offers state-level information on telehealth coverage and
reimbursement policies, with links to resources. For more information on telehealth policies in your state or
region, contact your regional
Telehealth Resource Center.