Telehealth Use in Rural Healthcare

Telehealth has great potential to increase access to and quality of healthcare in rural communities. Technology can now allow rural patients to see specialists without leaving their communities, permits local providers to take advantage of distant expertise, and improves timeliness of care.

What is telemedicine?

Telemedicine is the remote delivery of healthcare services and information using telecommunications technology.

What is 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. 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 “telemedicine” and “telehealth” interchangeably.

While one of the most common images of telehealth is of a patient speaking by videoconference with a remote physician, telehealth can take many forms. The Health Resources Services Administration defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health and health administration.

Telehealth technologies can include:

  • Videoconferencing,
  • Store-and-forward data, images or videos,
  • Remote patient monitoring, and
  • mHealth (mobile health) applications

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 issues, reimbursement, licensure, and access to broadband services.

Frequently Asked Questions


How does telehealth improve healthcare access in rural communities?

According to a 2012 document, The Role of Telehealth in an Evolving Health Care Environment, telehealth drives volume, increases quality of care and reduces costs by reducing readmissions and unnecessary emergency department visits for rural communities. Telehealth allows small rural hospitals to continue providing quality care at low costs. Also, rural patients receiving care via telehealth can avoid driving long distances to access specialty care.

Using telehealth services is more feasible for rural healthcare facilities than staffing the facilities with specialist providers. Telehealth allows specialists to visit rural patients virtually. Specialties provided to rural communities via telemedicine include:

  • Teleradiology
  • Telepsychiatry
  • Teleopthalmology
  • Teledermatology
  • Teledentistry

Specific examples of telemedicine improving rural healthcare access include:

  • Intensive Care Unit Telemonitoring (e-ICUs):
    A 2012 article highlights an e-ICU system in rural Alaska that has extended the reach of healthcare professionals located in urban areas. Rural providers can collaborate with tele-hub professionals to assist in monitoring and treating patients and provide “an extra set of eyes for the bedside nurse.” These systems can also provide access to assistance during “tricky, and often lifesaving, procedures.”
  • Extension for Community Healthcare Outcomes (ECHO):
    Project ECHO allows better chronic disease management in rural New Mexico. Primary care providers and specialists work as a team to manage chronic conditions of rural patients.
  • Access Telehealth is a website developed by the Health Resources and Services Administration that highlights many other telehealth successes such as Evangelical Lutheran Good Samaritan Society’s use of telehealth monitoring to improve patient care.

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.
  • Monitoring systems can facilitate tracking of patient vital signs from their home, such as smarthomes that utilize home-based sensors to keep patients in their homes longer.
  • 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.

These and other 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.


For what types of care has telehealth technology been effectively used in rural communities?

Telehealth technology has been used effectively in rural communities for many types of care. Examples include:

  • Audiology
  • Behavioral healthcare
  • Cardiology
  • Chronic care management interventions
  • Dentistry
  • Dermatology
  • Emergency care
  • Gastroenterology
  • Hepatology
  • Home monitoring
  • Intensive care units
  • Long-term care
  • Obstetrics
  • Ophthalmology
  • Pharmacy
  • Radiology
  • Stroke interventions

In the August 2013 issue of the Rural Monitor, there are several examples of how rural telehealth capabilities continue to grow including:

  • The Georgia Partnership for Telehealth uses school telehealth to assess and treat students so that they do not need to travel to a clinic for healthcare. Schools and jails are among more than 350 Georgia locations where telehealth has replaced the traditional doctor’s office visit.
  • In North Carolina, telehealth is helping seniors remain in their homes longer. Hospitalization rates decreased for patients enrolled in the FirstHealth Home Care Chronic Disease model. Patients who had diagnoses of heart failure, diabetes or COPD and had experienced frequent hospitalizations were monitored by telehealth at home between skilled nursing visits. Response and intervention times improved substantially.
  • In South Dakota, Avera Health’s eCare telehealth services have expanded to include coverage for ICU, emergency departments, pharmacy and long-term care. They now serve more than 165 hospitals and clinics in South Dakota, North Dakota, Iowa, Minnesota, Montana, Nebraska and Wyoming.

How do the Telehealth Resource Centers help rural communities?

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 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 provides modules on staffing and recruiting specialists, credentialing and licensing, creating protocols, billing, evaluation and more.

On the third Thursday of every month, the Telehealth Resource Centers present a webinar on a topic related to telehealth. Past webinars can be viewed online at the national telehealth webinar series webpage.


What are some telehealth funding programs for rural providers?

There are several telehealth grant programs for rural providers 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.

    The Federal Office of Rural Health Policy plans to offer the Funding Opportunity Announcement (FOA) again in early 2016.
  • USAC Rural Health Care Telecommunications Program
    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.

    The USDA Office of Rural Development plans to offer the Funding Opportunity Announcement (FOA) again in early 2015.

What are the challenges related to telehealth services in rural communities?

Some of the challenges include the following:

Reimbursement

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:

  • The level of reimbursement in the fee-for-service system
  • Limitation of reimbursement to rural and health professional shortage areas
  • Limitation of reimbursement to certain types of care settings
  • Limitation to certain current procedural terminology codes

States have various standards by which their Medicaid programs will reimburse for telehealth expenses. Refer to the National Conference of State Legislatures (NCSL) State Coverage for Telehealth Services to learn which states have Medicaid reimbursement for telehealth services.

More information about Medicaid reimbursement for telehealth is also available on RAC’s Medicaid and Rural Health topic guide.

There is no single widely-accepted standard telehealth reimbursement for private payers. Some insurance companies value the benefits of telehealth and will reimburse a wide variety of services.

In addition, the Center for Telehealth and e-Health Law has information about telehealth reimbursement.

Licensure

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. The licensure of healthcare professionals is a function of a state’s professional licensing board. Physicians who wish to practice across state lines must be licensed in each state where care is given.

However, the Department of Veterans Affairs (VA) is distinctive, and VA physicians have license portability which allows them to practice across state lines to wherever the patient is receiving care.

Broadband

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.


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.

Issues to consider include:

  • Identifying an appropriate payment model
  • Training to develop a positive culture among staff
  • The standardization of processes; and
  • The use of care coordinators to implement telehealth programs

Facilities should carefully analyze what equipment is needed to provide telemedicine consultation services, as well as options and services available from each vendor. Low-cost equipment consists of simple, web-based videoconferencing. More costly equipment includes large screen, high-definition videoconferencing equipment. The specific equipment depends on the services being provided; for example, teledermatology usually requires a higher resolution image than telepsychiatry.

When setting up a facility for telehealth, having adequate space within the facility for the equipment is a priority. The videoconferencing equipment should be well secured at all times, even when it is not in use. Data services such as picture archiving and communication systems (PACS) will require heavy use of the facility’s network. The universal format for PACS image storage and transfer is DICOM (Digital Imaging and Communications in Medicine). DICOM is a standard for handling, storing, printing, and transmitting medical information. PACS has the ability to deliver timely and efficient access to images, interpretations, and related data.

Within your facility, it is important to train your staff on the technology and develop a positive attitude to telehealth services among staff. The California Telehealth Resource Center developed a telehealth training module with success tips.

For assistance that is specific to your facility, contact your regional Telehealth Resource Center.


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 his provider in a different location for use in care and related support. The Rural Assistance Center has a topic guide on Home Health with more information on reaching patients in their homes.

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 elderly or disabled people, providing the care and monitoring to allow them to live independently in their homes.


How does the use of telehealth impact rural healthcare providers?

There are many ways that telehealth systems impact providers including:

Provider Retention

A report from the Agency for Healthcare Research and Quality, Using Telehealth to Improve Quality and Safety, highlights the positive impact of telehealth systems on provider retention in rural areas. These systems can reduce rural isolation and provide a "network of peers from other rural and urban communities."

Providers are able to receive health education through telehealth such as lectures and computer-based training programs. This includes teleconferencing with other healthcare professionals to share knowledge and experiences.

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.”

Training

The introduction of telehealth systems in the healthcare workplace has created a need for new training for practicing professionals and students. The national network of Telehealth Resource Centers provides information related to training programs on telehealth systems.


What financial impact could the addition of telehealth services have for 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 relatively rural states in the Midwest including Kansas, Oklahoma, Arkansas and Texas. All of these communities have hospitals that use some form of telemedicine. The authors of the report conclude:

  • Each community recognizes an economic impact of at least $20,000 per year in savings or other economic opportunities generated by the hospital’s telemedicine equipment.
  • The average annual community impact is around $522,000, and the maximum impact is over $1,300,000.
  • Most communities tend to obtain the majority of their savings from increased lab and pharmacy revenues, due to additional work performed locally.

Is telehealth usage widespread in rural facilities?

The RUPRI Center for Rural Health Analysis completed a report in 2014 titled Extent of Telehealth Use in Rural and Urban Hospitals. Data from 4,727 hospitals in the 2013 HIMSS Analytics database found:

  • Two-thirds of the hospitals had no telehealth services or were only in the process of implementing a telehealth application. One-third of the hospitals had at least one telehealth application currently in use.
  • Hospitals that were more likely to have implemented at least one telehealth service were academic medical centers, not-for-profit institutions, hospitals belonging to integrated delivery systems, and larger institutions.
  • Rural and urban hospitals did not differ significantly in overall telehealth implementation.
  • Urban and rural hospitals did differ in the department where telehealth was implemented. Urban hospitals were more likely than rural hospitals to have operational telehealth implementations in cardiology/stroke/heart attack programs, neurology, and obstetrics/gynecology/NICU/pediatrics.
  • In contrast, rural hospitals were more likely than urban hospital to have operational telehealth implementations in radiology departments and in emergency and trauma care.