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 Pew Research Center, as of 2021 only 72% of rural areas have access to high-speed broadband internet. In addition, only 65% of housing units on rural tribal lands have 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 other populations. In 2020, 80% of rural residents reported owning a smartphone, compared to 89% of urban residents. 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. During the COVID-19 pandemic, many states increased reimbursement for telehealth services. The Center for Connected Health Policy's State Telehealth Laws and Reimbursement Policies Report reports that all 50 states were providing Medicaid reimbursement for live video visits, but only 42 were reimbursing for remote patient monitoring.

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 lack trust in the quality of telehealth services. In addition, patients may 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

Telehealth in Response to the COVID-19 Pandemic: Implications for Rural Health Disparities
Document
Describes how telehealth initiatives, in response to the pandemic, have developed in rural healthcare, and how reliance on telehealth in rural areas without adequate broadband may increase rural health disparities. Offers recommendations for policymakers and researchers supporting telehealth proposals that do not intensify health disparities in rural communities.
Author(s): Hirko, K.A., Kerver, J.M., Ford, S., et al.
Citation: Journal of the American Medical Informatics Association, 27(11), 1816-1818
Date: 11/2020

Telehealth Policy Barriers
Document
Discusses existing policy barriers at the federal and state level that inhibit the use of telehealth in rural and urban areas, such as reimbursement, malpractice, licensing, HIPAA/privacy/security, prescribing, and credentialing.
Organization(s): Center for Connected Health Policy: The National Telehealth Policy Resource Center
Date: 2/2019

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