Telehealth Implementation Barriers
By Gift Nnamdi
The Rise of Telehealth in Medicine
Telehealth is defined as the use of telecommunications technology (i.e., telephone, email, video chats) to deliver healthcare services to patients across distance and time. While telehealth was initially adopted to provide healthcare services to patients from rural and underserved communities, it has garnered wider acceptance across U.S. hospitals and medical clinics due to improvements in technology. In addition, the onset of the COVID-19 pandemic in recent years has created a higher demand for telehealth to limit physical contact and reduce viral transmission. Despite the milestones made with telehealth, there remain significant barriers that impede its widespread adoption.
Advantages of Telehealth on a Patient and Provider Level
Before discussing these barriers, it is important to recognize the advantages telehealth provides. Firstly, telehealth has allowed for the reduction in prolonged hospitalizations and unnecessary emergency room visits. On a patient level, these services reduce hospital wait times and travel time, increasing convenience and accessibility to healthcare. It also limits the burden of transportation to and from a medical clinic, making it ideal for patients from rural communities and patients with disabilities. On a provider level, it can reduce overhead costs, allowing providers to save some money which can be used to invest in other needs such as office space. Additionally, providers are less likely to be exposed to illnesses and disorders when they are practicing medicine remotely.
Telehealth Can Stifle Physician-Patient Relationships
While the stated advantages have been generally linked to increased patient and provider satisfaction, critics have identified the strain that telehealth services have placed on the relationship between physicians and patients. Trust and communication are important qualities that both physicians and patients need to develop for medicine to be most effective. However, telehealth can be impersonal due to the lack of physical contact and decreased body language cues. In turn, it can be difficult for physicians to accurately diagnose a patient in a remote setting. For instance, procedures including physical examinations and blood tests or those requiring expensive tools and expertise, such as X-rays and brain scans, need to be conducted in person. Therefore, telehealth must be supplemented with in-person visits by the patient. Ideally, providers and patients should establish an in-person relationship for the initial visit. In fact, some states including Arkansas require that physicians meet their patients face-to-face before prescribing treatment (Gajarawala and Pelkowski 2020).
In a University of Missouri School of Medicine qualitative study investigating how healthcare providers feel about the adoption of telehealth practices into primary care resident outpatient training, residents found the decreased physical contact with patients frustrating. They believed it limited the quality and quantity of time with the patient and felt that “not many primary care physicians have telehealth capability” (Fleming et al. 2009). However, they added that telehealth skills are beneficial for physicians to learn, nonetheless. Nurses voiced that while telehealth may enhance the physician-patient relationship due to one-on-one time together during the visit, some patients may be camera shy.
Online Security and Protecting Patient Privacy
In accordance with the Health Insurance Portability and Accountability Act, telehealth software systems are highly encrypted and consistently monitored. However, no software system is completely safe from data breaches and hackers, making the protection of patient privacy and confidentiality a concern for critics. According to an article identifying telehealth security and privacy, there is limited control of information flow for individuals since technology companies largely determine information use and disclosure (Hall and McGraw 2014). Patients need to be able to access medical information through secure platforms and trust that their information is being handled with care. Violation of patient privacy and confidentiality leads to mistrust of providers and the healthcare system on a patient level and increased medical liability and reputation damage on a provider level. Laws including the Health Information Technology for Economic and Clinical Health and the Children’s Online Privacy Protection Act provide more regulations aimed at enhancing the protection of patient medical information.
Lack of Reimbursement
Currently, many health insurance coverage plans do not provide full coverage for telehealth services, leaving patients to pay hefty out-of-pocket costs. Patients who cannot afford these costs are likely not to use telehealth services if in-person services are covered more by their health insurance. 41 U.S states as of Fall 2019 have laws governing reimbursement specifically for telemedicine services, however, these laws vary greatly by state. Coverage plans such as Medicare have made some strides in the coverage of remote patient monitoring while expanding their geographic reach. In general, if telemedicine meets the same standards of care as in-person, state-regulated private plans must adequately cover the costs. However, fewer states have this payment parity clause or requirement for similar payment rate reimbursement for telehealth as compared to in-person.
Licensure Regulations for Telehealth Practice Vary by State
Providers need to abide by the telehealth licensure rules and regulations implemented by state boards. Due to varying state laws, it is difficult for providers to continue their remote practices across states. The Interstate Medical Licensure Compact by the Federation of State Medical Boards tried to tackle the licensure issue by increasing the portability of licenses across states for physicians and physician assistants. Under this contract, the state board maintains licensure and disciplinary actions (Weigel and Ramaswamy 2020). While this is a step forward for physicians, a contract that eases the portability of telehealth licensure for nurse practitioners has yet to be established. Therefore, all healthcare providers always need to be cognizant and knowledgeable about their licensure contract and state laws and regulations when practicing telehealth.
Medical Liability for Providers
Medical liability can also impede the implementation of telehealth nationwide. Incorporating existing standard principles against malpractice into remote and virtual settings is not easy. Malpractice liability involving informed consent, standard of care protocols, and liability coverage is not as easily adapted to remote services as definitions of these terms begin to change when we transition to telehealth. Therefore, it is especially important to create guidelines for preventing errors and licensure contract breaches while practicing medicine via telehealth. Additionally, providers need to refer to their liability insurance policies and coverages to ensure that they are not potentially engaging in medical malpractice.
Moving Forward
Telehealth offers convenience for patients and providers, but there exists barriers and gaps that limit its widespread adoption across states. While telehealth can increase access to healthcare services, the technological divide amongst patients including those from rural areas and low- income communities may hinder access (Cortelyou-Ward et al. 2020). Major barriers to telehealth relate to concerns about physician-patient relationships, online security and patient privacy, reimbursement and licensure issues, and medical liability. Increasing payment parity for telehealth services across states will effectively increase patient access and incentivize providers to offer them. It is still unclear whether telehealth services will be sustainable in the long run, but its expanded use has ushered in new ways of delivering healthcare services.
References
[1] Fleming, David A., et al. “Incorporating Telehealth into Primary Care Resident Outpatient Training.” Liebertpub, Apr. 2009, https://www.liebertpub.com/doi/10.1089/tmj.2008.0113.
[2] Gajarawala, Shilpa N., and Jessica N. Pelkowski. “Telehealth Benefits and Barriers.” The Journal for Nurse Practitioners, Elsevier, 21 Oct. 2020, https://www.sciencedirect.com/science/article/pii/S1555415520305158.
[3] Hall , Joseph L., and Deven McGraw. “For Telehealth to Succeed, Privacy and Security Risks Must Be Identified and Addressed: Health Affairs Journal.” Health Affairs, 1 Feb. 2014, https://www.healthaffairs.org/doi/10.1377/hlthaff.2013.0997.
[4] Cortelyou-Ward, Kendall, et al. “Navigating the Digital Divide: Barriers to Telehealth in Rural Areas.” Journal of Health Care for the Poor and Underserved, Johns Hopkins University Press, 10 Nov. 2020, https://muse.jhu.edu/article/772756.
[5] Weigel, Gabriela, and Amrutha Ramaswamy. “Opportunities and Barriers for Telemedicine in the U.S. during the COVID-19 Emergency and Beyond.” KFF, 17 Mar. 2021, https://www.kff.org/womens-health-policy/issue-brief/opportunities-and-barriers-for-telemedicine-in-the-u-s-during-the-covid-19-emergency-and-beyond/.
Gift Nnamdi is a third year Neuroscience major at UCLA and is a THINQ 2021–2022 clinical fellow.
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