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.

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Evidence for Efficacy and Quality

Quality and Effectiveness. Evidence is growing on telemedicine use among diverse and low-income patient populations, including individual and population-level factors associated with telemedicine uptake and satisfaction.

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. Evidence is growing on telemedicine use among diverse and low-income patient populations, including individual and population-level factors associated with telemedicine uptake and satisfaction

  • American Journal of Preventive Medicine: Who Is (And Is Not) Receiving Telemedicine Care During the COVID-19 Pandemic — This research brief examines changes in telehealth use during the COVID-19 pandemic among over 6 million employer-based health plan beneficiaries. The authors found the increase in telemedicine use during the pandemic was greatest among patients in counties with low poverty levels, patients in metropolitan areas, and among adults (as opposed to children). They note the importance of prioritizing outreach to patients whose in-person care is not currently being replaced with telemedicine visits.

Adjusted rates of telemedicine utilization before versus that after the start of the COVID-19 pandemic. Cantor et al. 2021

Primary Care and Behavioral Health Visits per 1000 Patients by Visit Type from February 2019 through August 2020. Uscher-Pines et al. 2021.

Association of Telemedicine Visit Type with Patient- and Zip Code-Level Factors. Rodriguez et al. 2021.

  • Health Affairs: Disparities in Telehealth Use Among California Patients with Limited English Proficiency — This study examines the association between patients’ limited English proficiency (LEP) and telemedicine use (phone and video visits). They also evaluated the impact of telemedicine on healthcare access and use. The authors found that LEP patients had lower rates of telemedicine use compared to proficient English speakers, and that telemedicine use was associated with increased emergency department use for all patients.
  • 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.

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.

California Health Care Foundation

Resources from the Centers for Medicare & Medicaid Services:

Resource 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.

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.

  • Roots Community Health Center: Telehealth Vendor Evaluation — This is a link to download a spreadsheet with a list of questions to evaluate the functionality and usability of a potential telehealth vendor. The questions are divided into sections regarding technical requirements and hardware, patient digital experiences, training, support, and maintenance, equity-centered considerations, and financial considerations. This tool was created by Roots Community Health Center — a nonprofit organization founded in Oakland, California with a mission to uplift those impacted by systemic inequities and poverty through medical and behavioral health care, health navigation, workforce enterprises, housing, outreach, and advocacy — as part of their work through CCI’s Connected Care Accelerator.

Roots Community Health Center

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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