Telehealth Use in Rural Healthcare
Telehealth has great potential to expand access and improve the quality of rural healthcare. It can reduce burdens for patients, such as travel to receive specialty care, and improve monitoring, timeliness, and communications within the healthcare system.
The Health Resources & Services Administration defines telehealth as:
“the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration.”
While one of the most common images of telehealth is of a patient speaking by videoconference with a remote physician, telehealth can take other forms including:
- Mobile health communication or mHealth
- Remote patient monitoring or RPM
- Store and forward transmission of medical information
This guide helps healthcare providers find information on telehealth services and highlights funding opportunities and initiatives to implement telehealth services. It also provides examples of telehealth projects as models for rural hospitals and clinics to develop and implement programs. The guide discusses challenges for providing telehealth services in rural areas including 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 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?
According to a 2012 document, The Role of Telehealth in an Evolving Health Care Environment, telehealth drives volume, increases quality of care, and reduces cost by reducing readmissions and unnecessary emergency department visits for rural communities. Telehealth allows small rural hospitals to continue providing quality care at low cost. Also, rural patients receiving care via telehealth can avoid driving long distances to access specialty care.
Using telehealth to provide specialty services is more feasible for rural healthcare facilities than staffing the facilities with specialist providers. Telehealth allows specialists to visit rural patients virtually, improving access to healthcare as well as offering a wide range of specialty care to rural communities via telemedicine, including:
- Dental care
Often, rural primary care providers and specialists are able to work as a team to manage patient care as found in programs like the Extension for Community Healthcare Outcomes (Project ECHO).
Several types of services administered through telehealth technology have been used effectively in rural communities for a wide variety of patient care. Examples include:
- Chronic care management interventions – Uses telehealth to provide patients with access to integrated care during their primary care visits, such as the TeleTEAM Care for Diabetes Program which offers the services of behavioral therapists, dietitians, clinical pharmacists, and a medical diabetologist.
- Emergency care – Access to specialists in real time providing evaluations and consults to local providers for emergency care. Intermountain Healthcare TeleHealth Services provides this type of service for stroke victims.
- Home monitoring – Accommodates patients in their homes between medical visits by helping them to 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 in chronic disease management and behavioral health conditions in their homes.
- Intensive care units (ICU) – Provides round the clock critical care monitoring of ICU patients by a team of specialists and critical care nurses. Avera eCARE provides 24/7 intensive care monitoring of critically ill patients.
- Long-term care – Brings specialized health services to elderly populations who reside in long-term care facilities that are inaccessible due to their rural location. Telehealth technology, implemented in the SD eResidential Facilities Healthcare Services Access Project, allows specialists in more urban areas to reach residents with chronic health problems.
- Online therapy and remote counseling – Links urban behavioral health and mental health counseling services to rural residents. In Texas, the Madison Outreach and Services through Telehealth (MOST) Network offers counseling services by video and by phone to Spanish speaking residents.
Other ways that telehealth can be used to improve rural healthcare include:
- Telepharmacy services extend access to medications and medication counseling at rural facilities and community pharmacies.
- Electronic communications can link providers that serve in isolated areas and create virtual professional communities to improve patient care. Healthcare providers' use of mobile devices, such as tablet computers and smartphones can improve communication to their patients as well as to other providers.
- Interpreter services transmitted on-demand through audio or visual technology for patients who speak little or no English.
Telehealth-supported programs 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. The RHIhub's Models and Innovations provides several examples of how telehealth technology continues to advance healthcare in rural areas.
What is the difference between telemedicine and telehealth?
According to the Office of the National Coordinator for Health Information Technology, telehealth is often used
to refer to a broader scope of remote healthcare services than the term telemedicine.
Telemedicine is the remote delivery of clinical healthcare services and information using
Telehealth includes 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
How do Telehealth Resource Centers help rural healthcare facilities develop telehealth services within their organization?
The Telehealth Resource Centers (TRCs) are funded by the Office for the Advancement of Telehealth to assist healthcare organizations, healthcare networks, and healthcare providers in the implementation of cost-effective telehealth programs to serve rural and medically underserved areas and populations.
There are a total of 14 Telehealth Resource Centers which include 12 regional centers and two national centers. The national centers focus on the areas of technology assessment and telehealth policy. Their website includes a national map, which shows the region served by each center. The Centers provide technical assistance on developing and implementing telemedicine services. The Telehealth Resource Centers' website includes modules on:
- Staffing and recruiting specialists
- Education and training
- Credentialing and licensing
- Medical malpractice and liability
Monthly webinars are presented on telehealth topics and past webinars can be viewed on the national TRC webinar series webpage.
What are some telehealth funding programs for rural providers?
There are several grant programs that fund rural telehealth projects, including the following:
Rural Broadband Access Loan and Loan Guarantee Program
Loans and loan guarantees to provide funds for the costs of construction, improvement, or acquisition of facilities and equipment needed to provide service at the broadband lending speed in eligible rural areas.
Telehealth Network Grant Program (TNGP)
Funding to show how telehealth networks can improve access to healthcare services in rural, frontier, and underserved areas. Eligible applicants include rural or urban nonprofit entities that will provide services through a telehealth network. Applicants are encouraged to develop innovative proposals that meet new and emerging needs in a changing healthcare delivery system with a focus on value and improved healthcare outcomes.
USAC Rural Health Care
Discounts to rural healthcare providers to obtain internet and telecommunications access.
USDA Community Facilities Loan and Grant Program
Funding to construct, enlarge, or improve essential community facilities for healthcare, public safety, and public services in rural areas and towns of up to 20,000 in population. These facilities include schools, libraries, childcare centers, hospitals, medical clinics, assisted living facilities, fire and rescue stations, police stations, community centers, public buildings, and transportation. Funds may be used for telehealth initiatives.
USDA Distance Learning and Telemedicine Loan and Grant Program (DLT)
Financial assistance to improve telemedicine services and distance learning services in rural areas through the use of telecommunications, computer networks, and related advanced technologies to be used by students, teachers, medical professionals, and rural residents. Applicants must operate a rural community facility directly or deliver telemedicine services to another organization that operates a rural community facility.
Additional funding for rural telehealth programs can be found in the Funding & Opportunities section of this guide.
What are the challenges related to telehealth services in rural communities?
Despite the promise of telehealth for improving access in rural areas, there are often policy barriers and infrastructure inadequacies that must be overcome. Some of the challenges to telehealth adoption and success include:
The issue of Medicare reimbursement is commonly cited as a major challenge for telemedicine. Some criticisms of the current Medicare reimbursement model for telehealth include:
- Level of reimbursement in the fee-for-service system
- Restriction of eligible healthcare professionals who can provide telehealth-delivered services
- Limitation of reimbursement to rural and Health Professional Shortage Areas
- Limitation of reimbursement to certain types of healthcare facilities
- Limitation to certain current procedural terminology codes
State Medicaid programs vary in their guidelines regarding reimbursement for telehealth expenses. Refer to the Center for Connected Health Policy's State Laws and Reimbursement Policies for information about current and pending state laws and regulations related to telehealth and Medicaid.
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, an organization that addresses the legal and regulatory barriers to the adoption of telehealth, provides a general overview about telehealth reimbursement and more in depth discussions on Medicaid and Medicare reimbursement.
According to the 2013 article Streamlining Telemedicine Licensure to Improve Rural America, the current licensure system places burdens on physicians who want 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 care is given. Telehealth and Licensing Interstate Providers explores actions states have taken to ease licensure barriers, such as:
- Telehealth-specific licenses
- Reciprocity and endorsement with other states
- Interstate compacts
For example, the Interstate Medical Licensure Compact (IMLC), an agreement between 18 states and 23 osteopathic and medical boards, offers an expedited process for qualified physicians to be licensed to practice in multiple states. The Department of Veterans Affairs (VA) is an exception, and VA physicians have license portability which allows them to practice across state lines to wherever the patient is receiving care.
Affordable broadband is needed to support telehealth and health information exchange, in order to increase access to quality care. 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 Telehealth Policy Barriers.
What facilities, technology, and staffing would our facility need to implement telehealth services?
While technological issues, such as baseline connectivity and the interoperability of data, can impact the implementation of telehealth services, successful programs realize that the technology has to be implemented in the right care processes to get the best outcomes.
Some issues to consider 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
- Facilities able to accommodate the technology
- Appropriate accommodations where services are to be provided
- Data services for handling, storing, printing, and transmitting medical information
- Training of providers and staff
- Staff buy-in
- Support staff to implement telehealth programs
The California Telehealth Resource Center developed a Telehealth Training Module that addresses how to establish and operate a telemedicine service. Topics covered in the module include: staffing and recruiting, training, provider and patient site facilities, credentialing and licensing, privacy issues, billing, and evaluation.
For assistance that is specific to your facility, contact your regional Telehealth Resource Center (TRC). For information on how TRCs can assist with the implementation of telehealth programs see How do Telehealth Resource Centers help healthcare facilities develop telehealth services within their rural communities?
How can telehealth be used to reach patients in their homes?
Telehealth can be used to reach patients in their homes through remote monitoring where personal health and medical data is collected from a patient in his home. The data is transmitted to the provider in a different location for use in care and related support.
Mobile health, referred to as mHealth, can be used by providers and public health units to communicate to patients and citizens in their homes. It can also be used for remote monitoring, where personal health and medical data is collected from a patient in his home. The Rise of mHealth: 10 Trends reports that mobile devices and apps are becoming an integral part of telemedicine.
Telecare is a term for offering remote monitoring to people who are elderly or have disabilities, providing the care and monitoring to allow them to live independently in their homes.
How does the use of telehealth impact rural healthcare providers?
Telehealth use in rural areas has been shown to reduce provider isolation and burn-out, and subsequently improve retention. In the article, Telemedicine: Changing the Landscape of Rural Physician Practice, Dr. Wilbur Hitt reports that 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.”
Telehealth systems impact how rural providers do their work by giving them access to:
- Team-based care
- Specialists 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
The implementation of telehealth will necessitate staff training and changes in workflows and policies and procedures. The national network of Telehealth Resource Centers offers in depth information and training programs for physicians and other healthcare staff.
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 service and the patient population. However, previous experience has shown that individual facilities and providers can increase revenue by seeing a higher volume of patients.
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. The American Telemedicine Association's website includes a map of states with parity laws for private insurance coverage of telemedicine.
Hospitals that use teleconsultation and telementoring services have also been able to retain revenue when they are able to treat patients in the local facility, instead of transferring to another facility for specialty care.
A 2011 report titled 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.
Is telehealth usage widespread in rural facilities?
The RUPRI Center for Rural Health Policy Analysis completed a report in 2014 titled Extent of Telehealth Use in Rural and Urban Hospitals.
Some of the key findings of the data used in the study found:
- Only one-third of the rural hospitals in the study provided some telehealth services whereas two-thirds of the rural hospitals did not provide telehealth services or were in the beginning stages of implementing telehealth services.
- Hospitals identified as academic medical centers, not-for-profit institutions, or hospitals belonging to a larger integrated system were more likely to have some form of telehealth service.
- Rural and urban hospitals had similar rates of telehealth implementation.
- Rural hospitals were more likely to use telehealth in radiology departments, and in emergency and trauma care.
- Urban hospitals were more likely to use telehealth services in numerous specialties including: cardiology, stroke, heart attack programs, neurology, obstetrics, gynecology, NICU, and pediatrics.
Since the 2014 report, HIMSS Analytics released a 2016 report demonstrating an overall increase in the adoption of telemedicine technology in the U.S. from 54.5% to 61.3%, or 3.5% per year since 2014, suggesting continued growth in rural areas.
Last Reviewed: 8/2/2017