Telehealth and Telemedicine: A Research Anthology of Law and Policy Resources

Telehealth is “the use of electronic information and telecommunication technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration.”¹ Often, telehealth is used interchangeably with the terms telemedicine² or eHealth. Telehealth, however, is broader than these other terms; telemedicine and eHealth are distinct areas within telehealth.³ Telemedicine is defined by the Federation of State Medical Boards as “the practice of medicine using electronic communication, information technology, or other means between a physician in one location, and a patient in another location, with or without an intervening health care provider.”⁴ The World Health Organization defines eHealth as “the use of information and communication technologies (ICT) for health.”⁵

Telehealth is a promising public health tool because of its potential to significantly increase access to health care for medically underserved populations, as well as the widespread belief that it can reduce healthcare costs and improve health outcomes overall. In rural areas, with federal legislation increasing demand for medical services already in short supply, telehealth is often seen as a more efficient way for people to receive care.

Despite its growth in popularity in recent years, telehealth faces a number of barriers hindering more widespread adoption. Information security, patient privacy, licensing, insurance reimbursement, and liability concerns are all areas where gaps exist in state statutes and regulations. The following resources describe policy and legal considerations for implementing and governing telehealth.⁶

Resources for Identification and Discussion of Barriers to Telehealth

The following resources identify and discuss barriers limiting implementation and expansion of telehealth.

• Utilization of Outpatient Telehealth Services in Parity and Nonparity States 2010–2015 Jillian B. Harvey et al., Telemedicine Journal and e-Health (2018), http://doi.org/10.1089/tmj.2017.0265. Compares private insurance reimbursement rates for use of telehealth for outpatient health care in states with and without laws requiring such reimbursement.

• Telehealth and Remote Patient Monitoring Use in Medicare and Selected Federal Programs United States Government Accountability Office (2017). A report by the US Government Accountability Office highlighting views of provider, payer, and patient associations about the potential benefits of and barriers to telehealth in government healthcare programs. The study provides data on the use of telehealth in services offered by the Centers for Medicare & Medicaid Services, the Department of Defense, and the Department of Veterans Affairs.

• Telehealth Reed V. Tuckson et al., 377 New England Journal of Medicine 1585 (2017), doi: 10.1056/NEJMsr1503323.A review of several reports and studies that inform the authors’ policy recommendations.  Much of the article is devoted to the disconnect between electronic health records, patient and provider interaction with software and devices, and the prioritization of a technological platform for telehealth that would serve as a sort of one-stop-shop for healthcare providers and consumers.

• Legal Considerations in Telehealth and Telemedicine Edie Brous, 116 American Journal of Nursing 64 (2016), doi:10.1097/01.NAJ.0000494700.78616.d3. Subscription required.An article highlighting many of the provider barriers surrounding telehealth and telemedicine.  These barriers include lack of evidence for positive outcomes, liability concerns, technological barriers, and especially licensing requirements. The author provides a unique perspective, articulating barriers for nurses—who require their own state licensures—when much of the literature deals only with physicians.

• State of TelehealthE. Ray Dorsey & Eric J. Topol, 375 New England Journal of Medicine 154 (2016), doi: 10.1056/NEJMra1601705. Subscription required.An examination of the exponential rise in the investment in and adoption of telehealth. Gives particular focus to promising future applications, as well as limitations of the technology and healthcare industry. Particular attention is paid to social reasons that might limit expansion, including the high percentage of chronically ill patients over age 65 and the lower rates of internet usage by older and rural populations.

• Telehealth Policy Trends and Considerations [PDF – 1.18MB] National Conference of State Legislatures (2015). Comprehensive review of state telehealth legislation and policies in 2015. Meta-analysis of many peer-reviewed studies indicating substantial cost savings and suggesting improved health outcomes. The report highlights the expansion of licensing compacts among states, as well as the proliferation of private payer reimbursement of telehealth services.

• Private Payer Telehealth Reimbursement in the United States Nina M. Antoniotti et al., 20 Telemedicine Journal and e-Health 539 (2014), doi: 10.1089/tmj.2013.0256. Analyzes the difficulties healthcare providers have navigating insurance codes and reimbursement and identifies government payers’ influence over private payer insurance providers.

• For Telehealth to Succeed, Privacy and Security Risks Must be Identified and Addressed Joseph L. Hall & Deven McGraw, 33 Health Affairs (Millwood) 216 (2014), doi: 10.1377/hlthaff.2013.0997.Examines possible barriers to telehealth from privacy and security perspectives. Addresses privacy regulation beyond the Health Insurance Portability and Accountability Act (HIPAA) for information supplied and received by the patient. Contemplates the rights of patients when they are forced to accept terms and licensing in order to use an app or device.

Resources for Evidence of Cost and Health Outcomes Through the Use of Telehealth

Proponents of telehealth assert that remote technologies will expand access, reduce costs, and improve health outcomes. The following resources discuss attempts made by researchers to empirically evaluate claims that telehealth improves health outcomes, reduces healthcare costs, or both.

• What is the Economic Evidence for mHealth? A Systematic Review of Economic Evaluations of mHealth Solutions Sarah J. Iribarren et al., 12 Plos One (2017), doi:10.1371/journal.pone.0170581.Summarizes and assesses the body of evidence related to economic evaluations of mHealth interventions. This meta-analysis takes a conservative approach by limiting cost savings to primary outcomes. While noting that most studies claiming cost benefits lack sufficient supporting evidence, the review itself supports an overall cost-effectiveness for mHealth interventions. However, it warns against generalizing to all interventions.

• Urban Telemedicine Enables Equity in Access to Acute Illness Care Sarah D. Ronis et al., 23 Telemedicine Journal and e-Health 1 (2017), doi: 10.1089/tmj.2016.0098.A study of urban telemedicine use for acute care compared to suburban populations without telehealth use. The study found an overall cost savings, due largely to reductions in visits to the emergency department. The study found that the use of telemedicine increased healthcare access substantially in the urban population. Also, providers reported that a majority of office visits could have taken place via telemedicine.

• Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study Lucas Van Oeveren et al., 23 Telemedicine Journal and e-Health 1 (2017), doi: 10.1089/tmj.2016.0140.A study limited to rural, Midwestern hospitals’ use of telemedicine to assist nonemergency-trained physicians when they intubate patients. The study found that health outcomes improved through use of the technology.

• The Empirical Foundations of Telemedicine Interventions in Primary Care Rashid Bashshur et al., 22 Telemedicine Journal and e-Health 342 (2016), doi: 10.1089/tmj.2016.0045.A review of nearly three dozen studies of telemedicine intervention in primary care found 1) the studies commonly affirmed the feasibility and acceptance of telemedicine in primary care; and 2) telemedicine typically resulted in care quality improvements and cost savings.

• Cost-Utility and Cost-Effectiveness Studies of Telemedicine, Electronic, and Mobile Health Systems in the Literature: A Systematic Review Isabel de la Torre-Díez et al. 21 Telemedicine Journal and e-Health 81 (2015), doi: 10.1089/tmj.2014.0053.A review of thirty-five studies dealing with costs of various forms of telehealth. The review reports discrepancies in methods, aims, and results, prompting the authors to declare that current studies are inconclusive on the matters of cost-utility and cost-effectiveness of telehealth.

• Interactive Telemedicine: Effects on Professional Practice and Health Care Outcomes Gerd Flodgren et al., Cochrane Database of Systematic Reviews (2015), doi: 10.1002/14651858.CD002098.pub2.A large meta-analysis of more than 90 studies evaluating telemedicine use and effectiveness across many medical conditions. The review looks at remote monitoring and real-time teleconferencing interventions. The review finds that cost-savings claims in telemedicine are inconclusive across studies. But a reduction in the number of hospitalizations for patients with chronic conditions is indicated, and the review calls for further study.

• Telepsychiatry Integration of Mental Health Services into Rural Primary Care Settings John C. Fortney et al., 27 International Review of Psychiatry 525 (2015), doi: 10.3109/09540261.2015.1085838. Subscription required, link to abstract provided.A comparison of several models that combine telepsychiatry with in-person care. The authors conclude that telepsychiatry has the potential to significantly improve access to care, based on the results of implementation by the US Department of Veterans Affairs.

• High-Intensity Telemedicine Decreases Emergency Department Use by Senior Living Community Residents Manish N. Shah et al., 22 Telemedicine Journal and e-Health 251 (2015), doi: 10.1089/tmj.2015.0103.A study of the effectiveness and acceptance of telemedicine in senior living communities. The study found that more than 80 percent of residents surveyed would prefer a community with telemedicine capabilities for acute illness. In terms of cost savings, the study found an 18 percent reduction in emergency department visits annually, which the authors indicate is a conservative number based on study limitations.

Resources for Telehealth Statutes and Regulations

The following resources discuss state- and federal-level statutes and regulations governing the use of telehealth. Federal regulations generally pertain to use of telehealth in government-supported health care through the Department of Veterans Affairs and Medicare. State laws govern use of telehealth in Medicaid programs, licensing requirements for practicing telehealth within the state, and private insurance reimbursement for telehealth services.

• State Telehealth Laws and Reimbursement Policies Report Center for Connected Health Policy (2018). A survey of the 50 states and the District of Columbia on telehealth-related statutes, regulations, and Medicaid provider manuals. Areas covered include telehealth and telemedicine definitions, insurance reimbursement, prescribing, consent, and location of services provided.

• 50-State Survey: Establishment of a Patient-Physician Relationship via Telemedicine [PDF – 1.50MB] American Medical Association (2017). A collection of laws demonstrating that all states allow physicians to establish new patient relationships via telemedicine, noting that state laws vary. Provides a table of existing state laws with citations and the relevant language of each statute.

• State Telemedicine Gap Analysis American Telemedicine Association (2017).Reports on coverage and reimbursement gaps in state laws related to provision of telehealth services.

• Legal Mapping Analysis of State Telehealth Reimbursement Policies Kate E. Trout et al., 23 Telemedicine Journal and e-Health 1 (2017), doi: 10.1089/tmj.2017.0016.A 50-state survey of state laws and policies relating to telehealth reimbursement implemented since 1997. The authors identify where policies exist, the types of telehealth covered or restricted by state, and the form of telehealth. They also provide a separate analyses of state Medicaid reimbursement.

• Telehealth: Applications from a Legal and Regulatory Perspective Rita M. Marcoux & F. Randy Vogenberg, 41 Pharmacology & Therapeutics 567 (2016).An assessment of policies and regulations, identifying which agencies have the ability to regulate telehealth and the scope of those regulatory authorities. The authors point to successful government implementations of telehealth, but also acknowledge the lack of consistency across policies and the murky status of the law around telehealth.

• US and Territory Telemedicine Policies: Identifying Gaps in Perinatal Care Ekwutosi M. Okorohet et al., 215 American Journal of Obstetrics & Gynecology 1 (2016), doi: http://dx.doi.org/10.1016/j.ajog.2016.08.020. Subscription required, link to abstract provided.A survey of state telemedicine policies focused on three aspects of maternal and neonatal care: consultation, diagnosis, and treatment. Noting only three states specifically mention maternal or neonatal concerns, the authors looked to the 50 states, the District of Columbia, and eight territories for applicable, broad telemedicine policies.

• HIPAA and Telehealth [PDF – 68KB] Center for Connected Health Policy (2014).A concise guide to HIPAA compliance for covered entities using telehealth technologies for providing health care. The guide specifically talks about the role of conduits—a narrowly defined role in information delivery—such as Skype and FaceTime.

Resources for Recent Policy Recommendations

Telehealth faces regulation at multiple levels. Each state sets its own rules for practicing telehealth within its borders. Additionally, many federal agencies have the authority to regulate various aspects of telehealth. The following resources identify the existing reach and gaps in the web of state and federal regulations and statutory provisions.

• An Emergent Research and Policy Framework for Telehealth Margo Edmunds et al., 5 Journal of Electronic Health Data and Methods (2017), doi: http://doi.org/10.13063/2327-9214.1303.Proposed framework for moving forward with telehealth, including standardization of terms and policies for both consistent outcomes in research and practice, and implementation of policies.

• Health Policy Brief: Telehealth Parity Laws Tony Yang, Health Affairs (2016), doi: 10.1377/hpb2016.12.A brief overview of the debate surrounding reimbursement parity. The author summarizes the concerns of the opponents to parity and offers support for parity through studies and other reports. There is also a brief discussion of state parity laws on the books in 2016.

• Going Online With Telemedicine: What Barriers Exist and How Might They Be Resolved Pierron Tackes, 11 Oklahoma Journal of Law & Technology 80 (2015).Identifies obstacles to telemedicine policy as politically based rather than science based. The author contrasts the attempts at telemedicine expansion by the federal government with the hindering effects of state regulation of medical practice. A solution proposed is mandating arbitration for claims arising out of interstate telemedicine use.

• Patient Safety Risks Associated with Telecare: A Systematic Review and Narrative Synthesis of the Literature Veslemøy Guise et al., 14 BMC Health Services Research 588 (2014), doi: http://doi.org.ezproxy.library.tamu.edu/10.1186/s12913-014-0588-z.Analyzes several patient safety studies concerning telecare, identifying gaps in the research and potential areas for study. Suggests a human factors framework to study patient safety risks of home telecare.

• Interstate Licensure for Telemedicine: The Time Has Come Mei Wa Kwong et al., 16 American Medical Association Journal of Ethics 1010 (2014), doi: 10.1001/virtualmentor.2014.16.12.pfor2-1412.Addresses the need for uniform regulation of interstate medical licensing to better implement telemedicine and expand access.

Resources for Telehealth in Rural Areas

The ability to provide access to medically underserved populations is often cited as a chief benefit of telehealth. Attention is paid predominately to providing access to rural areas. The following resources discuss attempts to broaden healthcare access through telehealth interventions, including successes and opportunities for expanding telehealth.

• The Promise of Telehealth: Strategies to Increase Access to Quality Healthcare in Rural America [PDF – 3.70 MB] Center for Health Law and Policy Innovation, Harvard Law School (2018).Identifies legal and administrative barriers and strategies for broadening the use of telehealth to increase healthcare access in rural communities.

• Rural and Urban/Suburban Families’ Use of a Web-Based Mental Health Intervention Brian E. Bunnell et al., 23 Telemedicine Journal and e-Health 1 (2017), doi: 10.1089/tmj.2016.0153.A study investigating the applicability of web-based approaches to mental health care. The study found that geographic differences did not affect the likelihood of patients or caregivers using the technology, suggesting that advancements in telehealth will lead to improved access to historically underserved rural areas.

• Rural Family Physicians Are Twice as Likely to Use Telehealth as Urban Family Physicians Anuradha Jetty et al., 24 Telemedicine Journal and e-Health 1 (2017), doi: 10.1089/tmj.2017.0161.Studies the perceptions of family physicians in both rural and urban settings, comparing attitudes toward telehealth and likelihood of future use and controlling for a number of variables.

• Rapid Growth in Mental Health Telemedicine Use Among Rural Medicare Beneficiaries, Wide Variation Across States Ateev Mehrotra et al., 36 Health Affairs (Millwood) 909 (2017), doi: 10.1377/hlthaff.2016.1461. Subscription required, link to abstract provided.A study of telemedicine use from 2004 through 2014 among rural Medicare beneficiaries. The study found that despite an annual growth rate of 28% over a decade, fewer than 1% of rural beneficiaries received any telemedicine care. Particular attention is paid to how parity laws affect use of telemedicine.

• Utilization of Telemedicine Among Rural Medicare Beneficiaries Ateev Mehrotra et al., 315 Journal of the American Medical Association 2015 (2016), doi: 10.1001/jama.2016.2186.Reviews use of telehealth services in rural populations with mental illness and coverage under Medicare. The review found that telehealth use is concentrated geographically, and used by an extremely small percentage of mental health care recipients under Medicare.

• Telehealth in Rural America National Advisory Committee on Rural Health and Human Services (2015).A policy brief on the current state of telehealth in rural areas at the federal level. The committee makes a number of recommendations regarding expansion of telehealth to traditionally underserved areas, mostly concerning barriers caused by current Medicare reimbursement policies.

• Transforming Rural Health Care: High-Quality, Sustainable Access to Specialty Care Kavita Patel et al., Health Affairs Blog (2014). A commentary on the slow US adoption of telehealth, specifically the opportunities of expansion into rural areas.

References

1. Health Resources & Services Administration, Telehealth Programs (last accessed October 2, 2018).
2. Reed V. Tuckson et al., Telehealth, 377 N. Engl. J. Med. 1585 (2017), doi: 10.1056/NEJMsr1503323.
3. Office of the National Coordinator for Health Information Technology, What is telehealth? How is telehealth different from telemedicine? HealthIT.gov (last accessed September 19, 2018).
4. Federation of State Medical Boards, Guidelines for the Structure and Function of a State Medical and Osteopathic Board[PDF – 6/55MB], April 28, 2018 (last visited October 22, 2018).
5. World Health Organization, eHealth, (last visited October 2, 2018).
6. The resources were identified using online databases. PHLP searched in Google, PubMed, and WestLawNext for the terms “telemedicine,” “telehealth,” “ehealth,” and “mhealth,” along with “policy” and “law.” Searches were completed between August 2017 and September 2018. PHLP used WestlawNext to conduct searches for legal publications and Google and PubMed for additional resources.