8- TELEMEDECINE & TELEHEALTH by PHARMAGEEK

If there’s one dialogue that’s been growing louder across the healthcare landscape, it’s the consumerization of healthcare. Market trends are undeniably steering the healthcare experience into a new paradigm where patients are seizing control. Yet this new direction is not always beneficial for patients or providers.

Just as consumer-driven industries like Uber and Netflix offer quick and seamless digital transactions, many patients want greater convenience and speed from care delivery. Many are also seeking more cost-effective options, thanks to climbing medical debt and high-deductible insurance plans. They’re less willing to tolerate care delays and inefficiencies; many will leave a poor online review after a frustrating appointment.

These are all understandable goals and reactions. But as patients climb into the driver’s seat of healthcare, they’re not always given a roadmap to their intended destination. As they navigate their options, some are running up against four dynamics:

1. Dr. Google

In our fast-paced world, many patients don’t want to wait weeks for an appointment or take time off from work to bring their child to the pediatrician.

Instead they take out their smartphone and look up symptoms to get a quick and theoretical diagnosis. Patients can view photographs of lesions, read checklists of cancer symptoms and lurk on forums where people describe surgery experiences – and encourage each other to self-diagnose.

2. Retail Clinics

Retail clinics like CVS and Walgreens have exploded in popularity – and the market is expected to surpass $8 billion USD by 2028. Patients who feel they’re too busy or too peripatetic to maintain a consistent PCP relationship often prefer the extended hours and easy access of these clinics.

3. Cost Avoidance

Patients are paying higher and higher coinsurances, deductibles and copays – and they’re sick of it.

They’re annoyed by a hospital’s inability to give them an accurate procedure cost in advance; many are stuck with “surprise” invoices after checking into a network hospital and receiving care from an out-of-network doctor.

4. Application Chaos

As applications and portals take over the Internet, many healthcare systems have turned a great idea into patient confusion.

Even patients with moderate care needs may find themselves managing an overwhelming collection of healthcare apps for their OB/GYN practice, dentist, dermatologist, PCP, various hospital online payment portals, lab result repositories and data from their wearables.

In 2005, Tift Regional Health System began exploring telemedicine as a way to connect its physicians and specialists with patients in the rural area surrounding its Tifton, Georgia, home base.

At that time, telehealth technology largely consisted of a hub-and-spoke network, based out of large tertiary care centers or academic medical centers.

"We understood [telehealth] was the future and we needed to be a part of this technology that could get our patients to the specialists that they needed to see 200 or more miles away," said Jeff Robbins, MD, director of telehealth and neurodiagnostics at Tift Regional Medical Center.

The virtual visits idea was starting to be discussed in rural parts of the country. The Internet was slow, but the tech was getting close to making distant encounters possible.

"In the early days, every encounter was basically a telehealth network within itself," Robbins said. "The technology only allowed us to connect to one endpoint at a time. The technology didn't allow us to network to a new endpoint or customer without a lot of IT involvement. Internet was slow and the devices used to conduct a patient-to-provider encounter were primitive compared to what we have today."

These issues prevented Tift Regional from achieving the outcomes it knew were possible but staff understood, given its track record at other hospitals, that telehealth could play a very important part in delivering healthcare in the near future.

Tift at that point partnered with the Global Partnership for Telehealth, a nonprofit with a 12-year track record in developing and implementing sustainable, cost-effective telehealth programs.

The Global Partnership for Telehealth markets telehealth systems to hospitals and other medical facilities in 11 states. There are a variety of telemedicine technology vendors with varied offerings on the market. These include American Well, Avizia, Cisco Systems, HealthTap, InTouch Health, MDLive, SnapMD, TeleHealth Services and Tellus -- many of those are in the Healthcare IT News Buyers Guide: Comparing 11 top telehealth platforms.

GPT's network of caregivers and its technology gave Tift Regional the ability to connect to nursing homes, school clinics, emergency rooms, stroke teams, specialized wound care teams and advanced critical care teams hundreds of miles away from its rural location in South Georgia.

"I like to say the miracle of telehealth is that it gives us the ability to erase time and distance," Robbins said. "Our patients benefit with virtually no travel time or expenses, decreased time waiting for an appointment, reduced medical costs, and extra value to the patient encounter and extended access to consultations with specialists not offered in their area and usually hundreds of miles away."

The partnership with GPT also allows Tift Regional's employed physicians to increase revenue because they can see patients outside their area, reducing missed appointments, and giving them the tools to treat more patients over time and have better patient follow-ups that improve outcomes, which also cuts down on readmissions, he added.

Telehealth carts generally include a monitor, camera, keyboard and remote control. Peripherals give physicians the ability to monitor vital signs, use a digital stethoscope, and use high-definition cameras for specific types of care such as dermatology or wound care.

Telehealth has become a critical component in Tift Regional's ability to deliver quality healthcare, and the healthcare organization has seen success in using the technology.

"Telehealth has increased access to healthcare within our organization by making it easier for our patients to obtain clinical services," Robbins said. "It also allows our hospital to provide emergency services that we cannot always provide like advanced/emergency stroke care. We have also seen an increase in improved health outcomes."

Telehealth allows Tift Regional to get its patients seen, diagnosed and treated earlier. This leads to improved outcomes and less costly treatments, Robbins explained.

"Telehealth has allowed us to have advanced ICU support and that has reduced mortality rates, reduced complications and subsequent hospital stays," he added. "We are seeing a reduction in healthcare costs through home monitoring, which is lowering costly hospital visits. Our stroke program is reducing the high cost of transferring stroke and other emergencies."

And Tift Regional has used telehealth to address the shortage in healthcare providers by allowing its patient population to see specialists outside Tift's area, also enabling Tift's own specialists to serve more patients, he said.

Before telemedicine, a virtual encounter meant both the presenter and the provider had to switch between many different programs. This presented issues when programs failed and data didn't link up correctly.

"The provider can now see who is waiting to be seen in the virtual waiting room, and data entry has been streamlined to allow patient data and notes to be uploaded into our existing EHR," Robbins said. "And maybe the best improvement is the ability to switch programs, going from Pathways to the stethoscope then the cameras within the same encounter."

CMS has unveiled its first-ever Rural Health Strategy in an effort to improve access to healthcare for the estimated 60 million Americans living in rural areas. The plan includes an emphasis on modernizing and advancing telehealth and telemedicine.

The Centers for Medicare & Medicaid Services unveiled the first-ever program this past week, releasing a five-point, eight-page initiative to improve access to care for the estimated 60 million Americans living in rural and underserved communities.

“For the first time, CMS is organizing and focusing our efforts to apply a rural lens to the vision and work of the agency,” CMS Administrator Seema Verma said in a press release. “The Rural Health Strategy supports CMS’s goal of putting patients first. Through its implementation and our continued stakeholder engagement, this strategy will enhance the positive impacts CMS policies have on beneficiaries who live in rural areas.”

One part of the strategy focuses on using connected care technologies to bring healthcare to those residents.

“Telehealth has been identified as a promising solution to meet some of the needs of rural and underserved areas that lack sufficient health care services, including specialty care, and has been shown to improve access to needed care, increase the quality of care, and reduce costs by reducing readmissions and unnecessary emergency department visits,” the plan states. “To promote the use of telehealth, CMS will seek to reduce some of the barriers to telehealth use that stakeholders identified in the listening sessions, such as reimbursement, cross-state licensure issues, and the administrative and financial burden to implement telemedicine.”

In its strategy, CMS says it will look to modernize and expand telehealth and telemedicine programs, particularly through the Next Generation Accountable Care Organization Model, Frontier Community Health Integration Project Demonstration and Bundled Payments for Care Initiative advanced model.

CMS has long come under criticism for its guidelines on reimbursing healthcare providers for telehealth delivered in rural areas, including restrictions on what services can be reimbursed under Medicare, where those services can be delivered, and even how rural areas are defined.

The agency has been the focus of several lobbying efforts to improve telehealth and telemedicine reimbursement, as well as several bills introduced in Congress. But few of those bills have become law, and healthcare providers still see Medicare reimbursement as one of the biggest barriers to pushing sustainable virtual care into rural America.

Last year, The Healthcare Information and Management Systems Society (HIMSS), American Medical Association (AMA), American Medical Informatics Association (AMIA), Center for Connected Health Policy (CCHP) and Personal Connected Health Alliance (PCHA) all called on CMS to go beyond current proposals to amend the Medicare 2018 physician fee schedule and open the doors to more connected care services.

“HIMSS encourages CMS to embrace a reimbursement system that recognizes the unique characteristics of connected health that enhances the care experience for the patient, providers and caregivers,” former HIMSS President and CEO H. Stephen Lieber and Denise W. Hines, chair of the HIMSS North America Board of Directors and CEO of the eHealth Services Group, wrote.

In that letter, HIMSS called on CMS to support:

Collaborative decision-making involving diverse care-teams. “Decisions are no longer just between a doctor and patient,” the organization wrote. “Connected technologies allow for the incorporation of a patient’s family and trusted advisors, as well as other allied health professionals, in the decision-making process.”
Expanded care locations and always-on monitoring. “When patients are always connected, care (the interpretation of data and decision support) can occur at any time and in any place,” HIMSS said.

A reliance on technology, connectivity and devices. “Connected health involves communication systems using a variety of components; these may be managed by the provider, the patient, or other parties in the care team,” HIMSS said.
And “empowerment tools and trackers that enable patients to become active members of the care continuum outside of the hospital setting and promote long-term engagement which, in turn, leads to a healthier population.”

Recognizing the challenges faced by healthcare providers in sustaining and scaling telehealth, the National Quality Forum (NQF) issued its own report last year, in which it proposed to set a national framework for measuring and supporting success in telehealth and telemedicine.

“Telehealth is a vital resource, especially for people in rural areas seeking help from specialists, such as mental health providers,” Marcia Ward, PhD, director of the Rural Telehealth Research Center at the University of Iowa and co-chair of NQF’s Telehealth Committee, said in a release accompanying the 81-page report. “Telehealth is healthcare. It is critically important that we measure the quality of telehealth and identify areas for improvement just as we do for in-person care.”

CMS’ Rural Health Strategy, developed by the CMS Rural Health Council, formed in 2016, and culled from input gained at 14 public hearings, features five objectives:

• Apply a rural lens to CMS programs and policies;
• Improve access to care through provider engagement and support;
• Advance telehealth and telemedicine;
• Empower patients in rural communities to make decisions about their healthcare; and
• Leverage partnerships to achieve the goals of the strategy.
  The effort was met with words of support from several organizations.

“(The) AHA is pleased CMS put forward thoughtful recommendations to address the unique challenges of providing care to patients in rural communities,” Joanna Hiatt Kim, the American Hospital Association’s vice president of payment and policy, said in a release. “We look forward to working with CMS and Congress to take meaningful action to stabilize access in rural communities, such as creating new alternative payment models, expanding coverage of telemedicine and access to broadband and reducing regulatory burden.”

The long-awaited promise of telemedicine may finally be realized as a response to Covid-19.

For decades, advocates hailed telemedicine as the way forward to improve access and reduce cost, while maintaining high-quality care.

There have been steady gains in investment and growth across the country, and an increasing number of studies suggest that for certain services, namely chronic care management and mental health services, telemedicine may be superior to in-person care. Specifically, studies showed better health outcomes through improved medication adherence, integration of medical tests, and reduced hospital readmissions. However, even with these positive steps, it would be a stretch to claim that telemedicine had transformed the US healthcare system and, in large part, that is because of legal barriers that were in place prior to Covid-19.

In the Fall of 2019, my colleague at the University of Arizona James E. Rogers College of Law, Christopher Robertson, and I identified three major legal barriers in federal and state laws that were inhibiting telemedicine utilization.

We reviewed (1) establishment of a healthcare relationship, (2) state licensure laws, and (3) reimbursement. We focused on these areas because of the legal ambiguities or inconsistencies, which varied across the states. Arguably, these variations could hinder telemedicine operators’ ability to leverage resources across state lines for efficient scalability without necessarily improving quality of care. 

Aging Population

We proposed that the

growing aging population would be the driver to achieve greater utilization of telemedicine services largely because of changes with reimbursement under Medicare Advantage (MA).

The Center for Medicare and Medicaid Services (CMS) issued a rule that became effective at the start of 2020, which relaxed geographic and originating site requirements to allow reimbursement for telemedicine services received directly in the home, irrespective of whether the MA beneficiary lives in a rural or urban area.

In addition, many state Medicaid programs, including Arizona’s AHCCCS, reported plans to expand reimbursement, especially around long-term care services and for home healthcare.

We found that older adults, aged 65 or over, represented a large market that was unfamiliar with telemedicine. A 2018 study found 16-times greater telemedicine utilization among adults aged 24-44 and a 2019 survey reported that while half of older adults would be interested in a telemedicine visit, only four percent had one in the last year.

These findings highlight major growth opportunities, particularly given telemedicine’s demonstrated ability to effectively manage chronic conditions, where 80 percent of older adults have at least one chronic condition, and 77 percent have at least two.

We had no idea that COVID-19 would be the watershed event that would bring the long-anticipated discussion of how to expand telemedicine and care for the aging population to the forefront of this pandemic.

Legal Barriers

Our recommendations for a more unified approach to telemedicine regulation incorporates core bioethics principles of doctor-patient relationship, competence, patient autonomy, as well as population-wide questions of resource allocation and access. In the time of Covid-19, many lawmakers have embraced some of these principles and allow greater flexibility.

Specifically, in how a healthcare relationship may be established outside of a “hands on” visit (see e.g., Maryland’s Governor amended an order to allow formation of a provider-patient relationship to include audio-only calls).

In addition, many states relaxed licensure laws and reimbursement under CMS has expanded to include all Medicare beneficiaries (approx. 56 million people). Section 3701 of the CARES Act went even further to encourage telemedicine use by removing cost-sharing exposure under Medicare for any telemedicine services, irrespective if related to COVID-19.

Conclusion

The threat that Covid-19 poses to the elderly population and a resource-strained healthcare system greatly outweighs some of the former legal barriers to telemedicine expansion. The new economies of scale that have now undoubtedly been achieved have the opportunity to bring the telemedicine promise of - greater access, improved health outcomes, and lower costs – and would benefit from using core bioethics principles as a guide in this new era of virtual care. 

Flash back to the brink of the Patient Protection and Affordable Care Act. On the cusp of the passage of the ACA, more than 41 million Americans were uninsured or underinsured, driving one of the largest health care overhauls in history. While controlling costs was an important consideration, the main focus of the ACA was expanding coverage. To increase accessibility to affordable health insurance options, the law employs a mixture of mandates, subsidies, tax credits, and penalties to increase coverage of the uninsured, spur health care innovation, and provide for new payment models to reward quality of care and improved health care outcomes.

More than five years into the ACA era, the White House touts that the number of people without health insurance continues to decline and has dropped by 15.8 million since 2013. Of the roughly 11 million people who enrolled in state or federal Marketplaces in 2015, about 4.2 million were auto-renewals or renewals, indicating that roughly half of all 2015 enrollees kept their 2014 Marketplace insurance plan.

The rurally ignored

Despite the widely publicized successes of the ACA, many rural Americans were forgotten by health care reform. Although the ACA proclaimed a renewed focus on rural America, little was accomplished for rural populations outside of Medicaid expansion. A policy brief published by the National Advisory Committee on Rural Health and Human Services stressed the importance of coverage in rural areas, where the population is disproportionately older, more chronically ill, lower in income, and less insured compared to urban areas.

Where are the rural communities? "Rural" encompasses all populations, housing, and territories not included in an urban area; essentially, it is defined by what it is not. In 2010, the U.S. Census estimated that 59.5 million people – 19.3 percent of the population – lived in rural areas.

Rural residents tend to be poorer, earning a per capita average income of $19,000, which is nearly $7,000 less than what their urban counterparts earn. Although rural Americans account for only 22 percent of the population, rural residents account for 31 percent of the nation's food stamp beneficiaries. Only 64 percent of rural residents are covered by private insurance, and the rural poor are less likely to be covered by Medicaid benefits than their urban counterparts (45 percent versus 49 percent, respectively). Compounding the issue of obtaining affordable coverage, rural areas rarely have access to the same types of coverage. According to the National Rural Health Association, only about 10 percent of physicians practice in rural America, even though nearly 25 percent of the population lives in rural areas. There are only 401 specialists per 100,000 people, compared to 910 in urban areas.

"Rural Americans face a unique combination of factors that create disparities in health care not found in urban areas. Economic factors, cultural and social differences, educational shortcomings, lack of recognition by legislators, and the sheer isolation of living in remote rural areas all conspire to impede rural Americans in their struggle to lead a normal, healthy life."

Perpetuated by the inability to find and afford care, rural populations face higher incidences of chronic disease. Obesity, diabetes, heart disease, and alcohol and substance abuse are all chronic conditions that disproportionately affect rural populations.

Turns out, chronic disease is costly

In the U.S., chronic diseases and the health risk behaviors that cause them account for highest health care costs. In fact, 86 percent of all health care spending in 2010 was for people with one or more chronic medical conditions. The total estimated cost of diagnosed diabetes in 2012 was $245 billion, including $176 billion in direct medical costs and $69 billion in decreased productivity. Medical costs linked to obesity were estimated to be $147 billion in 2008. Annual medical costs for people who are obese were $1,429 higher than those for people of normal weight in 2006. Of the top 10 states with the highest rural populations, half fell on the list of the states with the highest rates of adult obesity and diagnosed diabetes

So what is the government doing? Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services recently awarded $2.7 million to improve rural health, however, those grants will support 3-year pilot programs designed to train health professionals and expand health insurance coverage in rural areas, rather than impact rural health directly. Essentially, the 20 recipients of the grants (ranging from $75,000 to $200,000) are community colleges, hospitals, health education centers, individual counties, and other various providers, which are to use the money for formal training programs for health professional students. To put it in perspective, HRSA responded to the outcry by millions of rural Americans by awarding grants equal to the price of 17-year-old Kylie Jenner's first home, after spending hundreds of millions of dollars implementing the ACA and federal and state Marketplaces.

Is telemedicine the perfect solution? Maybe

Although the ACA does not specifically link telemedicine to rural populations, "telehealth" or "telemedicine," which is using telecommunication and information technologies to provide clinical health care at a distance, is a critical component of transitioning to value-based treatments, and to better serving rural communities and chronic conditions.

For rural populations, telemedicine has the potential to increase accessibility to providers and specialists who can remotely monitor and treat chronic disease, without the hassle or costs associated with traveling. In many states, telemedicine services are covered by insurance to the same extent as in-person services. It helps eliminate distance barriers to medical services that would often not be consistently available in distant rural communities.

Although it seems like a catch-all, it is important to note that telemedicine is not a replacement for an annual, in-person physical; it is used most effectively to manage chronic condition and preventive health care costs. Even the best physicians in the world cannot take the blood pressure of a patient or press on the abdomen of a sick patient remotely. While certainly this represents a drawback, it also presents an opportunity. The rules governing the practice of medicine do not need to be the same rules that govern the practice of telemedicine. By linking patients with doctors either via telephone or video chat, barriers of distance can be eliminated, which proves crucial for rural areas.

Telemedicine snapshot: Mississippi

To address the prevalence of chronic conditions, Mississippi became the 16th state to pass advanced telemedicine provisions. In 2014, the American Telemedicine Association (ATA) graded existing state telemedicine programs based on reimbursement and physician practice standards, rating Mississippi with the highest possible composite score. Evidence of a collaborative landscape accommodating telemedicine, Mississippi requires telemedicine services to be a 'real-time' consultation, which does not include the use of audio-only telephone, email, or fax. Additionally, the Mississippi legislature also required that telemedicine services are covered to the same extent as in-person services, although a health plan may limit the number of telemedicine providers to a local network.

With the highest prevalence of adult obesity and diabetes in the country, Mississippi prioritized remote patient monitoring services to coordinate primary, acute, behavioral, and long-term social service needs for high-need, high-cost patients. For telemedicine services to be reimbursed, patients must be eligible for remote patient monitoring and specific patient criteria must be met. For example, qualifying patients for remote patient monitoring must be recommended by their physician, be diagnosed in the last 18 months with a chronic condition like diabetes or heart disease, and have a history of costly services because of that condition.

Initial barriers to telemedicine implementation

Although Mississippi has faced relatively little resistance incorporating these laws, many states still need to consider a number of issues or barriers when developing telemedicine programs and policy.

1. Requiring coverage for telemedicine under private insurance, state employee health plans, and public assistance

Reimbursement continues to be a barrier to telemedicine adoption in some states. Medicare, which typically sets reimbursement standards, reimburses for telehealth services with relatively stringent requirements. Medicare pays for telemedicine services only when patients live in Health Professional Shortage Areas (HPSAs) and those who engage in "face-to-face" interactive video consultation services and some store-and-forward applications (e.g., teleradiology, remote electrocardiogram applications). As stated in a report by the American Hospital Association, "Without adequate reimbursement and revenue streams, providers may face obstacles in investing in these technologies."

Plan administrators and providers need to work together to discuss telemedicine benefits and determine coverage options and reimbursement policies, similar to the Mississippi State Legislature passing a bill requiring private insurance to pay for telemedicine services at the same rate as it does for in-person care. States considering telemedicine will have to wrestle with similar decisions about what to cover (e.g., video consultations, asynchronous store-and-forward platforms, patient monitoring) and review technology guidelines that determine reimbursement eligibility to ensure maximum reimbursement. To put it simply, if providers are not getting paid, they cannot provide.

2. Patient consent and education

Consent is a vital component of health care and is more complicated with a telemedicine platform. States must consider requirements for how to approach and obtain patient consent. The risk of consent-based claims for providers is a concern, and malpractice laws are currently geared toward face-to-face interactions; if consent-based claims become rampant, the willingness of providers to administer health care via telemedicine will likely decrease. Nebraska, for example, requires written informed consent, while California and Arizona law permit verbal consent to satisfy the statutory informed consent requirement. Since telehealth is a new and emerging field, patient education is critical to patients' health and providers' ability to practice.

Ideally, patients need to understand details about the expected risks and benefits of telemedicine, available alternatives, and how telemedicine fits into their personal wellness plan.

3. Geographical restrictions on telemedicine services

Although many states are ironing out provisions for health professional licensure requirements, including implementing special telemedicine licenses, border state and consultation exceptions, and interstate reciprocity and endorsements, little research has been done regarding restrictions on limitations for patient location while receiving telehealth services. For instance, can a patient on vacation in another state or country meet with his or her physician for an appointment? If the physician prescribes medication, can the patient fill his or her prescription outside of state lines?

Consideration needs to be placed on not just where the provider is operating from but also where the patient is located at the time of treatment and how treatment is administered.

4. Establishing the provider-patient relationship

Trust is an essential factor in a provider-patient relationship. It has been historically built during face-to-face interactions. States need to consider whether an in-person examination component is necessary or telemedicine can be used instead of an initial in-person patient evaluation.

The face of health care is changing, but prioritizing relationships is at the core of what creates value and better outcomes in health care. When implementing telemedicine programs, it is essential to consider the health of the patient first and design an interaction model that will create the most effective patient-provider relationship.

Overwhelmed? Here's what we know, and where we're going. We know that there are a significant number of rural Americans in the U.S. who have a difficult time accessing and affording health care. We know that many of these Americans are the ones who really need it, given their higher incidence of chronic disease. We know that chronic disease costs a lot and that most rural Americans cannot afford to treat it conventionally. We know that on its face, telemedicine may be one solution to solving the problem of rural health care.

A continued focus on this population of Americans and a renewed sense of urgency will allow for thoughtful state legislation and progressive development. Using Mississippi as a model of telemedicine implementation that is more thorough than many of its counterparts, other states can review their successes and challenges, with specific focus on the issues identified in this piece. For instance, considering where a patient must be located to receive care from providers, as well where they are legally able to fill a prescription from that provider are critical considerations for every state developing and amending telemedicine laws. There are a number of stakeholders involved in the telemedicine field. To ensure comprehensive, thoughtful laws and reforms, state legislature should reach out to local health care providers, nonprofit research centers, state insurance and Medicare/Medicaid departments, private insurance companies, state legislators, and patients to evaluate needs and requirements, and implement suitable legislation.

The adoption of telehealth technologies in rural areas can result in significant cost savings for hospitals and their communities due to transportation cost savings, lost wages savings, hospital cost savings and increased revenues for local labs and pharmacies, according to a white paper by the NTCA-The Rural Broadband Association.

In the white paper, titled “Anticipating Economic Returns on Rural Telehealth,” Rick Schadelbauer, manager, economic research and analysis at the organization, outlines the case to be made for increasing adoption of telehealth in rural areas, and throughout the country, by keeping patients using local health care services rather than traveling to bigger, nearby cities for health care services. Schadelbauer noted that within the United States, there is a distinct health disparity between rural and non-rural Americans, primarily as a result of demographics and limited access to health care.

Telehealth and telemedicine, or the remote delivery of health care services and clinical information using telecommunications technology, holds potential to improve the quality, cost and availability of health care in rural areas. However, telemedicine is not viable without access to robust, reliable broadband service, Schadelbauer wrote. “Rural areas currently lag in broadband deployment, but continue to make impressive gains due in large part to the efforts of small telecommunications providers. Wireless applications require wireline infrastructure in order to be viable options,” he wrote.

The white paper examines the rural health care challenges, telehealth adoption and the potential benefit of telehealth technologies, both non-quantifiable and quantifiable. And the white paper drills down into challenges for rural health, such as reimbursement, cost, patient privacy and licensing.

According to the paper, the non-quantifiable benefits of telehealth are numerous: improved access to specialists, speedier treatment, the comfort of remaining close to home, eliminating the need for long-distance transportation, the ability for health care providers to sharpen their skills, and improved patient outcomes.

The white paper also quantifies several categories of quantifiable benefits of telehealth: transportation cost savings (median cost savings: $5,718 per medical facility, annually); lost wages savings ($3,431 per medical facility, annually); hospital cost savings ($20,841 per medical facility, annually); and increased revenues for local labs ($145,109 per medical facility, annually) and pharmacies ($8,558 per medical facility, annually.)

More specifically, hospitals in rural communities could potentially save more than $81,000 a year on employing doctors, and the white paper presented as one example a hospital that reduced its use of a full-time radiologist from five days a week to one. And, at the same time, hospitals could potentially generate revenue from lab work and pharmacy services that would remain local as a result of telemedicine, according to the white paper. For example, the authors estimated that tens of thousands of dollars could generated by local MRIs, CTs and other lab and pharmacy billings.

“The decision to implement telemedicine is unique to each medical facility, and should take into account not only costs but also non-quantifiable benefits and quantifiable benefits accruing to parties other than the medical facility, such as the patient and local labs and pharmacies located in the communities where telemedicine takes place,” the authors wrote.

As potentially significant as the potential benefits to telehealth—both non-quantifiable and quantifiable—may be, , Schadelbauer wrote that “it is critically important to remember that rural telehealth’s role in addressing the significant health problems inherent to rural areas will depends upon the availability of an underlying, future-proof, fiber-based broadband infrastructure. Further investment in, and expansion of, broadband infrastructure is a critical need not only for rural Americans but also our country as a whole.” Further, he noted, “Absent access to such an infrastructure, the benefits of telemedicine will remain merely theoretical.”