Telemedicine

Evidence Rating  
Some Evidence
Evidence rating: Some Evidence

Strategies with this rating are likely to work, but further research is needed to confirm effects. These strategies have been tested more than once and results trend positive overall.

Health Factors  
Community in Action

Telemedicine uses information-communication technologies to provide clinical services between patients and health care providers or to share clinical information between providers. Telemedicine includes video conferencing or telephone-only visits, provided synchronously in real time, with patient-provider interaction, or asynchronously, where the patient and provider exchanges messages, text, images, or other materials1, 2. Telemedicine is sometimes called telehealth, but telehealth can be understood as broader than telemedicine and can refer to other health services and medical education or training provided remotely1.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Increased access to care

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Improved access to reproductive health care

  • Improved chronic disease management

  • Reduced vehicle miles traveled

  • Reduced emissions

What does the research say about effectiveness? This strategy is rated some evidence.

There is some evidence that telemedicine increases access to care3, 4, 5, 6, 7, particularly through increasing patients’ direct access to providers, services, and medication for women’s reproductive health care8, 9, 10. Telemedicine may increase access to care among rural populations and other groups who experience challenges in access, such as mobility1, 4. Telemedicine appears, in some cases, to provide care equivalent to more traditional in person care1, 11, 12, but more rigorous research is needed evaluating whether telemedicine improves health outcomes among individuals when used to treat acute conditions or more complex or chronic diseases, compared to solely in-person care1, 4, 12, especially as the focus of telemedicine services shifts to increasing patient convenience and reducing costs11.

Reproductive health care. Telemedicine can provide early access to medical abortion services8, 10. A British study suggests a telemedicine/in-person hybrid model for providing remote medical abortions could lead to significantly shorter wait times from referral to treatment, increasing the number of abortions provided at 6 weeks or less gestation8. There is demand for self-managed abortion care, where medication is received through the mail and patients are supported via telemedicine13, and telemedicine-supported abortion care appears to be as safe and effective as in-person services, and acceptable to providers and patients9, 10. However, in the U.S. legal and policy challenges to telemedicine-supported abortion care are increasing13.

Telemedicine interventions for reproductive health can impact some pregnancy and birth-related health outcomes, including increasing perinatal smoking cessation and breastfeeding10, reducing postpartum depression14, and are a comparable alternative to in-person office visits to monitor patients for high-risk obstetric conditions10. However, it may not significantly improve maternal and fetal outcomes related to pregestational and gestational diabetes compared to usual care, although that may be because pregnant individuals are often already closely monitored for some conditions, limiting telemedicine’s effect15. Additionally, telemedicine interventions designed for adolescent sexual health may improve self-efficacy and condom use and increase screening and testing for sexually transmitted infections3.

Chronic disease. Telemedicine may improve chronic disease management in some cases, including reducing Hba1c in diabetic patients16 and modestly improving disease control in patients with multiple morbidities when interventions focus on a specific risk factor17. Pharmacist-delivered telemedicine care, especially interventions delivered at predetermined times, may improve disease management, self-management, and treatment adherence for chronic diseases, as much as or more than in-person visits18. A variety of telemedicine interventions appear to modestly improve blood pressure in patients with cardiovascular disease and hypertension, particularly if the interventions last 6 months or longer; experts recommend telemedicine interventions include monitoring devices which report data automatically19. Asynchronous patient-physician messaging may decrease emergency department and hospital utilization among patients with multiple chronic conditions20. Conditions that have been shown to be sensitive to telemedicine include hypertension, diabetes16, 21, 22, 23, anticoagulation, hyperlipidemia, asthma, heart failure, HIV, chronic kidney disease, stroke, and COPD, as well as depression and posttraumatic stress disorder18, 24. Experts caution, however, that the type and intensity of interventions vary widely, and that overall evidence quality is low. More rigorous research is needed on whether telemedicine improves clinical outcomes for chronic diseases and overall health status among patients with multiple morbidities1, 16, 17.

Acute conditions. Telemedicine may be an appropriate alternative, or first step in triage, for low-risk acute conditions for which people commonly seek treatment at an in-person appointment, such as conjunctivitis, emergency contraception, urinary tract infection (UTI), upper respiratory tract infections (URI), and sore throat (pharyngitis)25; such e-visits do not appear to increase emergency department use, and may be cost effective due to their short length (often only two or three minutes)25. Evidence is mixed, with some studies suggesting telemedicine leads to similar or better care outcomes such as appropriate prescribing of antibiotics or ordering of medical imaging12 while other studies suggest patients may be more likely to receive inappropriate antibiotics or that clinicians may not order appropriate tests. Telemedicine may reduce physician-related medication errors among seriously ill or injured children in rural emergency departments26. Experts suggest telemedicine may be more likely to produce beneficial outcomes, such as appropriate prescribing and expected rates of follow-up care, when providers and patients have an established relationship, the patient’s medical record is available, and on-site testing and follow-up care are accessible1. More research is needed about difficult-to-assess conditions and among patients with communication barriers1.

Other specialties. Telerehabilitation services may improve motor function following total knee replacement27 and reduce short-term disability and symptoms for patients with multiple sclerosis28. Telerehabilitation also appears to produce similar outcomes to center-based cardiac rehabilitation for low to moderate risk coronary artery disease patients29. Teleglaucoma screening detects more cases of glaucoma than in-person screening in remote and underserved communities30, and, overall, telemedicine appears to increase access to care for speech, language, and hearing services5. Telemedicine is also used globally for routine dermatologic care, but more research is needed which compares tele-dermatology with in-person consultation; experts suggest it may be well-suited for initial evaluations and follow-up visits1.

Environmental benefits. Telemedicine has the potential to reduce the carbon footprint of the health care industry, primarily by reducing vehicle miles traveled (VMT) and greenhouse gas emissions from patients driving to appointments. Telemedicine does generate some carbon emissions and those amounts vary, for example, with the length of the appointment, type of teleconferencing platform used, energy used to support the virtual connection, and different broadband capacities. In general, telemedicine appointments that replace a car trip of a few kilometers or more reduce carbon emissions31, 32. Experts also suggest that telemedicine can reduce traffic, wear on medical facilities, and reduce staff and patients’ exposure to infectious disease1.

Challenges. Providers and patients may encounter challenges in using telemedicine, including inconsistent reimbursement policies, inadequate reimbursement amounts, restrictions on which technologies can be used, and from what settings, and privacy regulations that can increase costs to ensure exchanges are secure1. Patients who are traveling may be excluded from care due to states’ different medical licensing systems, and certain prescription, visit, and patient types may also be excluded1. Telemedicine can also be challenging to evaluate because telemedicine visits can be simple or intensive and complex. Providers may prefer in-patient visits for high-risk patients or those with complex conditions when there is no disincentive for using in-person visits1. More research is also needed on diagnostic accuracy and timing in telemedicine, as well as delayed diagnosis legal claims in telemedicine compared to standard care1.

Recommendations. Overall, experts recommend telemedicine alongside standard care, not as a replacement1, 4. More research is needed on the effects of telemedicine on patient-provider trust and rapport; the ability to pick up on less easily observed symptoms and non-verbal communication remotely; the unavailability of therapeutic touch; and patients’ treatment adherence1, 4. Experts suggest that video appointments may allow providers to check on a patient’s home environment, perform a partial physical exam, observe some non-verbal communication, and may enhance the patient-provider relationship compared to audio only appointments33. Experts suggest asynchronous messaging may be well-suited for hospitals’ busiest times, such as flu seasons or during disasters, but recommend measures to prevent physician fatigue or burnout; increased care burdens may fall on outpatient clinicians handling a high message volume and could contribute to fatigue or burnout over time if not addressed1.

How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by expert opinion.

Telemedicine is a suggested strategy to decrease geographic disparities in access to health care between rural and urban areas1 by improving access for rural populations and in areas with medical provider shortages11. Experts also suggest telemedicine could improve access to care for populations experiencing transportation barriers11, such as among older adults with limited mobility outside the home4. Telemedicine-supported abortion care may increase access for women who live in states that prohibit or restrict abortion13.

However, telemedicine use appears to differ significantly by patients’ race, household income, insurance status, and whether the household has high-speed internet1, 33. Adults without health insurance are least likely to use telemedicine33 and video-enabled visits in particular appear to be used more by younger, higher income, urban, white adults, and less by those with lower incomes, adults with less than a high school degree, individuals who identify as Black, Latino/a, or Asian, and adults over age 6533, even with significant increases in use in 2020 and 2021 when barriers were removed due to the COVID-19 pandemic1, 33. One study suggests that video visits appear to be used more often by individuals who identify as transgender, compared with other groups33.

More research is needed on telemedicine acceptability among diverse groups. Among individuals aged 50 and older, individuals of color appear more likely than white individuals to express concerns about telemedicine related to quality of care; health information security; privacy; and coverage or reimbursement issues33. However, among patients who use telemedicine, those from households with lower incomes or households that do not identify as white appear to be as satisfied with their experiences as other groups1. A Michigan-based study of rural patients’ satisfaction with telemedicine visits in a rural health care system also suggests a high percentage of patients have positive perceptions of telemedicine visits, though satisfaction was highest among younger patients39.

Evaluating whether telemedicine improves health equitably among different demographic groups is also challenging, because prior to COVID-19, patients using telemedicine were mostly self-selecting though use is expanding1. Barriers to using telemedicine may still include health insurance coverage, and, especially among older adults, access to the internet and equipment (e.g., desktop, laptop, or smartphone), technological literacy, and cognitive and physical ability33. Telemedicine may also not be available to those who desire to use it.

What is the relevant historical background?

Telemedicine was initially used for acute conditions, such as strokes or traumatic injuries, to connect specialist providers with clinicians treating patients in emergency departments. Telemedicine programs have also historically focused on rural populations, as well as those in the military and individuals who are incarcerated4. Before March 2020 and the onset of the COVID-19 pandemic in the U.S., provider-patient telemedicine use was increasing but was a tiny proportion of overall care1, especially video-enabled visits4. Most patients in the U.S. who used telemedicine did so through large academic medical centers, the Veterans Administration (VA) health systems, or purchased access if their healthcare provider offered direct-to-consumer services. Barriers to internet access and use prevented patients in rural areas, those with lower household incomes, disabilities1, and older adults from accessing care via telemedicine4. Legal barriers and differing state rules, such as whether medication could be prescribed over the internet also restricted use4. For example, prior to the legal decision to reverse Roe v. Wade in 2022, 19 states had banned or restricted use of telehealth for medication abortion40.

In March 2020, to support access to care and financial solvency for health care systems, Congress adjusted telemedicine restrictions for Medicare, including removing some restrictions for reimbursement, geography, and platform, as well as including telephone-only visits, and addressing interstate barriers to practice and privacy related to states’ differing rules, with state and private health insurance payors following this example1. A study of private and Medicare health care claims estimates that telehealth claims increased from 0.1% in 2019 to 5% of overall claims, as of 20211.

Telemedicine-supported abortion care has also been affected by recent changes in state and federal law and regulation. Medication abortion in early pregnancy has been available since 2000, when mifeprestone was approved by the U.S. Food and Drug Administration (FDA) for this use. As of 2017, medication abortion comprised 39% of all abortions in the U.S., and by 2020, it comprised more than half38.

Equity Considerations
  • How widely available and used is telemedicine in your community or state – between providers, as well as providers and patients?
  • Who is choosing which types of telemedicine interventions to offer patients and how are those decisions being reached? Which health needs are the focus? Which patient groups?
  • How are health care providers, as well as community members, engaged in efforts to expand telemedicine use? What local or state laws and regulations restrict its use?
  • What barriers might people experience at the local or state level in accessing telemedicine (e.g., health insurance coverage, internet access)? To using telemedicine meaningfully (e.g., digital literacy)?
Implementation Examples

As of January 2023, all 50 states and Washington, D.C. provide Medicaid reimbursement for live video telehealth services, 43 states and Washington, D.C. have telehealth private payer laws, and the same number also reimburse for audio-only telephone services, which is a significant increase since 202134. As of 2018, 76% of U.S. hospital systems use telemedicine in some form, most often for radiology, cardiology, and psychiatry1. Telemedicine visits increased among all patient types, especially those with chronic illnesses, after the onset of the COVID-19 pandemic in March 20201.

A number of telemedicine and telehealth programs exist in the United States35. The Missouri Telehealth Network36, for example, is aimed at enhancing access to care in rural and underserved areas of Missouri. The Children’s National Medical Center in Washington, D.C. has a telemedicine program that serves community hospitals, suburban health centers, inner-city health clinics, national hospitals, and international partners37.

U.S. regulations on abortion care are changing quickly, complicating telemedicine-supported care. The U.S. Food and Drug Administration (FDA) removed restrictions on dispensing medication for abortions in 2023, making it possible for individuals to obtain medication abortion pills from retail pharmacies except in states with a near-total ban on abortion. Other states limit prescribing power to physicians, despite guidance from the World Health Organization (WHO) and others which says it is safe for advanced practice clinicians, such as physician assistants, to provide medication abortion38.

Implementation Resources

Resources with a focus on equity.

HRSA-HHS Telehealth - Health Resources & Services Administration (HRSA). Telehealth.HHS.gov.

CCHP-Telehealth Fall 2023 - Center for Connected Health Policy (CCHP). State Telehealth Laws and Reimbursement Policies Report, Fall 2023. October 2023.

RHIhub-Telehealth - Rural Health Information Hub (RHIhub). Telehealth use in rural healthcare.

LawAtlas-Telehealth - LawAtlas. Telehealth and primary care provider laws map.

ATA - American Telemedicine Association (ATA).

HRSA-Telehealth - Health Resources and Services Administration (HRSA), Office for the Advancement of Telehealth. Telehealth active programs.

Footnotes

* Journal subscription may be required for access.

1 Shaver 2022 - Shaver J. The state of telehealth before and after the COVID-19 pandemic. Primary Care: Clinics in Office Practice. 2022;49(4):517-530.

2 HRSA-HHS Telehealth - Health Resources & Services Administration (HRSA). Telehealth.HHS.gov.

3 Saragih 2021 - Saragih ID, Imanuel Tonapa S, Porta CM, Lee BO. Effects of telehealth interventions for adolescent sexual health: A systematic review and meta-analysis of randomized controlled studies. Journal of Telemedicine and Telecare. 2021.

4 Dorsey 2016 - Dorsey ER, Topol EJ. State of telehealth. New England Journal of Medicine. 2016;375(2):154-161.

5 Molini-Avejonas 2015 - Molini-Avejonas DR, Rondon-Melo S, de La Higuera Amato CA, Samelli AG. A systematic review of the use of telehealth in speech, language and hearing sciences. Journal of Telemedicine and Telecare. 2015;21(7):367-376.

6 Penate 2012 - Peñate W. About the effectiveness of telehealth procedures in psychological treatments. International Journal of Clinical and Health Psychology. 2012;12(3):475-487.

7 Kehle 2011 - Kehle SM, Greer N, Rutks I, Wilt T. Interventions to improve veterans’ access to care: A systematic review of the literature. Journal of General Internal Medicine. 2011;26(Suppl 2):689-96.

8 Aiken 2021 - Aiken ARA, Lohr PA, Lord J, Ghosh N, Starling J. Effectiveness, safety and acceptability of no-test medical abortion (termination of pregnancy) provided via telemedicine: A national cohort study. BJOG: An International Journal of Obstetrics and Gynaecology. 2021;128(9):1464-1474.

9 Endler 2019 - Endler M, Lavelanet A, Cleeve A, et al. Telemedicine for medical abortion: A systematic review. BJOG: An International Journal of Obstetrics & Gynaecology. 2019;126(9):1094-1102.

10 DeNicola 2020 - DeNicola N, Grossman D, Marko K, et al. Telehealth interventions to improve obstetric and gynecologic health outcomes. Obstetrics & Gynecology. 2020;135(2):371-382.

11 Shigekawa 2018 - Shigekawa E, Fix M, Corbett G, Roby DH, Coffman J. The current state of telehealth evidence: A rapid review. Health Affairs. 2018;37(12):1975-1982.

12 Bashshur 2016 - Bashshur RL, Howell JD, Krupinski EA, et al. The empirical foundations of telemedicine interventions in primary care. Telemedicine and e-Health. 2016;22(5):342-375.

13 Skuster 2022 - Skuster P, Moseson H. The growing importance of self-managed and telemedicine abortion in the United States: Medically safe, but legal risk remains. American Journal of Public Health. 2022;112(8):1100-1103.

14 Hanach 2021 - Hanach N, de Vries N, Radwan H, Bissani N. The effectiveness of telemedicine interventions, delivered exclusively during the postnatal period, on postpartum depression in mothers without history or existing mental disorders: A systematic review and meta-analysis. Midwifery. 2021;94:102906.

15 Laursen 2022 - Laursen SH, Boel L, Udsen FW, et al. Effectiveness of telemedicine in managing diabetes in pregnancy: A systematic review and meta-analysis. Journal of Diabetes Science and Technology. 2022;17(5):1364-1375.

16 Timpel 2020 - Timpel P, Oswald S, Schwarz PEH, Harst L. Mapping the evidence on the effectiveness of telemedicine interventions in diabetes, dyslipidemia, and hypertension: An umbrella review of systematic reviews and meta-analyses. Journal of Medical Internet Research. 2020;22(3):e16791.

17 Kraef 2020 - Kraef C, van der Meirschen M, Free C. Digital telemedicine interventions for patients with multimorbidity: A systematic review and meta-analysis. BMJ Open. 2020;10:e036904.

18 Niznik 2018 - Niznik JD, He H, Kane-Gill SL. Impact of clinical pharmacist services delivered via telemedicine in the outpatient or ambulatory care setting: A systematic review. Research in Social and Administrative Pharmacy. 2018;14(8):707-717.

19 Gao 2022 - Gao W, Lv X, Xu X, et al. Telemedicine interventions to reduce blood pressure in a chronic disease population: A meta-analysis. Journal of Telemedicine and Telecare. 2022;28(9):621-631.

20 Reed 2019 - Reed ME, Huang J, Brand RJ, et al. Patients with complex chronic conditions: Health care use and clinical events associated with access to a patient portal. PLoS ONE. 2019;14(6):e0217636.

21 Cochrane-Flodgren 2015 - Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: Effects on professional practice and health care outcomes (Review). Cochrane Database of Systematic Reviews. 2015;(9):CD002098.

22 Huang 2015 - Huang Z, Tao H, Meng Q, Jing L. Effects of telecare intervention on glycemic control in type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials. European Journal of Endocrinology. 2015;172(3):R93-R101.

23 Greenwood 2014 - Greenwood DA, Young HM, Quinn CC. Telehealth remote monitoring systematic review: Structured self-monitoring of blood glucose and impact on A1C. Journal of Diabetes Science and Technology. 2014;8(2):378-389.

24 Wootton 2012 - Wootton R. Twenty years of telemedicine in chronic disease management - An evidence synthesis. Journal of Telemedicine and Telecare. 2012;18(4):211-20.

25 Reed 2021a - Reed M, Huang J, Graetz I, et al. Treatment and follow-up care associated with patient-scheduled primary care telemedicine and in-person visits in a large integrated health system. JAMA Network Open. 2021;4(11):e2132793.

26 Dharmar 2013 - Dharmar M, Kuppermann N, Romano PS, et al. Telemedicine consultations and medication errors in rural emergency departments. Pediatrics. 2013;132(6):1090-1097.

27 Agostini 2015 - Agostini M, Moja L, Banzi R, et al. Telerehabilitation and recovery of motor function: A systematic review and meta-analysis. Journal of Telemedicine and Telecare. 2015;21(4):202-213.

28 Cochrane-Khan 2015 - Khan F, Amatya B, Kesselring J, Galea M. Telerehabilitation for persons with multiple sclerosis (Review). Cochrane Database of Systematic Reviews. 2015;(4):CD010508.

29 Huang 2015a - Huang K, Liu W, He D, et al. Telehealth interventions versus center-based cardiac rehabilitation of coronary artery disease: A systematic review and meta-analysis. European Journal of Preventive Cardiology. 2015;22(8):959-971.

30 Thomas 2014b - Thomas SM, Jeyaraman M, Hodge WG, et al. The effectiveness of teleglaucoma versus in-patient examination for glaucoma screening: A systematic review and meta-analysis. PLOS ONE. 2014;9(12):e113779.

31 Dacones 2021 - Dacones I, Cave C, Furie GL, Ogden CA, Slutzman JE. Patient transport greenhouse gas emissions from outpatient care at an integrated health care system in the Northwestern United States, 2015–2020. The Journal of Climate Change and Health. 2021;3.

32 Holmner 2014 - Holmner Å, Ebi KL, Lazuardi L, Nilsson M. Carbon footprint of telemedicine solutions - Unexplored opportunity for reducing carbon emissions in the health sector. PLoS ONE. 2014;9(9).

33 US DHHS-Karimi 2022 - Karimi M, Lee EC, Couture SJ, et al. National survey trends in telehealth use in 2021: Disparities in utilization and audio vs. video services. Washington, D.C.: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services (US DHHS); 2022.

34 CCHP-Telehealth glance - Center for Connected Health Policy (CCHP). State Telehealth Laws and Reimbursement Policies At-A-Glance. Fall 2023.

35 HRSA-Telehealth - Health Resources and Services Administration (HRSA), Office for the Advancement of Telehealth. Telehealth active programs.

36 MTN - Missouri Telehealth Network (MTN). Improving health with telecommunications technology.

37 CNHS-Telemedicine - Children’s National Health System (CNHS). Telemedicine.

38 Guttmacher-Medication Abortion 2023 - Guttmacher Institute. State Laws and Policies: Medication Abortion. October 31, 2023.

39 Klee 2023 - Klee D, Pyne D, Kroll J, James W, Hirko KA. Rural patient and provider perceptions of telehealth implemented during the COVID-19 pandemic. BMC Health Services Research. 2023;23:981.

40 KFF-Anderson 2021 - Anderson E, Salganicoff A, Sobel L. State restrictions on telehealth abortion. KFF; 2021.

Date Last Updated