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.

  • Telehealth and Remote Patient Monitoring Use in Medicare and Selected Federal Programsexternal icon

    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.

  • Telehealthexternal icon

    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 Telemedicineexternal icon

    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 Telehealthexternal icon

    E. 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 Considerationspdf icon[PDF – 1.18MB]external icon

    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 Statesexternal icon

    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 Addressedexternal icon

    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 Solutionsexternal icon

    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 Careexternal icon

    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.

  • The Empirical Foundations of Telemedicine Interventions in Primary Careexternal icon

    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.

  • Interactive Telemedicine: Effects on Professional Practice and Health Care Outcomesexternal icon

    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 Settingsexternal icon

    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 Residentsexternal icon

    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 Reportexternal icon

    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.

  • Legal Mapping Analysis of State Telehealth Reimbursement Policiesexternal icon

    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 Perspectiveexternal icon

    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.

  • HIPAA and Telehealthpdf icon[PDF – 68KB]external icon

    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 Telehealthexternal icon

    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 Lawsexternal icon

    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 Resolvedexternal icon

    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.

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.

  • Rural and Urban/Suburban Families’ Use of a Web-Based Mental Health Interventionexternal icon

    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.

  • Utilization of Telemedicine Among Rural Medicare Beneficiariesexternal icon

    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 Americaexternal icon

    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.

References

  1. Health Resources & Services Administration, Telehealth Programsexternal icon (last accessed October 2, 2018).
  2. Reed V. Tuckson et al., Telehealthexternal icon, 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?external icon, 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 Boardpdf icon[PDF – 6/55MB]external icon, April 28, 2018 (last visited October 22, 2018).
  5. World Health Organization, eHealthexternal icon, (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.

This document was developed by Jack Brackney, JD, MS, intern with the Public Health Law Program (PHLP) within the Center for State, Tribal, Local, and Territorial Support at the Centers for Disease Control and Prevention (CDC); Rachel Hulkower, JD, MSPH, and Dawn Pepin, JD, MPH, Cherokee Nation Assurance contractors with PHLP; and Russell McCord, JD, Oak Ridge Institute for Science and Education fellow with CDC’s National Center on Birth Defects and Developmental Disabilities.

For further technical assistance with this inventory, please contact phlawprogram@cdc.gov. PHLP provides technical assistance and public health law resources to advance the use of law as a public health tool. PHLP cannot provide legal advice on any issue and cannot represent any individual or entity in any matter. PHLP recommends seeking the advice of an attorney or other qualified professional with questions regarding the application of law to a specific circumstance. This research was supported in part by an appointment to the Research Participation Program at CDC administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the US Department of Energy and CDC. The findings and conclusions in this summary are those of the authors and do not necessarily represent the official position of CDC.

Page last reviewed: July 31, 2019