Introduction
The outbreak of the coronavirus pandemic significantly accelerated the adoption of telemedicine across the world. As a result, many patients have shown an increased preference for seeking healthcare services through digital methods than in-person appointments. This can be attributed to the low costs, convenience, and increased efficiency of care services linked to telemedicine. Telemedicine is mostly used to conduct patient assessments, write or renew prescriptions, and offer certain medical services such as psychological treatment (Kichloo et al., 2020). The integration of telemedicine in the healthcare system has been linked to shorter hospital stays and decreased readmissions and hospital mortality rates. Legislative initiatives implemented during the Covid-19 pandemic promoted the widespread adoption of telemedicine.
The Utilization of Telemedicine Prior to the Novel Coronavirus?
Before the onset of the coronavirus, the utilization of telemedicine in the United States had been experiencing a rapid increase. Between 2010 and 2017, the percentage of hospitals using video and other electronic technologies to administer patient care rose from 35% to 76% (Kichloo et al., 2020). In addition, from 2016 to 2017, telemedicine insurance claims had increased by 53%. Neurologists have largely used telemedicine to provide care to stroke patients. The shortage of neurologists in the United States inspired the invention of telestroke, which offers care services to stroke patients (Hyder & Razzak, 2020). Over the years, Tele-stroke has been used by neurologists to communicate with stroke patients or emergency physicians to recommend appropriate treatment approaches.
Telemedicine has considerably been used in radiology to transmit radiological images from one place to another, a process known as teleradiology. Reports or images gathered through telemedicine or in-person examinations were transferred remotely to radiologists whose clinical assessments would be sent to the patient’s physician or other care providers to inform treatment plans. Research indicates that in 2014, teleradiology accounted for over half of the telemedicine services in the United States (Hyder & Razzak, 2020). Thus, telemedicine has been pivotal in providing care services long before the onset of the Covid-19 pandemic.
Telemedicine has significantly been used to administer mental health assessments and services, a process referred to as telepsychiatry. Through telepsychiatry, psychiatrists can directly interact with patients through video conferencing or telephone to evaluate and diagnose different mental disorders. Telepsychiatry has also been instrumental in providing individual, family, or group therapy to clients suffering from various mental illnesses. For instance, the University of Rochester in New York invented a telepsychiatry program to manage mental health disorders, including Parkinson’s disease (Hyder & Razzak, 2020). The program has been conducting over 2000 telepsychiatry consultations annually for over a decade (Hyder & Razzak, 2020). Equally important, telemedicine has been utilized for remote patient monitoring, also referred to as telemonitoring. Through this process, healthcare professionals could track a patient’s activities and vital signs from their homes to manage chronic conditions such as congestive heart failure and diabetes, among other cardiopulmonary diseases (Hyder & Razzak, 2020). Telemonitoring assisted care providers in detecting anomalies in a patient’s blood pressure, sugar levels, and pulse rate and recommended when to visit a physician.
Prior to the coronavirus pandemic, telemedicine use in rural areas was slightly higher than in urban regions. This can be attributed to the inadequate healthcare providers in rural areas, which necessitated patients in remote areas to seek care virtually or through other electronic means. A study indicates that between 2012 and 2019, there were 7 visits per 1,000 patients in the urban regions compared to 11 telemedicine visits per 1,000 patients in the rural areas (Chu et al., 2021). Therefore, before the coronavirus outbreak, healthcare providers utilized telemedicine to offer various care services, particularly to patients in remote areas.
The Barriers to Telemedicine Use and Existing Concerns That Prevented Its Use
Legal and regulatory challenges have long obstructed the use of telemedicine. The variations in policies, laws, and regulations regarding telemedicine across the states have greatly limited the practice. The lack of multistate licensure was a significant barrier to the telemedicine practice. The state licensure rules dictated that physicians and other care providers could be licensed in the states where their patients are located (Gajarawala & Pelkowski, 2020). This made it difficult for healthcare professionals to offer clinical services to patients across other states. In addition, limited coverage and payment posed greatly hindered the telemedicine practice. The law restricted most telemedicine services to patients in rural regions and specific settings such as hospitals. There were also limitations to the number of services and the nature of communication; the policies only allowed real-time and two-way video conference methods except for telestroke (Gajarawala & Pelkowski, 2020). Regarding payment, Medicare and other private payers had greatly limited the reimbursement of telemedicine services. Medicare’s reimbursement was limited to nonmetropolitan regions and certain institutions (Gajarawala & Pelkowski, 2020). Thus, restrictions on licensure and limited coverage and payment hindered the adoption of telemedicine.
The standards set by the Centers for Medicare and Medicaid (CMS) in regards to credentialing and privileging significantly obstructed the telemedicine practice. The CMS conditions stipulate that hospitals should have a credentialing and privileging procedure for care providers offering clinical services to the hospital’s patients, including those providing telemedicine services (Rheuban & Krupinski, 2017). Although credentialing by proxy was feasible, it was restricted to telemedicine services offered by practitioners located at a Medicare-linked distant site hospital or a telemedicine services entity. Similarly, the credentialing by proxy necessitated that the originating site hospital signs a contract with the distant site hospital or the telemedicine entity ascertaining that credentialing and privileging procedure met the CMS standards, among other requirements (Rheuban & Krupinski, 2017). Such lengthy conditions considerably hampered the provision of telemedicine services.
The telemedicine practice was greatly impeded by regulations on internet-based prescribing. Even though states differed in their online prescribing policies, most states required an in-person visit to be conducted before engaging in telemedicine follow-ups. As a result, some states prohibited the issuance of prescriptions solely based on internet questionnaires, consultations, or phone consultations (Fields, 2020). This considerably deterred the provision of telemedicine services across different states. Similarly, telemedicine was barred by federal and state regulations on privacy and security of patient information. Complying with such regulations presented a great challenge to care providers who could not guarantee the safety of patient information due to the susceptibility of electronic mediums to cyber threats. Additionally, telemedicine was also hindered by laws regarding medical liability in regards to informed consent, supervision requirements for non-physician providers, and practice protocols and standards (Gajarawala & Pelkowski, 2020). Moreover, the federal fraud and abuse laws, including the Stark and Anti-kick statutes, have considerably impaired telemedicine practice (Gajarawala & Pelkowski, 2020). Thus, regulations on online prescribing, privacy and security, and fraud and abuse restricted the telemedicine practice.
The Factors That Allowed for Telemedicine’s Widespread Use During the Pandemic
The government restrictions on public gatherings and interactions greatly influenced the adoption of telemedicine during the Covid-19 pandemic. The need to access healthcare services amid an epidemic obliged many individuals to resort to telemedicine. This is because telemedicine lessened the risk of exposure for both the patients and the care providers (Monaghesh & Hajizadeh, 2020). In addition, during the pandemic, many healthcare facilities prioritized healthcare services to patients suffering from the virus. As a result, patients suffering from other chronic diseases such as cancer, kidney diseases, diabetes, and other cardiovascular ailments were forced to adopt telemedicine to ensure continued care. Similarly, due to the constant lockdowns that considerably limited people’s movements, care providers were obliged to use telemedicine channels to follow up with their patients and expand access to care for other individuals in dire need of care services (Monaghesh & Hajizadeh, 2020). The need for healthcare providers to lessen patient demand on care facilities was a major drive toward telemedicine. The coronavirus exerted a lot of pressure on the available healthcare resources, which necessitated health professionals to find alternative means to deliver care to the rest of the population.
The government’s efforts to slow the spread of the coronavirus significantly led to the increased use of telemedicine. The federal and state governments eased many regulatory policies on telemedicine to encourage its use among the public. For instance, many states adopted a multistate licensure approach where care providers could offer clinical services to patients across the state lines (Busch et al., 2021). Furthermore, the need to monitor the progress of Covid-19 patients placed under quarantine in different locations also encouraged the widespread use of telemedicine (Monaghesh & Hajizadeh, 2020). During the corona pandemic, some patients suffering from the virus would self-isolate in their homes. Hence, healthcare professionals would use telemedicine channels such as video conferencing to monitor the recovery progress of such patients. Therefore, the need to lower and slow down the risk of coronavirus and to lessen patient demand on healthcare facilities considerably enhanced the adoption of telemedicine.
How the Concerns of Prior Were Addressed
Due to the Covid-19 pandemic, some changes were introduced to the federal and state regulations and health plan reimbursement directives that significantly lessened the existing telemedicine barriers. Some of the concerns that have been addressed include the licensure issues where states have now permitted out-of-state care providers to provide clinical services to patients across state lines (Busch et al., 2021). Additionally, the states have eased their regulations on online prescribing and now allow authorized care providers to prescribe medications through telemedicine even without an in-person clinical evaluation (Busch et al., 2021). Regarding the issue of coverage and payment, Medicare has expanded the list of telemedicine services and types of care providers who can administer telemedicine (Busch et al., 2021). It has also included the coverage for phone visits while increasing the charges for telemedicine visits to equal those of in-person appointments (Kichloo et al., 2020). Such modifications have extensively promoted the use of telemedicine services across the country.
The government has eased telemedicine’s Health Insurance Portability and Accountability Act (HIPAA). The waiver of certain federal privacy and security standards has enhanced telemedicine practice (Busch et al., 2021). In addition, states have also diversified the originating and distant sites from which patients can receive telemedicine services (Busch et al., 2021). In this case, patients’ homes can now act as originating sites, making the health delivery process convenient. Additionally, physicians and care providers can offer clinical care from different locations without any restrictions. Similarly, some states have eased their patient consent restrictions by allowing verbal consent. Equally important, some states have permitted federally qualified health centers or rural clinics to offer telemedicine services. Moreover, various private insurers have stretched telemedicine coverage (Busch et al., 2021). Thus the modifications made to the regulatory policies regarding licensure, online prescribing, originating sites, coverage, and payments have significantly increased the telemedicine practice across the country.
The Future Outlook of Telemedicine
The use of telemedicine has the potential to continue growing to become an integral part of healthcare service delivery in the future. Research indicates that by 2020, 76% of health facilities in the United States had already adopted some telemedicine approaches to connect with their patients (Hyder & Razzak, 2020). Thus, with the widespread acceptance of telemedicine, the number of healthcare facilities and care providers using telemedicine may increase significantly. The continuous growth may be attributed to its low costs, comfort and convenience, and improved patient care access (Gajarawala & Pelkowski, 2021). In addition, the reduction in overhead expenses, less exposure to diseases, and increased revenue may encourage care providers to expand their telemedicine services. There is also a big possibility that telemedicine will continue expanding to link care providers and patients globally. Thus telemedicine will evolve to become a critical part of the healthcare system.
Telemedicine will grow to serve a crucial role in healthcare delivery for patients in rural areas. Research indicates that about 85% of individuals living in rural regions in the United States have internet connections, while 71% of rural residents have smartphones (Kichloo et al., 2020). Many individuals living in rural or remote areas often experience challenges in accessing care partly due to their geographical locations or inadequate healthcare staff at local clinics. However, telemedicine can promote the provision of primary and secondary care to individuals in remote and marginalized regions. Additionally, the Association of American Medical Colleges (AAMC) estimates that the country will have a deficit of about 122,000 physicians by 2032 (Kichloo et al., 2020). Even though the shortage is likely to affect the entire nation, the rural and underserved populations may be the most affected. Currently, the proportion of primary care providers (PCPs) to patients in rural regions is 39.8% per 100,000 individuals compared to 53.3% per 100,000 in urban areas (Kichloo et al., 2020). This proves that telemedicine will play a key role in healthcare delivery to patients in remote places, thus improving patient outcomes.
Conclusion
Even though telemedicine existed for several years, its use increased tremendously during the Covid-19 pandemic. Telemedicine’s reduced costs, increased access to healthcare, and convenience has benefited many patients. However, before the coronavirus outbreak, its use was greatly impeded by regulatory and legal constraints. The lack of multistate licensure and limitations to online prescribing and credentialing and privileging hindered telemedicine use before the onset of Covid-19. Nevertheless, the government’s effort to slow down the spread of the virus and the need to relieve pressure on healthcare resources prompted the increased adoption of telemedicine. Consequently, many federal and state regulations were eased to encourage widespread telemedicine use. Telemedicine has the potential to become an integral part of healthcare system delivery because it has been linked to a considerable decrease in readmission rates, shorter hospital stays, and reduced mortalities. In addition, telemedicine can narrow the gaps in healthcare delivery by providing increased access to care services to people living in marginalized regions. Therefore, the changes in telemedicine regulations should not be temporary; they should be long-term to promote its use in the future.
References
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