Telemedicine: Is the Shine Wearing Off? Benefits, Barriers, and the Road Ahead

In March 2020, the World Health Organization officially declared the spread of COVID-19 to be a pandemic (World Health Organization, 2020). In response, telemedicine played a crucial role during the pandemic, transforming healthcare delivery.  Four years later, it appears the momentum of telemedicine has faded.  The Centers for Disease Control and Prevention (CDC) published an article reporting the decline in telemedicine usage from 2021 to 2022 (Lucas & Wang, 2024).  In January 2021, New York based company, Teledoc (TDOC) stock traded just over $263 per share and as of August 2024, the stock was trading below $7.00 per share, a drop of over 97% in value.

Benefits of Telemedicine

Despite of the decline in the use of telemedicine, some of the benefits in expanding telemedicine are: (1) increased access and convenience, (2) reduced risk of disease transmission, (3) efficient use of resources, (4) stable healthcare delivery, (5) patient preference and satisfaction, (6) equity and inclusion, and (7) provider perspectives.

1. Increased Access and Convenience: Telemedicine allows patients to access healthcare remotely, overcoming geographical barriers and reducing travel time and costs (Chang, Penfold, & Berkman, 2024). Patients can consult with healthcare providers from the comfort of their homes, improving convenience and accessibility.
2. Reduced Risk of Disease Transmission: Telemedicine minimizes exposure to contagious diseases, especially during pandemics like COVID-19 (Chang, Penfold, & Berkman, 2024). Patients and healthcare workers can interact without physical contact, reducing the risk of infection.
3. Efficient Use of Resources: Telemedicine optimizes resource allocation by reducing unnecessary in-person visits (Chang, Penfold, & Berkman, 2024). It helps manage patient flow and ensures that critical cases receive timely attention.
4. Stable Healthcare Delivery: Despite pandemic-related disruptions, telemedicine maintained stable outpatient visits (Chang, Penfold, & Berkman, 2024). Patients continued to receive care, even during lockdowns and surges in COVID-19 cases.
5. Patient Preferences and Satisfaction: Many patients prefer telehealth services, appreciating the convenience and reduced waiting times and positive experiences during the pandemic have influenced patient preferences for telemedicine (Mann, Chen, Chunara, Testa, & Nov, 2020).
6. Equity and Inclusion: Telemedicine addresses disparities by providing care to underserved populations bridging gaps in access, especially for those with limited mobility or living in remote areas (Ng & Park, 2021)
7. Provider Perspectives: Physicians find telemedicine beneficial due to flexibility, reduced administrative burden, and improved work-life balance, allowing them to reach more patients efficiently (Ng & Park, 2021).

Emory Healthcare Case Study

In a case study published in the Journal of Healthcare Management, prior to the pandemic, Emory Healthcare (EHC), like many other healthcare providers, initially faced barriers to implement and offer telehealth services to patients.  One of the barriers were regulatory and legislative changes that needed to be implemented during the onset of the COVID-19 pandemic which put restraints on the collection of payment in part or at full for patient care services which previously required in-person visits and allowing Advanced Practice Providers (APPs) to prescribe schedule II to V medications in states that allow the practice (Esper, et al., 2020).

Several other challenges implementing telehealth to patients include:

1. Training and Certification: Healthcare providers need to be trained and certified to use telehealth platforms effectively. This includes understanding state and federal regulations, billing, coding, and patient privacy standards.
2. Technological Barriers: Patients may face difficulties with the required technology, such as downloading and using telehealth applications. This can be a significant barrier, especially for those who are not tech-savvy.
3. Infrastructure Limitations: Health systems without pre-existing telehealth infrastructure may struggle to implement it quickly, as building the necessary infrastructure takes time and resources.
4. Regulatory and Payment Models: The lack of appropriate payment models and regulatory barriers can hinder the widespread adoption of telehealth services. Although some regulations were relaxed during the COVID-19 pandemic, sustained deregulation is necessary for the long-term success of telehealth.
5. Patient Engagement: Ensuring patients are willing and able to engage in telehealth visits is essential. This involves clear communication about how to participate in telehealth visits and addressing any concerns or reluctance they may have.
6. Quality and Safety Concerns: Providers must ensure that telehealth visits meet the same quality and safety standards as in-person visits. This includes accurately documenting patient information and ensuring that the care provided is appropriate for the telehealth format.
7. Financial Sustainability: While telehealth can generate revenue, its financial sustainability depends on continued support from legislative and regulatory bodies to maintain favorable conditions for telehealth billing and reimbursement

The case study concluded that the overall implementation was a success.  In the period from March 2020 – May 2020, EHC conducted 64,290 virtual visits (audio-video and telephone visits), generated over $14.6 million in charges, and patient satisfaction was comparable to in-person visits (Esper, et al., 2020).

Reasons Telemedicine Use Is Declining

Privacy Concerns: Patients may worry about the security of their personal health information during virtual visits.  The National Cancer Institute put out a brief in January 2024 indicating that 16.4% of patients surveyed had “privacy concerns as reasons for not participating in telehealth visits” (National Cancer Institute, 2024).  Patients who prefer using audio only over audio and video telemedicine are also concerned about privacy issues (Chang, Penfold, & Berkman, 2024).

Technical Difficulties: Some individuals, especially older adults, may struggle with technology or lack access to reliable internet connections or devices.  National Institute of Health (NIH) reports 19% of patients surveyed cite concerns about the difficulty using telemedicine technology as a reason for not participating (National Cancer Institute, 2024).  Some patients may have limited understanding or access to the technology necessary for telemedicine (Chang, Penfold, & Berkman, 2024).

Clinical Buy-in and Workflow Challenges: Integrating telehealth into existing clinical workflows can be complex.  While patients may be reluctant to use telehealth, some healthcare professionals are reluctant to integrate technology into their practice.  Implementing telehealth into a healthcare practice will require a change in workflow operations for healthcare providers which creates an obstacle for the buy-in to invest technology and operational changes into the practice (Demeke, et al., 2020)

Patient Preferences: Some patients still prefer in-person visits due to the perceived quality of care, interpersonal interactions, and physical examination. The NIH survey cited that 84.4% of patients just prefer to have in-person consultation (National Cancer Institute, 2024).

Reimbursement Policies: Historically, reimbursement for telehealth services has been limited.  Some of these policies prevented billing Medicare for services typically done in-person or penalties for using technology that may not be compliant with the Health Insurance Portability and Accountability Act (HIPAA) (Ng & Park, 2021).  Reimbursement policies tie back into the workflow challenges healthcare providers face when adopting telehealth.

Limitation

While studies show in-person visits declined and virtual or telemedicine increase during the beginning of the pandemic, the studies do differentiate if this was due to preference or accessibility to schedule an appointment with a healthcare provider.  Patient satisfaction remained the same in the studies, it is difficult to determine if that was due to the patient’s perception in comparing a virtual visit to an in-person visit or a virtual visit compared to no visit at all due to difficulty seeing a provider in-person during the pandemic.

Conclusion

While there are significant challenges for healthcare providers to adopt telehealth, including patient’s demand and willingness to participate in virtual clinic visits, the benefits will also appeal to those who are willing to utilize the technology.  Although there are still discussions of the inequality of accessing telehealth, such as internet connectivity or access to hardware, those that can use it will free up waiting rooms for those who still prefer, or only have access to, in-person visits.  Hoping that regulators still keep policies in place to make telemedicine easier to integrate into a clinical workflow, including allowing for virtual visit billing, this could expand the ability for patients to access care while freeing up in-person waiting rooms, and create revenue to allow the sustainability of this new model.

Works Cited

• Chang, E., Penfold, R. B., & Berkman, N. D. (2024). Patient Characteristics and Telemedicine Use in the US, 2022. JAMA Network Open.
• Demeke, H. B., Pao, L. Z., Clark, H., Romero, L., Neri, A., Shah, R., . . . Rose, M. A. (2020, December 18). Centers for Disease Control and Prevention. Retrieved from Telehealth Practice Among Health Centers During the COVID-19 Pandemic — United States, July 11–17, 2020: https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a4.htm#suggestedcitation
• Esper, G. J., Sweeney, R. L., Winchell, E., Duffell, J., Kier, S. C., Lukens, H. W., & Krupinski, E. A. (2020). Rapid Systemwide Implementation of Outpatient Telehealth in Response to the COVID-19 Pandemic. Journal of Healthcare Management 65(6), 443-452.
• Lucas, J. W., & Wang, X. (2024, June 20). Declines in Telemedicine Use Among Adults: United States, 2021 and 2022. Hyattsville: National Center for Health Statistics.
• Mann, D. M., Chen, J., Chunara, R., Testa, P. A., & Nov, O. (2020). COVID-19 transforms health care through telemedicine: Evidence from the field. Journal of Information in Health and Biomedicine, 1132-1135.
• National Cancer Institute. (2024, January). Health Information National Trends Survey. Retrieved from HINTS Briefs number 53: https://hints.cancer.gov/docs/Briefs/HINTS_Brief_53.pdf
• Ng, B. P., & Park, C. (2021, July 1). Centers for Disease Control and Prevention. Retrieved from Accessibility of Telehealth Services During the COVID-19 Pandemic: A Cross-Sectional Survey of Medicare Beneficiaries: https://www.cdc.gov/pcd/issues/2021/21_0056.htm
• World Health Organization. (2020, April 27). Archived: WHO Timeline – COVID-19. Retrieved from World Health Organization: https://www.who.int/news/item/27-04-2020-who-timeline—covid-19