Telemedicine and Telehealth: Essentials for Review

Definitions

• Telemedicine: provision of healthcare when distance/time separate participants, using telecommunications technology. Often domain-specific (e.g., teleradiology, teledermatology).

• Telehealth: broad term for health interactions via telecommunications; now used interchangeably with telemedicine in many contexts. Historically included non-video interactions; during COVID-19, telephone-only care was often reimbursed as telemedicine.

Core concepts and taxonomy

• Asynchronous (store-and-forward): not real time (e.g., image transfer reviewed later).

• Synchronous: real-time interaction (video/phone between patient and provider).

• Remote patient monitoring: patients monitored at home/other living settings with sensors, devices, and telecommunication.

• Mobile health care: use of mobile technologies (smartphones) with messaging/tracking.

Uses and classic applications

• Access in underserved rural areas to specialists.

• Home-based monitoring of frail elderly or chronically ill patients.

• Outsourcing non-direct-care services (e.g., radiology, pathology).

• Early market leaders: Nighthawk (US-licensed radiologists across time zones).

• Professional guidelines: ATA practice guidelines.

New and expanding uses

• Direct-to-consumer telehealth: patients interact online with physicians not necessarily their regular PCP.

  • Teladoc: video visits (network access via patients or employers/health plans).

  • Remedy Medical: online chat-based interactions.

  • HealthTap: similar services.

• Before and during COVID-19, health systems began offering video visits via telehealth platforms; ONC best-practices emphasize simplicity and integration of telehealth records into official patient records.

• Hospital-at-home: hospital-level care at home with nurse/physician visits, IV meds, remote monitoring, and tests; associated with reduced overall costs and readmissions.

COVID-19 impact and policy changes

• CMS Section 1135 waiver (COVID-19): broad expansion of telehealth services beyond traditional rural settings; allowed care from home; allowed audio-only visits; allowed patients without pre-existing relationships; cross-state practice with license in state; any service type not limited to COVID-19; relaxed HIPAA rules to permit more widely used platforms.

• Expanded eligible providers and sites (including FQHCs, rural health clinics); allowed audio-only interactions; reduced or waived cost sharing for some services.

• Usage surge statistics (Medicare beneficiaries): approx. 63-fold increase in telehealth; total visits from baseline of 0.1 o 5.3 ext{ ext{ extperthousand}}, i.e., from 0.1 ext{ extpercent} to 5.3 ext{ extpercent} of all fee-for-service visits; behavioral health from 1 ext{ extpercent} to 38 ext{ extpercent}.

• By 2021: telehealth use varied but remained above pre-pandemic baselines; Census Household Pulse Survey showed about one in four respondents used telehealth in the prior four weeks.

• Disparities during the pandemic: video use higher among younger, privately insured, higher-income, and White populations; lower among uninsured, 18–24 vs older adults; digital divide affected access for older adults, non-English speakers, rural residents, and lower-education/income groups.

• Academic center findings: rapid telehealth adoption across clinics; variable clinician well-being; mixed effects on access disparities; some patient satisfaction data favored telehealth (comparable or better than in-person for certain domains).

State coverage, reimbursement, and licensure landscape

• Pre-pandemic barriers: limited reimbursement for non-radiology telemedicine; Medicaid and private payer coverage highly state-dependent; parity laws advocated but not universal.

• Post-pandemic landscape (state-level): Medicaid usually a floor; state variations persist; many states now cover audio-only, home-based, school-based, and remote monitoring to varying degrees; store-and-forward coverage in some states; private payer mandates to cover telehealth services increasing; licensure compacts exist but trends toward partial reversion to pre-pandemic norms as the pandemic wanes.

• Licensure and credentialing: state-based medical licensure; reciprocity and cross-state practice discussed; some easing during the pandemic but concerns persist about interstate practice and credentialing burden.

Challenges and inequities

• Quality and safety concerns: reduced home BP/lipid monitoring in some primary care telehealth encounters; diagnostic/testing and medication-ordering reductions during remote visits in some specialties.

• Digital divide: limited internet access correlates with higher prevalence of diabetes, hypertension; older age, minority status, rural residence, lower income associated with fewer completed telehealth visits and lower video usage.

• Barriers to equity: non-English language preferences, Medicaid enrollment, older age, race/ethnicity; non-completion of video visits linked to clinician inexperience with telehealth tech, patient age, SES, and minority status.

• Privacy, patient safety, and privacy concerns: telehealth raises issues in diagnostic errors and medication safety; need for policy, research, and practice guidelines.

• Prenatal care and other specialties: internet/phone connectivity is major barrier; childcare, privacy, and equipment access also critical.

• Concept of digital redlining: technology has potential to reduce inequities but can also exacerbate them if access gaps are not addressed.

Pre-COVID barriers and policy landscape

• Reimbursement: limited for non-radiology telemedicine; rural telemedicine more commonly covered; variability across Medicaid and private insurers.

• Licensure/credentialing: state-based licensure; calls for reciprocity and cross-state licensing; EF for broader telehealth coverage across states.

Best practices and competencies for the future

• Telemedicine/telehealth are here to stay; need to address safety and quality concerns and integrate into standard care.

• AAMC telemedicine competency framework (for medical trainees):

  • Patient Safety and Appropriate Use – when/how to use; safety/readiness of patient and clinician.

  • Access and Equity – reduce biases; promote equitable access.

  • Communication – effective communication with patients, families, and care teams.

  • Data Collection and Assessment – collect/manage clinical information for high-quality care.

  • Technology for Telehealth – basic tech knowledge for delivery of services.

  • Ethical Practices and Legal Requirements – comply with privacy and regulatory standards.

• Integration of trainees into televisits; ensure proper supervision and learning.

• Engagement and patient experience: prioritizing telehealth, choose secure platforms, minimize patient burden (no mandatory apps, minimal login hurdles).

  • Patient-desired features (from TigerConnect survey): secure texting, add family to calls, upload notes, video/voice calling.

• Practice optimization recommendations: consolidate vendors, EHR integration, cloud-based solutions, simple workflows, cost-effective approaches, and patient/provider education.

• Policy guidance: Nastasi & Archambault framework for state adherence; modalities should be parity-based and broad to cover a range of care; avoid mandating every telehealth service or fixed payment rates; move toward digital transformation (not just digitization) in care delivery.

• AMA Digital Health Playbook: shift from telehealth to digitally enabled care; consider disruption and sustainability of clinical care.

• Notes on policy trajectory: debate about ongoing cost, coverage, and licensing; some argue the telehealth bubble has subsided but the utility remains.

Practical takeaways for implementation

• Telemedicine/telehealth is a permanent component of care delivery; plan for ongoing integration with in-person visits.

• Address digital divide with infrastructure investments, language/interpretation support, and accessible technology solutions.

• Prioritize secure, user-friendly platforms; aim for minimal patient burden and EHR interoperability.

• Develop training and competency programs aligned with AAMC framework for trainees and staff.

• Monitor policy changes at the state and federal levels and adapt reimbursement and licensure strategies accordingly.

Conclusion

• Telemedicine and telehealth are here to stay and must be integrated thoughtfully into healthcare delivery to maximize access, quality, and equity while addressing safety, privacy, and policy challenges.