- 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

Stanford 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 

Loeb, Alexander E. MD; Rao, Sandesh S. MD; Ficke, James R. MD; Morris, Carol D. MD; Riley, Lee H. III MD; Levin, Adam S. MD Departmental Experience and Lessons Learned With Accelerated Introduction of Telemedicine During the COVID-19 Crisis, Journal of the American Academy of Orthopaedic Surgeons: June 1, 2020 - Volume 28 - Issue 11 - p e469-e476 doi: 10.5435/JAAOS-D-20-00380

Departmental Experience and Lessons Learned With Accelerated Introduction of Telemedicine During the COVID-19 Crisis

Smith, A. C., Thomas, E., Snoswell, C. L., Haydon, H., Mehrotra, A., Clemensen, J., & Caffery, L. J. (2020). Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). Journal of Telemedicine and Telecare, 26(5), 309–313. https://doi.org/10.1177/1357633X20916567

Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19)

- 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

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


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

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

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