Telemedicine

There is some evidence that telemedicine increases access to care^{3, 4, 5, 6, 7}, particularly through increasing patients’ direct access to providers, services, and medication for women’s reproductive health care^{8, 9, 10}. Telemedicine may increase access to care among rural populations and other groups who experience challenges in access, such as mobility^{1, 4}. Telemedicine appears, in some cases, to provide care equivalent to more traditional in person care^{1, 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 care^{1, 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 services^{8, 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 patients^{9, 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, diabetes^{16, 21, 22, 23}, anticoagulation, hyperlipidemia, asthma, heart failure, HIV, chronic kidney disease, stroke, and COPD, as well as depression and posttraumatic stress disorder^{18, 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 morbidities^{1, 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 emissions^{31, 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 replacement^{1, 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 adherence^{1, 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.

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.

^‡ 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.