Telehealth's Future Success Requires a Paradigm Shift

One of five articles featuring telehealth leaders answering the question:
"The promise of telehealth for rural communities has been touted for decades. Why is it taking so long to become mainstream in the practice of rural medicine? How can we change the trajectory of telehealth adoption?"

by William England, PhD, JD, Director of the Office for the Advancement of Telehealth

Like kids who ask "Are we there yet?" when starting a long journey, the destination of telehealth's adoption into mainstream medical practice has been elusively far off.

In the 1960s and 70s, the true potential of telepractice was demonstrated when technology made video conferencing from remote rural clinics feasible. However, technology at that time was very expensive, which was the first obvious roadblock to mainstream integration. The 1980s brought dramatic reductions in cost, size, and reliability of video technology, but bandwidth emerged as a significant roadblock. In the 1990s, fiber began to replace copper, and the Internet replaced direct connection, so the roadblock of bandwidth began to resolve.

With technology being resolved, telehealth hit the detour of state-based licensing. Just as we figured out how to drive cross-country with state-based driver's licenses, the problem can and is being resolved by regulatory agreements. However, it has taken longer than expected because medicine is much more complicated than "red means stop" and "green means go."

By the early 2000s, the main impediment to telehealth going mainstream appeared to be reimbursement.  That remains a "chicken and egg" problem: Payers only cover standard practice, but practitioners won't make telehealth standard practice until receiving reimbursement for it. The process of bringing telehealth into mainstream medicine accelerated recently as some states have adopted parity rules that require equal reimbursement for telehealth and in-person medical services. Insurers have also discovered telehealth is a marketable benefit. For programs like Medicaid or the VA that cover patient travel costs to medical appointments, the adoption of telehealth has been much faster because the savings are obvious.

To be sure, reimbursement is not universal or adequate, but in some states and in some clinical fields, reimbursement can sustain telehealth and then bootstrap itself into other areas. In increasingly capitated systems, the use of telehealth rests with busy practitioners who will only use it if there is proven productivity increase. So, the goal is to make its case to clinical directors who are key to adopting telepractice.

How can telehealth become a regular method, chosen for clinical efficacy, without being distinguished as a separate practice? The answer is this: Telehealth is not a tool but a concept – a paradigm shift for both providers and patients.

So, how can we advance the pace of telehealth to becoming a mainstream practice? How can telehealth become a regular method, chosen for clinical efficacy, without being distinguished as a separate practice? The answer is this: Telehealth is not a tool but a concept – a paradigm shift for both providers and patients. In the past, we have not chosen health plans or shopped for doctors based on their telehealth availability. The next generation that is growing up on smartphones will expect and demand telehealth, both as patients and as providers. The work of perfecting technology, negotiating regulations, and chipping away at reimbursement may soon pay off.

The simple answer is that we are almost there.