1. Nelson, Roxanne


Despite the promise of remote health care services, their operation faces hurdles.


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There are a number of challenges associated with the U.S. health care system-and Americans living in rural areas may experience them more keenly. Socioeconomic factors, geographic circumstances, and workforce shortages all present significant barriers within rural communities, particularly for individuals who need specialty care. Telemedicine and telehealth services, however, which have long been considered valuable to improving health care access, have the potential to address these issues and to reduce some of the disparities between rural and urban health care.

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The terms telemedicine and telehealth are often used interchangeably, but they are not quite the same thing. According to the Federal Communications Commission, telemedicine refers to medical services provided with the support of telecommunications technologies, such as diagnostic testing or monitoring a patient's posttreatment progress. Telehealth, on the other hand, includes a broader variety of clinical and nonclinical remote health care services-often provided by nurses-like patient education, help with medication adherence, and troubleshooting health issues.



"Rural health is one of the areas where there is the most promise and the most need," says Pamela Stewart Fahs, PhD, RN, associate dean, professor, and Decker Chair in Rural Nursing at Binghamton University's Decker School of Nursing in Binghamton, New York. "Many people live long distances from hospitals or clinics, and the weather can be problematic in winter."


Victoria L. S. Britson, PhD, APRN, CNP, FNP-BC, CNE, a family NP and assistant professor at the South Dakota State University College of Nursing in Sioux Falls, points out that 34 of South Dakota's 66 counties are classified as "frontier," with less than six people per square mile. "Due to the sparse population, many areas do not have the capacity to support sufficient health care services, [which may explain] the higher death rates in nonmetropolitan areas compared with urban areas," she says.


Fahs notes that telehealth can help bridge distances-and that it applies broadly to a variety of settings, including primary, acute, and long-term care; mental health; and school health. And virtually any specialty can be provided via telemedicine, whether it be cardiology, dermatology, or emergency medicine. This aspect of telemedicine is particularly valuable, as establishing specialty services in rural and frontier locations can be difficult. Britson explains that such services are frequently offered to rural areas via outreach clinics-which means providers experience the same travel-related issues as their patients.


"But with telemedicine, patients can stay in their own communities and avoid unnecessary travel and expense," Britson says. "Providers more distant to the patient also avoid travel obstacles." However, the use of telehealth and telemedicine in rural facilities is not as widespread as it could be.



In 2014, the University of Iowa's RUPRI (Rural Policy Research Institute) Center for Rural Health Policy Analysis published findings from a data analysis it conducted regarding the use of telehealth in both rural and urban hospitals. (The center examined 2013 data from 4,727 facilities gathered by the Healthcare Information and Management Systems Society.) According to the analysis, two-thirds of both rural and urban health care facilities either did not offer telehealth services or were only in the process of implementing a telehealth application. One-third of hospitals (rural and urban) had at least one telehealth application in use.


The analysis also revealed that the use of telehealth services wasn't necessarily widespread at the facilities that did offer them: among hospitals with "live and operational" telehealth services, 61.4% reported that these services were operational only in a single department or program, and 38.6% said they were operational in two or more departments or programs. Rural hospitals were significantly less likely to have multiple services than urban hospitals (35.2% versus 42.1%).


Given the associated challenges and obstacles, it's not surprising that telehealth and telemedicine services haven't made deeper inroads into rural health. "For one thing," says Britson, "rural and remote sites must have telemedicine capability. There are start-up, equipment, training, and maintenance costs."


She also points out that telemedicine may not be a curricular component in medical and nursing education. "It was not a part of our family NP program until 2016, yet graduating students were being offered job placements in facilities where they were expected to conduct telemedicine visits."


Another challenge is that provider education in telehealth use isn't standardized, and industry-wide competencies haven't been developed; training is often provided only on the job. And providers may not be comfortable with the technology, Britson adds. "Patients may also be uncomfortable, especially if the provider or staff are not skilled."


The question of reimbursement presents an additional barrier. "One issue is whether reimbursement for a telehealth visit should be the same as for a face-to-face visit," says Fahs. Medicare does cover telehealth, but only under certain circumstances and within certain time frames. For example, Medicare limits reimbursement for telehealth in nursing homes to one visit every 30 days. "That isn't enough," she says. "Access to telehealth may be able to prevent hospitalization, which would lower costs and unnecessary stress for the patient."


Licensing, too, must be sorted out. While most virtual providers are located in the same state as the patient, some are not. "So we have the question: Can you give care across state lines without a license in that state? We need to streamline these issues," Fahs points out. And despite the benefits of telehealth, robust data on its outcomes are lacking. "What we have now is spotty," she says.


Ann Fronczek, PhD, RN, assistant professor at the Decker School of Nursing at Binghamton University, recently received a grant to help get a telehealth service off the ground. One of the biggest challenges she and her colleagues have experienced so far, she says, is the need to sort out broadband Internet access, especially for high-definition videoconferencing.


"Another big problem is interoperability-a lot of the programs are proprietary and don't 'talk' to each other," Fronczek says. "So when we are looking at equipment, we want to make sure there is a high probability that it will be able to 'talk' to equipment being used elsewhere."


Costs for the initial operation of telehealth services can be high. "We decided to go with a basic setup, and the cost is over $30,000," she says. "For a rural hospital without a lot of resources, that can be a very big outlay of cash."


One of the challenges of grants is that in the academic world they are primarily for creating infrastructure-not for hiring personnel. But as Fronczek knows firsthand, people are needed to run telehealth systems. Figuring out how to finance and support both necessary infrastructure and staff may be the biggest challenge of all.-Roxanne Nelson



To learn more about telehealth and telemedicine, visit these websites.


Intermountain Healthcare


Northwest Regional Telehealth Resource Center


Project ECHO


Telehealth Resource Centers