Barriers to Telehealth in Rural Areas

This section provides an overview of barriers to establishing, expanding, and sustaining telehealth programs in rural communities. For more information about considerations for implementing telehealth programs, see Module 4: Implementation Considerations.

Limited Access to High Speed Internet

According to the Federal Communications Commission (FCC), rural areas have more limited access to high-speed internet when compared to urban areas. In rural areas, 28% of people lack access to high-speed broadband internet. In addition, 24% of people in Tribal lands lack access to broadband services. The availability of broadband affects the ability of patients to participate in video consultations, transmit health information, and monitor their health at home.

Limited Access to Smartphones

Many mobile health and remote patient monitoring systems require access to smartphone applications. However, rural populations are less likely to own smartphones when compared to others. Rural programs may have to allocate additional funds in order to purchase equipment for patients participating in mobile health interventions.

Credentialing and Licensing

State requirements for licensing and credentialing of telehealth providers vary widely. States typically require providers to be licensed in the state where the patient receives services. In addition, credentialing and licensing requirements underwent several changes because of the COVID-19 pandemic and continue to be subject to new regulations from federal and state legislatures. Some states participate in interstate compacts that make it easier for rural providers to practice in more than one state and for rural patients to receive care from providers. Rural organizations with limited resources may also lack the capacity to credential telehealth providers, which involves verifying licenses and qualifications.

Reimbursement

Lack of reimbursement has been a historic barrier to use of telehealth services. For example, each state has different rules and regulations about the types of services that can be reimbursed by Medicaid. Further, rural programs have described a lack of clarity about existing regulations, such as eligibility and policies for reimbursement.

In addition to limited reimbursement policies, rural programs have also described a lack of clarity about existing regulations. For example, one report describes reduced provider participation in asynchronous telehealth as a result of a lack of clarity about the reimbursement policies.

Sustainability

Rural telehealth programs may face challenges with sustaining services. For example, programs may have issues with monetizing the value generated by telehealth services. Rural programs with very low patient volumes may have issues engaging specialists to provide services when the demand for telehealth is sporadic. In addition, rural programs may have difficulties with maintaining infrequently used telehealth equipment and paying expensive connectivity fees. For strategies to address sustainability, see Module 6: Funding & Sustainability of Rural Telehealth Programs.

Malpractice

The Center for Connected Health Policy fact sheet, Telehealth Policy Barriers, states that some malpractice policies do not cover telehealth services. Providers may decline to participate in telehealth because of liability concerns.

Interoperability

Interoperability, which includes the exchange of electronic health information, remains a challenge for many rural healthcare providers. Some rural telehealth programs may face difficulties with ensuring secure and effective methods for providers from different systems to share information and access electronic health records. In 2021, the Centers for Medicare & Medicaid Services began enforcing some additional regulations related to interoperability.

Mistrust of Technology and Healthcare

Some patients may have concerns about the quality of services they receive via telehealth. In addition, it can be difficult for patients and providers to build trust and rapport when communicating virtually. Patients may also have concerns about the security of information that is transmitted via telehealth.

Resources to Learn More

Rural Behavioral Health: Telehealth Challenges and Opportunities
Document
Reviews existing barriers to mental health and substance use disorder treatment. Discusses services in rural communities, presents ways telehealth can address these barriers, and identifies the challenges in implementing telehealth in rural areas.
Citation: In Brief, 9(2)
Organization(s): Substance Abuse and Mental Health Services Administration (SAMHSA)
Date: 2016

The Time Is Now: A Guide to Sustainable Telemedicine During COVID-19 and Beyond
Document
Outlines several important concepts, terminologies, and resources to help physicians stay abreast of telemedicine. Discusses barriers to utilization, billing procedures, platform selection, and changes in policies for telemedicine services during COVID-19.
Author(s): Shah, E.D., Amann, S.T. & Karlitz, J.J.
Location: American Journal of Gastroenterology, 115(9), 1371-1375
Date: 7/2020