- Technology requirements include the following: broadband internet/smart device, digital peripherals
- most complex conditions may be the least able to access medical attention


University of California, Santa Cruz

Syracuse University

- limitations to clinician-to-clinician communications
- limitations of remote patient monitoring
- limitations of video visits
- limitations to telephone visits
- limitations to patient initiated communication
- limitations to training clinicians in using telemedicine devices
- geographic region (in the U.S.)
- payment and reimbursement
- Interstate/ intrastate regulatory protocol and telehealth
- social barriers to telehealth implementation

Limitations of telehealth infrastructure 

A form of telehealth encounter involving synchronous patient-clinician communication with both audio and video, allowing care providers to visually observe patients.

Video visit

Wosik, J., Fudim, M., Cameron, B., Gellad, Z. F., Cho, A., Phinney, D., . . . Tcheng, J. (2020). Telehealth transformation: COVID-19 and the rise of virtual care. Journal of the American Medical Informatics Association, 27(6), 957-962. doi:10.1093/jamia/ocaa067

Telehealth transformation: COVID-19 and the rise of virtual care

- It can shift extra work to front-line medical providers
- Lack of a direct physical exam on patients
- Communication is through a platform rather than being face-to-face

Limitations to clinician-to-clinician communications

- devalued by insurance coverage 
- medical health providers cannot conduct a physical exam
- the patient's assessment is conducted solely on verbal cues


Limitations to telephone visits

Limitations of video visits

- Requires staffing infrastructure
- There needs to be a method of integrating patient data into the electronic health record

Limitations of remote patient monitoring

- Commercial and Medicaid reimbursement is states’ decision
- 20% of states require payment parity between telemedicine and in-person services
- Medicare grants payment parity between telehealth and in-person clinical care. 
- Center for Medicare and Medicaid Services (CMS) issued waivers during pandemic.
- CMS and some local commercial payers have modified their payment policy during the COVID-19 pandemic.

Payment and reimbursement for telehealth services

- Telemedicine usage is limited within the scope of medical, nursing, and allied health field training
- Sudden integration of telemedicine say be seen as "disruptive" or "complex" by clinicians

Limitations to training clinicians in using telemedicine devices

States possess varying regulatory protocol and in regional healthcare systems that stretch across numerous states, interstate licensing can inhibit some physicians from providing remote care


Interstate/ intrastate regulatory protocol and telehealth

- Patient discomfort or privacy concerns in addressing sensitive topics
- Cultural disapproval of employing telehealth services in place of traditional in-person care visits
- Healthcare providers and patients with limited access to stable connectivity or technological devices needed for telehealth services

Social barriers to telehealth implementation

- States in the southern and midwestern regions of the U.S. had a lower percentage of hospitals with telemedicine intensive care units (Tele-ICU) 
- Lack of funding for teleservices in metropolitan areas/cities, where people are especially vulnerable due to high population density
- Although ~20% of the American population lives in a rural area, only 9% of physicians actively practice in rural areas 

Geographic region (in the U.S.) related telemedicine limitations

- Requires staff and a thorough infrastructure to optimize workflow

Limitations to patient initiated (tele-)communication

- Improvement on clinical care in comparison to telephone visits
- A variation of a physical exam can be made using peripheral devices 
- favorable for reimbursement by insurance

Opportunities for video visits

- Due to COVID-19, the Department of Health and Human Services (HHS) has relaxed some of the restrictions on software/streaming-based violations of the Health Insurance Portability and Accountability Act (HIPAA).

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