The COVID-19 pandemic prompted health care providers and systems to rapidly adopt and expand telemedicine services. Telemedicine provides a safer alternative to in-person visits during the pandemic, but simultaneously introduces multiple decision points for implementation.

While many providers already have telemedicine in place, emerging evidence, policies, and guidance on implementation and maintenance indicate that answers to the question, “how do we implement telehealth equitably, safely, and sustainably?” are very much still evolving. In this chapter, we summarize many of the basic components of telemedicine implementation for health care system leaders, including:

  1. Evidence for implementing telemedicine,
  2. Risks, privacy and security,
  3. Reimbursement,
  4. Vendor selection, and
  5. Performance measurement

These topics are particularly important in safety-net settings that already face challenges related to limited resources and fragmented health information technology.

Evidence for Efficacy and Quality

Quality and Effectiveness. There is a considerable body of evidence supporting the quality and effectiveness of telemedicine interventions and technologies. For many clinical applications, virtual care has been shown to be either equivalent or even better than in-person care in some cases. In particular, there is strong evidence supporting the use of telemedicine for communication, counseling, and remote monitoring of chronic conditions such as cardiovascular and respiratory disease. Virtual care has shown improvements in outcomes such as mortality, quality of life, mental health conditions, and reductions in hospital admissions.

Patient Satisfaction. Telemedicine has also been found to have high patient satisfaction, on par with in-office visits, due to ease of use and improved communication.

Telemedicine to Address Health Equity. There is less evidence available on telemedicine use among diverse and low-income patient populations, including individual and population-level factors associated with telemedicine uptake and satisfaction. Some early evidence in these areas is below.

Zulman et al. JAMIA Open. 2019

  • JAMA Network Open: Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians — This article outlines patient characteristics associated with choosing between telemedicine and in-person visits within Kaiser Permanente Northern California. For example, the authors found that choosing telemedicine was associated with in-person visit barriers such as clinic parking costs. They also found that Black patients were more likely to choose telemedicine than other racial/ethnic groups, and patients living in lower socioeconomic status (SES) neighborhoods were more likely to choose telephone visits, but they were less likely to choose video visits than patients in higher SES neighborhoods.
  • Health Affairs: Are State Telehealth Policies Associated with the Use of Telehealth Services Among Underserved Populations? — This article finds that less restrictive state telehealth policies were not associated with increased telehealth use overall or among Medicaid, low-income, and rural populations between 2013-2016, though telehealth use, particularly video visits, grew substantially over that period across all groups. Further, the authors find that even among populations with low telehealth use, including underserved populations, interest in video visits was high. They suggest that new incentives for health care providers and patients, beyond state efforts, may be needed.

Privacy and Security

Regulations. The U.S. Department of Health and Human Services eased enforcement of telehealth regulations in March 2020 as a result of the COVID-19 pandemic. This discretion allows providers to use any nonpublic audio or video communication tool to connect with their patients remotely. More details about these changes in telehealth regulations can be found in the resources provided below.

Health Information Evaluation and Quality Center

Cybersecurity. In implementing telemedicine, cybersecurity is a critical consideration for health systems. Main recommendations for improving cybersecurity include using encrypted devices and technology, utilizing a Virtual Private Network (VPN), and employing strong authentication parameters.

  • UCSF Center for Vulnerable Populations: Resources for Telehealth at Safety Net Settings — This webpage provides resources for telehealth in safety net settings. The section “For Clinicians” includes a link to download a word document “Setting up your Zoom account for patient video visits” with concrete guidance on ensuring waiting rooms are enabled to maximize video visit security.
  • PCMag: How to Prevent Zoom-Bombing — This article includes concrete tips on how to keep Zoom video calls secure and prevent them from being hijacked by hackers. It goes through settings like waiting rooms, making sure only the host can share their screen, and removing someone from a call.


Licensure and Reimbursement

The Centers for Medicare and Medicaid Services (CMS) and other payers have changed reimbursement policies in response to COVID-19. Further, licensure requirements for telemedicine vary from state to state. The resources below provide information about new telemedicine billing, coding, and licensure policies that are relevant for safety net hospitals and clinics during the pandemic.

Resources from the Centers for Medicare & Medicaid Services:

Resources from the Center for Connected Health Policy:

  • COVID-19 Related State Actions — This webpage has a continually updated database of COVID-19 related state actions taken by each state’s Office of the Governor, Medicaid Program, Medical Board, and/or Department of Insurance regarding licensure and telemedicine and their current status.
  • Federally Qualified Health Centers & Rural Health Clinics Acting As Distant Site Providers in Medicare — This PDF has answers to frequently asked questions about telehealth costs and billing for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) acting as distant site providers in Medicare. Questions cover what modalities can be used, which staff can provide services, which services can be provided, reimbursement rates, and more.

Technical Infrastructure and Vendor Considerations

Technical Needs. Provision of high-volume telemedicine requires appropriate infrastructure including high-speed internet connectivity and camera and microphone enabled devices. Multiple resources emphasize the importance of updating electronic medical record software in advance of telemedicine implementation.

Vendor Selection. Many providers are looking to hire a telemedicine technology vendor to deliver virtual care for their patients during the COVID-19 pandemic. Key topics to consider when assessing potential telemedicine vendors include electronic medical record integration, HIPAA compliance, and good user experience for both patients and providers. The resources below offer guidance for the vendor selection process.

Impact on Quality Improvement Metrics and Payments

Health care quality measure sets have required modifications during COVID-19 to provide flexibility for care delivered remotely. Many measurement bodies and payers have approved adjustments to their measure sets for 2020 to align with recent telemedicine guidance from CMS and other federal and state regulators. The resources below provide information about how the HEDIS (health care effectiveness data and information set), PRIME (public hospital redesign incentives), and UDS (uniform data system) measure sets have been adapted for 2020-2021.



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