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Telehealth Use in Rural Healthcare

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 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 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:

  • Radiology
  • Psychiatry and behavioral health services
  • Ophthalmology
  • Dermatology
  • Dentistry
  • Audiology
  • Cardiology
  • Oncology
  • Obstetrics
  • Medication for Opioid Use Disorder (MOUD)

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.
  • 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 providers.
  • 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. 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 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.
  • 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 administration.”

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 removed 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 regulatory changes.

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 their organization?

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
  • Reimbursement
  • Billing
  • Evaluation
  • Marketing

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:

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.

Reimbursement

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 restrictions.

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.

Licensure

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:

Broadband

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

This 2020 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 services.

If you would like assistance with new or existing telehealth services or if you have specific questions regarding 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 or asynchronously.

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 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. 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 laws.

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 patient engagement.

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 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.

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.


Where can I find more information on my state's telehealth policies?

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.

The National 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.


Last Reviewed: 7/1/2021