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Telehealth: Technology meets health care

See how technology can improve your health care.

How many times have you heard it said that the internet has changed modern life? Indeed, it's likely changed how you stay in touch with family and friends and buy goods and services. And it's probably even changed how you search for information about health problems.

Several telehealth tools are offered to help you manage your health care and receive the services you need. During the coronavirus disease 2019 (COVID-19) pandemic, many people used telehealth. People often still use it. Find out more about telehealth.

What is telehealth?

Telehealth is the use of digital information and communication technologies to access health care services remotely and manage your health care. Technologies can include computers and mobile devices, such as tablets and smartphones. This may be technology you use from home. Or a nurse or other health care professional may provide telehealth from a medical office or mobile van, such as in rural areas. Telehealth can also be technology that your health care provider uses to improve or support health care services.

The goals of telehealth, sometimes called e-health or m-health (mobile health), include the following:

Make health care easier to get for people who live in communities that are remote or in the country.
Keep you and others safe if you have an infectious disease such as COVID-19.
Offer primary care for many conditions.
Make services more easily offered or handy for people who have limited ability to move, time or transportation.
Offer access to medical specialists.
Improve communication and coordination of care among health care team members and a person getting care.
Offer advice for self-management of health care.

Many people found telehealth helpful during the COVID-19 pandemic and still use it. Telehealth is being used more often.

Here are many examples of telehealth services that may be helpful for your health care.

Virtual visits

Some clinics may use telemedicine to offer remote care. For example, clinics may offer virtual visits. These can allow you to see a health care provider, mental health counselor or a nurse via online video or phone chats.

Virtual visits can offer care in many conditions such as migraines, skin conditions, diabetes, depression, anxiety, colds, coughs and COVID-19. These visits allow you to get care from a provider when you don't need or can't get an in-person visit.

Before your visit, your health care team may send you information or forms to fill out online and return to them. They may also make sure you have the technology you need. They'll check to see if you need to update or install any software or apps too. And they can tell you how to sign on and join the video chat for your visit. Also, the health care team can explain how to use the microphone, camera and text chat. If needed, ask a family member to help you set up the technology you need.

You only need a smartphone, tablet or computer with internet access to join the virtual visit. You can find a comfortable, quiet, private spot to sit during your visit. Your provider also meets from a private place.

Other options

Some people may use web or phone-based services for medical care or advice. When you log into a web-based service or call a service that offers primary or urgent care, you're guided through many questions. The provider or nurse practitioner can prescribe drugs. Or they may suggest home care tips or more medical care.

While these services are handy, they have drawbacks:

Treatment may not be coordinated with your regular provider.
Important details from your medical history may not be considered.
The computer-driven model used to make decisions may not be right for you if you have a complex medical history.
The service doesn't easily allow for you to make decisions with your provider about treatments.

Remote monitoring

Many technologies allow your provider or health care team to check your health remotely. These technologies include:

Web-based or mobile apps for uploading data to your provider or health care team. For example, if you have diabetes, you may upload food logs, blood sugar levels and drugs that a nurse checks.
Devices that measure and wirelessly send data, such as blood pressure, blood sugar and oxygen levels.
Wearable devices that automatically record and send data. For example, the devices may record data such as heart rate, blood sugar, how you walk, your posture, tremors, physical activity or your sleep.
Home monitoring devices for older people or people with dementia that can find changes in daily activities such as falls.
Devices that send notifications to remind you to do exercises or take drugs.

Providers talking to providers

Providers can also use technology to give people better care. For example, in a virtual consultation, primary care providers can get input from specialists in other locations when they have questions about your diagnosis or treatment.

The primary care provider sends exam notes, history, test results, X-rays or other images to the specialist to review. The specialist may answer by email. Or they may do a virtual visit with you at your provider's office. They may also ask for a face-to-face meeting.

In some cases, a nurse or other health care professional may use technology to provide care from a medical office, clinic or mobile van in a rural area. They may call a specialist or provider at a medical clinic to do a remote consult.

These virtual consultations may prevent unnecessary in-person referrals to a specialist. They may also cut wait times for you to see a specialist. And they may remove the need for you to travel to a specialist.

Patient portal

Your primary care clinic may have an online patient portal. These portals offer a safer way of contacting your provider instead of email. A portal provides a safe online tool to do the following:

Message your provider or a nurse.
Ask for prescription refills.
Review test results and summaries of earlier visits.
Schedule visits or ask for appointment reminders for preventive care.

If your provider is in a large health care system, the portal may also provide one point of contact for any specialists you may see.

Personal health apps

Many apps have been made to help people better organize their medical information in one secure place. These digital tools may help you:

Store personal health information.
Record vital signs.
Calculate and track your calories.
Schedule reminders for taking drugs.
Record physical activity such as your daily step count.
Personal health records

An electronic personal health record system (PHR system) is a collection of information about your health that you control and maintain. A PHR app is easy for you to see anytime via a web-enabled device, such as your computer, laptop, tablet or smartphone. A PHR also allows you to review your lab results, X-rays and notes from your provider. Your provider may give this to other providers with permission.

In an emergency, a personal health record can quickly give emergency staff vital information. For example, it can show your current conditions, drugs, drug allergies and your provider's contact details.

The potential of telehealth

Technology has the potential to improve the quality of health care. And technology can make it easier for more people to get health care.

Telehealth may offer ways to make health care more efficient, better coordinated and closer to home. You can go to a virtual visit anywhere — such as at home or in your car. And you don't need to travel to go to a virtual visit.

Telehealth can be useful so you can stay home if you're sick or if it's hard for you to travel. And you can use telehealth if you live far from a medical center. And many people have been able to keep distance from others at home and still receive care during the COVID-19 pandemic. And providers can diagnose and treat COVID-19 remotely.

Virtual visits can also provide you with the choice to meet with specialists who don't live where you do.

The limitations of telehealth

Telehealth has potential for better coordinated care. But it also runs the risk of gaps in care, overuse of medical care, inappropriate drug use or unnecessary care. Providers can't do a physical exam in-person, which can affect a diagnosis.

The potential benefits of telehealth services may be limited by other factors, such as costs. Insurance reimbursement for telehealth can vary by state and type of insurance in the U.S. But insurance keeps expanding for telehealth services in the U.S. And during the COVID-19 pandemic, insurance restrictions changed for a period of time. Check with your insurance company to see which providers have virtual visits covered by insurance.

Also, some people who need improved access to care may be limited because of not having internet access or a mobile device. People without internet access may be able to access telehealth services by using wireless internet offered at public places. For example, libraries or community centers may offer wireless internet for virtual visits that can take place in private rooms.

Sometimes technology doesn't work well. It's important to have a plan with your provider to call them by phone if there is an issue with the virtual visit.

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Telehealth. National Institute of Biomedical Imaging and Bioengineering. https://www.nibib.nih.gov/science-education/science-topics/telehealth. Accessed May 6, 2022.
What is telehealth? Telehealth.HHS.gov. https://telehealth.hhs.gov/patients/understanding-telehealth/. Accessed May 6, 2022.
Ong MK, et al. Telemedicine for adults. https://www.uptodate.com/contents/search. Accessed May 5, 2022.
Doraiswamy S, et al. Use of telehealth during the COVID-19 pandemic: Scoping review. Journal of Medical Internet Research. 2020; doi:10.2196/24087.
Brotman JJ, et al. Providing outpatient telehealth services in the United States: Before and during coronavirus disease 2019. Chest Reviews. 2021; doi:10.1016/j.chest.2020.11.020.
Telehealth: Defining 21st century care. The American Telemedicine Association. https://www.americantelemed.org/resource/why-telemedicine/. Accessed May 6, 2022.
Mahtta D, et al. Promises and perils of telehealth in the current era. Current Cardiology Reports. 2021; doi:10.1007/s11886-021-01544-w.
AskMayoExpert. COVID-19: Outpatient management. Mayo Clinic; 2021.
Tapuria A, et al. Impact of patient access to their electronic health record: Systematic review. 2021; doi:10.1080/17538157.2021.1879810.
Takahashi PY (expert opinion). Mayo Clinic. May 9, 2022.

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Virtual or In Person: Which Kind of Doctor’s Visit Is Better, and When It Matters

When the covid-19 pandemic swept the country in early 2020 and emptied doctors’ offices nationwide, telemedicine was suddenly thrust into the spotlight. Patients and their physicians turned to virtual visits by video or phone rather than risk meeting face-to-face.

During the early months of the pandemic, telehealth visits for care exploded .

“It was a dramatic shift in one or two weeks that we would expect to happen in a decade,” said Dr. Ateev Mehrotra , a professor at Harvard Medical School whose research focuses on telemedicine and other health care delivery innovations. “It’s great that we served patients, but we did not accumulate the norms and [research] papers that we would normally accumulate so that we can know what works and what doesn’t work.”

Now, three years after the start of the pandemic, we’re still figuring that out. Although telehealth use has moderated, it has found a role in many physician practices, and it is popular with patients.

More than any other field, behavioral health has embraced telehealth. Mental health conditions accounted for just under two-thirds of telehealth claims in November 2022, according to FairHealth , a nonprofit that manages a large database of private and Medicare insurance claims.

Telehealth appeals to a variety of patients because it allows them to simply log on to their computer and avoid the time and expense of driving, parking, and arranging child care that an in-person visit often requires.

But how do you gauge when to opt for a telehealth visit versus seeing your doctor in person? There are no hard-and-fast rules, but here’s some guidance about when it may make more sense to choose one or the other.

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If It’s Your First Visit

“As a patient, you’re trying to evaluate the physician, to see if you can talk to them and trust them,” said Dr. Russell Kohl , a family physician and board member of the American Academy of Family Physicians. “It’s hard to do that on a telemedicine visit.”

Maybe your insurance has changed and you need a new primary care doctor or OB-GYN. Or perhaps you have a chronic condition and your doctor has suggested adding a specialist to the team. A face-to-face visit can help you feel comfortable and confident with their participation.

Sometimes an in-person first visit can help doctors evaluate their patients in nontangible ways, too. After a cancer diagnosis, for example, an oncologist might want to examine the site of a biopsy. But just as important, he might want to assess a patient’s emotional state.

“A diagnosis of cancer is an emotional event; it’s a life-changing moment, and a doctor wants to respond to that,” said Dr. Arif Kamal , an oncologist and the chief patient officer at the American Cancer Society. “There are things you can miss unless you’re sitting a foot or two away from the person.”

Once it’s clearer how the patient is coping and responding to treatment, that’s a good time to discuss incorporating telemedicine visits.

If a Physical Exam Seems Necessary

This may seem like a no-brainer, but there are nuances. Increasingly, monitoring equipment that people can keep at home — a blood pressure cuff, a digital glucometer or stethoscope, a pulse oximeter to measure blood oxygen, or a Doppler monitor that checks a fetus’s heartbeat — may give doctors the information they need, reducing the number of in-person visits required.

Someone’s overall physical health may help tip the scales on whether an in-person exam is needed. A 25-year-old in generally good health is usually a better candidate for telehealth than a 75-year-old with multiple chronic conditions.

But some health complaints typically require an in-person examination, doctors said, such as abdominal pain, severe musculoskeletal pain, or problems related to the eyes and ears.

Abdominal pain could signal trouble with the gallbladder, liver, or appendix, among many other things.

“We wouldn’t know how to evaluate it without an exam,” said Dr. Ryan Mire , an internist who is president of the American College of Physicians.

Unless a doctor does a physical exam, too often children with ear infections receive prescriptions for antibiotics, said Mehrotra, pointing to a study he co-authored comparing prescribing differences between telemedicine visits, urgent care, and primary care visits.

In obstetrics, the pandemic accelerated a gradual shift to fewer in-person prenatal visits. Typically, pregnancy involves 14 in-person visits. Some models now recommend eight or fewer, said Dr. Nathaniel DeNicola, chair of telehealth for the American College of Obstetricians and Gynecologists. A study found no significant differences in rates of cesarean deliveries, preterm birth, birth weight, or admissions to the neonatal intensive care unit between women who received up to a dozen prenatal visits in person and those who received a mix of in-person and virtual visits.

Contraception is another area where less may be more, DeNicola said. Patients can discuss the pros and cons of different options virtually and may need to schedule a visit only if they want an IUD inserted.

If Something Is New, or Changes

When a new symptom crops up, patients should generally schedule an in-person visit. Even if the patient has a chronic condition like diabetes or heart disease that is under control and care is managed by a familiar physician, sometimes things change. That usually calls for a face-to-face meeting too.

“I tell my patients, ‘If it’s new symptoms or a worsening of existing symptoms, that probably warrants an in-person visit,’” said Dr. David Cho , a cardiologist who chairs the American College of Cardiology’s Health Care Innovation Council. Changes could include chest pain, losing consciousness, shortness of breath, or swollen legs.

When patients are sitting in front of him in the exam room, Cho can listen to their hearts and lungs and do an EKG if someone has chest pain or palpitations. He’ll check their blood pressure, examine their feet to see if they’re retaining fluid, and look at their neck veins to see if they are bulging .

But all that may not be necessary for a patient with heart failure, for example, whose condition is stable, he said. They can check their own weight and blood pressure at home, and a periodic video visit to check in may suffice.

Video check-ins are effective for many people whose chronic conditions are under control, experts said.

When someone is undergoing treatment for cancer, certain pivotal moments will require a face-to-face meeting, said Kamal, of the American Cancer Society.

“The cancer has changed or the treatment has changed,” he said. “If they’re going to stop chemotherapy, they need to be there in person.”

And one clear recommendation holds for almost all situations: Even if a physician or office scheduler suggests a virtual visit, you don’t have to agree to it.

“As a consumer, you should do what you feel comfortable doing,” said Dr. Joe Kvedar , a professor at Harvard Medical School and immediate past board chairman of the American Telemedicine Association . “And if you really want to be seen in the office, you should make that case.”

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By Michelle Andrews March 6, 2023

If It’s Your First Visit

Once it’s clearer how the patient is coping and responding to treatment, that’s a good time to discuss incorporating telemedicine visits.

“We wouldn’t know how to evaluate it without an exam,” said Dr. Ryan Mire , an internist who is president of the American College of Physicians.

“The cancer has changed or the treatment has changed,” he said. “If they’re going to stop chemotherapy, they need to be there in person.”

And one clear recommendation holds for almost all situations: Even if a physician or office scheduler suggests a virtual visit, you don’t have to agree to it.

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Episode 105: The Difference Between E-Visits & Telehealth: What to Know

Brian Gallagher
March 20, 2020

In light of current global events, Brian tackles a topic of major relevance and concern: telehealth and e-visits. He covers some specifics that practice owners should be aware of as they explore this avenue for patient care? Brian addresses common questions that we have been receiving from clients at this challenging time. Tune in to get Brian’s helpful tips and advice. Please note, he uses the APTA guidelines as a source for this podcast.

Episode at a glance:

We want you connected to legitimate resources
You can market that you’re doing e-visits, however you can not put people on them. They have to initiate the desire to do them.
You will still need to have appropriate documentation to show medical necessity.
For more information on setting up telehealth and compliance issues, reach out to TelePT Solutions , or email Daniel Seidler.

Brian Gallagher, PT is the founder and CEO of MEG Business Management, LLC. He has more than 27 years of experience in the field of rehabilitation and 19 years in business and specializes in Physical Therapy practice management and executive coaching nationwide. As a licensed business management consultant, Brian has helped hundreds of business owners nationwide improve their business operations through proper restructuring to achieve improved systems of efficiency and productivity as well as marketing and sales with effective public relations which have proven results for double-digit growth year-over-year with businesses around the country.

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What is an eVisit?

An eVisit is a type of telehealth where you answer questions about your symptoms via an in-depth, online medical interview that adapts as you answer questions. Interviews typically take 15 minutes to complete.

eVisits offer clinical-level, online healthcare with no need to turn on your video, 24/7 via your MyChart account. eVisits are available on your phone or computer. To get started, sign up for MyChart or sign in to MyChart .

How Does an eVisit Work?

Use your phone or computer to log in or sign up for MyChart. Spend 15 minutes answering questions about your symptoms and submit your personalized, symptom-specific questionnaire.

Get diagnosis and treatment from a Baptist Health provider straight to your inbox typically within 60 minutes. If a prescription is needed, pick up your medication at the pharmacy of your choice.

Pay for your eVisit securely ($30) with your HSA or a credit card.

Conditions Treated by an eVisit

Acne or rosacea
Bladder Infection
Breastfeeding Concerns (mastitis)
Constipation
Cough, Cold or Flu
Diarrhea, Nausea or Vomiting
GERD (Heartburn)
Low Back Pain
Motion Sickness
Mouth Sores
Sexually Transmitted Infections (STI)
Smoking Cessation
Urinary Tract Infection (UTI)

About eVisits

No appointment needed
$30 per eVisit, not billed to your insurance
25 conditions for you to choose from
Treatment from a trusted Baptist Health provider is sent typically within 60 minutes.
Available in English & Spanish
May be used for adults or kids, 1 and older

eVisit Benefits

A low-cost option for urgent care ($30)
No need to turn on your video
Skip the waiting room
Feel better faster with care right when you need it
Medications needed sent by your provider to pharmacy of your choice
Care & treatment provided is added to your MyChart for continuous care
Available anywhere, anytime

Need more information? Visit our frequently asked questions section about eVisits.

How to Get Started with an eVisit

1. Sign in to MyChart on your computer or the MyHealth mobile app .

2. Select Menu and then click eVisit.

3. Your eVisit will start by asking you questions about your symptoms.

4. After you submit your questionnaire, a virtual urgent care provider will follow up with a recommended treatment plan for you.

Next Steps with MyChart

Discover MyChart, a free patient portal that combines your Baptist Health medical records into one location. Schedule appointments, review lab results, financials, and more! If you have questions, give us a call.

Care Finder

Care Finder asks you about your symptoms to recommend the most convenient care options for you to receive care, including online eVisits or video visits or in-person care.

Find Care Now
Choosing a Virtual Care Visit

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Virtual Care E-Visits

A University of Michigan Health Virtual Care E-Visit is a convenient way to receive health care advice and treatment for common medical needs. It is an asynchronous way to receive care. This means you will send the information needed to treat you. Our health care providers will review and send a treatment plan in response.

There is no appointment or phone call needed for an E-Visit. You can submit one anytime, day or night, using your MyUofMHealth Patient Portal account.

What conditions can be treated by an E-Visit?

University of Michigan Health Virtual Care offers E-Visit treatment for a wide range of symptoms and conditions. Our Urgent Care E-Visits are available for symptoms you might normally visit a primary care provider or urgent care clinic for, including:

Cough, flu or COVID-19 like symptoms
Sinus issues
Insect bites and stings
Vaginal discharge, irritation, or painful urination

Our Specialty Care E-Visits are available for an ever-growing range of conditions you might normally see a specialist for, including:

Dermatology
Obstetrics and Gynecology (OB-GYN)
Ophthalmology

Log on to the MyUofMHealth Patient Portal to determine exactly what types of E-Visits are available to you.

How can I access an E-Visit?

Simply follow these steps:

Log in to your MyUofMHealth Patient Portal account.
Select the E-Visit option under the “Your Menu” tab.
Answer a few short questions about your health.
Receive a written response from a University of Michigan Health provider via your MyUofMHealth Patient Portal.

Who can submit an E-Visit?

You must be physically located in the State of Michigan to submit an e-visit due to state law and regulations. E-Visits are available for all active (having received care in the last 36 months) University of Michigan Health patients who are enrolled in the MyUofMHealth Patient Portal. E-Visits for patients under the age of 18 must be submitted by a parent or guardian with proxy access.

Learn more about proxy access at MyUofMHealth .

How much does an E-Visit cost?

E-Visits may be fully covered by your insurance. You may verify whether you have coverage for E-Visits by calling your insurance company and asking if the following billing codes are covered: 99421, 99422 and 99423.The standard out-of-pocket cost for an E-Visit depends on the type of E-Visit.

Urgent Care E-Visits, for conditions you would see your primary care provider or visit an urgent care clinic for, cost up to $37.
Specialty Care E-Visits, for conditions you would normally see a specialist for, cost up to $37 – $119.

Review the “What conditions can be treated by an E-Visit” section on this page for more information about Urgent Care and Specialty Care E-Visits.

What conditions should I not use an E-Visit for?

Do not use an E-Visit if you are experiencing any of the following symptoms:

Severe shortness of breath or difficulty breathing
Headache and stiff neck (can't touch chin to chest)
Too weak to stand
Fainting or passing out
High fever (>104F, 40C)

If you are experiencing these symptoms, please call 911 or your physician's office immediately.

For more information

For more information, check out our Virtual Care FAQs .

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Telehealth for emergency departments

E-consults, also known as electronic consultations or interprofessional consults, are communications between health care providers. Providers can use e-consults in the emergency department to get recommendations for complicated conditions from providers in other locations with additional expertise, for example in specialty areas like acute care for stroke, trauma, ICU, or behavioral health.

What platform or communication method you will use
What specialties will be available
What cases warrant initiating an e-consult
What your workflow will be, including turnaround time expectations
How you will share patient information or records
How you will train participating providers
How you will roll-out your e-consult program
How you will manage billing and reimbursement

More information about e-consults:

eConsult Standard Workflow (PDF) — from the California Telehealth Resource Center
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Planning your telehealth workflow →
Preparing patients for telehealth →

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Answer a few short questions about your health and get a prompt response

Existing patients with a MyChart account can use e-visits to seek treatment for non-urgent, common symptoms and conditions without having to step foot in the office. It’s a fast, convenient way to have your health concerns addressed by your primary care provider .

What is an E-Visit?

An e-visit is an online questionnaire, in which your provider can give you medical advice via secure message. When filling out the questionnaire, you are asked to share details about the reason you are contacting your doctor and to verify personal and medical information.

Once completed, you submit the form to your primary care provider who will review your answers and respond to you with a plan of care, including any prescriptions needed, in about two business days or less. If you need care more urgently, please contact your provider’s office or schedule a Same-Day Care appointment .

E-Visits are not covered by insurance. A flat fee of $25 will be charged to your account when you submit the e-visit. OSU Health Plan members will not be charged for e-visits.

Your provider’s office may contact you for more information about your symptoms. If it’s decided that you need to be further evaluated in the office or through a scheduled video visit , your e-visit will be canceled and transitioned to one of these appointment types, and you will not be charged the $25 fee.

Your primary care provider can treat the following using an e-visit:

Sinus problems
Urinary tract infection (UTI)
Cold/flu symptoms (including possible COVID-19)
Vaginal irritation/discharge

How do I have an E-Visit?

You can have an e-visit with a primary care provider that you have seen within the past two years.

Step 1: Log in to your MyChart account on a computer or through the MyHealth app on your mobile device.

In the mobile app: Choose the “E-Visit” icon on home screen
On desktop: Choose “Schedule an Appointment” and then select “E-Visit” icon on the right

Step 2: Accept the terms and conditions

Step 3: Fill out the reason for your visit, confirm your provider and preferred pharmacy

Step 4: Verify your personal information

Step 5: Complete the questionnaire with more detail about your health concern

Step 6: Select a provider from the drop-down list and submit your e-visit request

Step 7: Wait for your provider to respond within two business days

Troubleshooting and tips

If you do not hear from your provider within two business days, please call the office. If you need care more urgently, an e-visit may not be your best option. Contact your provider’s office or schedule a Same-Day Care appointment .

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Welcome to the world of telemedicine: Understanding the basics

Imagine the convenience of “visiting” your doctor through your smartphone or computer. Or, as a healthcare provider, being able to connect with your patients and offer them advice and care, no matter where they are. Welcome to the exciting world of telemedicine – a digital approach to healthcare that combines the speed and reach of technology with the personalization and expertise of medical professionals.

Telemedicine empowers you to have a real-time video chat with your medical practitioner, for example a dermatologist about a worrisome mole, from the comfort and privacy of your own home. For millions of people, telemedicine has the potential to significantly enhance health outcomes , particularly in rural or underserved regions where healthcare providers are few and far between.

Telemedicine has been used for decades, but it has become increasingly popular in recent years. As it becomes more widespread, it helps alleviate the pressure on overburdened healthcare facilities. And while it doesn’t take the place of in-person appointments, it can be an important addition to patient care. This article takes a look at what makes telemedicine a win-win for patients and healthcare providers alike.

What is telemedicine.

Picture an 80-year old patient having a video consultation with her doctor, discussing symptoms, receiving a diagnosis, and even getting a prescription – all from the comfort of her own living room. This innovative healthcare model is breaking down traditional barriers such as distance, time and mobility, making it easier than ever for individuals to receive the care they need, when they need it.

In short, telemedicine is “remote healthcare” or medical services provided from a distance using telecommunication technologies. It has the potential to transform the way healthcare is provided and consumed. There are three main strands of telemedicine, each serving different purposes and using different technologies:

Interactive medicine : Real-time interactive telemedicine enables live, two-way communication between patients and healthcare providers through video or phone conferencing.
Store-and-forward : Store-and-forward telemedicine involves transmitting patient medical data, such as images and records, from one healthcare provider to another for assessment and diagnosis at a later time. It is commonly used in specialties like dermatology and radiology for remote consultation and second opinions.
Remote monitoring : Remote patient monitoring utilizes digital health technologies to collect and transmit patients’ health data to healthcare providers for ongoing monitoring and management.

From simple phone consultations to advanced remote monitoring systems, telemedicine is tailored to fit a diverse range of patient needs and scenarios.

How does telemedicine differ from telehealth and telecare?

These three terms are often used interchangeably, but they mean slightly different things.

Telemedicine refers to the general use of technology for delivering healthcare services remotely. Using virtual consultations, remote monitoring and digital communication tools, they allow patients to consult with healthcare professionals without being physically present, enhancing accessibility and convenience.
Telehealth is a broader concept that encompasses not only clinical services like those provided in telemedicine, but also non-clinical services such as administrative meetings, continuing medical education, and public health initiatives conducted remotely through telecommunications technology.
Telecare specifically focuses on monitoring and managing patients’ health and safety from their homes using technology like sensors and alarms. It aims to support independent living and provide timely assistance to individuals with chronic illnesses or disabilities.

In essence, while telemedicine and telehealth encompass various remote healthcare services, telecare specifically concentrates on distance monitoring and support for patients’ health and well-being in their home environments.

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How does telemedicine work?

Patients typically schedule appointments via web-based platforms or mobile apps, and connect with healthcare providers through video conferencing, audio calls or messaging. During virtual consultations, patients describe their symptoms and medical history, while health practitioners conduct assessments and provide medical advice. Some platforms allow patients to upload medical records for easy access by their healthcare centre.

Telemedicine platforms rely on a variety of technologies to ensure efficiency and functionality for both patients and healthcare providers, including wireless communications, video conferencing, streaming media, mobile technologies, Internet of Things solutions and artificial intelligence.

Services may also include remote monitoring through wearable medical devices or at-home kits to track patients’ vital signs and health metrics. Based on the patient’s requirements, healthcare providers can prescribe medications, refer patients to specialists, and schedule follow-up appointments as needed.

Telemedicine in action: real-world applications

Today, there are many telemedicine examples being implemented by hospitals and care centres to provide high-quality healthcare services for all. Patients are increasingly turning to health applications to manage various aspects of their well-being, including chronic conditions (e.g. diabetes, hypertension, heart disease or asthma) and drug management . They can now connect with healthcare providers from the comfort of their home, eliminating the need for lengthy commutes, waiting room delays and time-consuming visits to a doctor’s clinic.

Telemedicine has expanded access to specialized care , such as dermatology assessments and eye examinations. In particular, mental health services have become more approachable and discreet through telepsychiatry, offering a lifeline to those who might have previously shied away from seeking support. It’s also a convenient way for patients to seek second opinions from a more diverse range of medical professionals.

Mobile health applications often serve as the interface through which patients interact with telemedicine platforms, facilitating communication with healthcare providers, scheduling appointments and sharing health data. For example, patients can use mobile apps , wearable sensors and remote monitoring devices to check their vital signs, track symptoms and communicate with healthcare providers remotely.

What are the benefits of telemedicine in healthcare?

Telemedicine applications offer significant benefits for both healthcare service providers and patients. Below are some of the key advantages:

Increased patient access : Telemedicine aims to deliver healthcare services to individuals regardless of their location, bridging the care gap in areas where specialized health providers and facilities may be scarce. It ensures swift and secure access to quality healthcare whenever required, thereby ensuring patient safety and convenience.
Better quality healthcare : Telemedicine boosts care quality for hospitals and medical organizations as it makes it much easier for physicians to follow up on patients without the need for the patients to be physically present. It also reduces hospital admissions and relapses, allowing for prompt medical attention at symptom onset.
Greater trust : Reports indicate that telemedicine also leads to increased patient satisfaction and engagement, offering greater flexibility and a wider range of healthcare service options. This also builds confidence in the healthcare system.
Cost efficiency : Telemedicine not only decreases transportation costs, it also effectively reduces expenses associated with managing chronic diseases and long-term care. It enables shorter hospital stays, and allows for remote professional staffing and consultation. In some cases, physicians can practice remotely, essentially creating a virtual hospital. Such instances help spread the benefits of telemedicine to a much wider range of patients.

Protecting patient privacy

While telemedicine has opened up new avenues for collaboration and knowledge sharing, safeguarding patient data and privacy is paramount. Patients should feel confident sharing their personal and health information without hesitation. This means deploying robust cybersecurity measures to ensure that every video call, message or shared document is protected to the highest level of confidentiality.

Standards provide a robust framework for telemedicine, fostering trust, safeguarding patient data and enabling a smooth and secure healthcare experience. Take, for instance, ISO 13131 . The comprehensive telehealth standard for quality, risk and resource management enhances data interoperability, security and user experience, facilitating both patient care and medical research. In short, ISO 13131 helps bolster telehealth services, making them not only a convenient option but a secure one.

ISO 13131 Telehealth services – Quality planning guidelines

ISO/TR 16056-1 Interoperability of telehealth systems and networks

ISO/IEC 27001 Information security, cybersecurity and privacy protection

A new era in healthcare

We stand at the threshold of transformative change in healthcare. Telemedicine combines technology, convenience and personalized care to make health services globally more affordable and accessible to people around the world. By establishing comprehensive policies and compliance frameworks, telehealth and telecare providers can protect patients’ data and uphold their rights to privacy, while delivering the best possible patient care. The future of healthcare is here, and with the help of standards, we can ensure the telemedicine revolution is accessible for all.

Welcome to the world of telemedicine: Understanding …

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The State of Telehealth Before and After the COVID-19 Pandemic

Telemedicine was underused and understudied until the COVID-19 pandemic, during which reduced regulations and increased payment parity facilitated a rapid increase in telemedicine consultation. Telemedicine literature to date suggests that it holds benefits for patients and health care providers, may result in outcomes not inferior to in-person care, and has cost-saving implications. Future research should investigate which conditions are best suited to assess and treat via telemedicine (including physical exam elements), what techniques improve telemedicine communication, how to help patients equitably access telemedicine, and how to best educate the future health care workforce.

• Telemedicine health care has grown in the United States since the beginning of the COVID-19 pandemic and will remain an integral part of medical care.
• Telemedicine is well received by many patients and health care providers but remains more accessible to certain groups of patients than others.
• Telemedicine care can be equivalent to in-person care for certain acute and chronic conditions. The telemedicine physical examination should be further studied for how it may contribute to patient assessment.
• Future clinicians and all levels of learners within health care will require more specific training on how to logistically manage telemedicine technology and how to clinically navigate a remote consultation.

Introduction

The “house call” from doctors is surging in the United States, and instead of ringing the doorbell, your doctor is pinging your smartphone. Telemedicine, or receiving one’s medical care remotely via synchronous, asynchronous, or store-and-forward technology, had been on a steady increase for the last decade, but the overall growth had remained slow until March 6, 2020. In response to the SARS-CoV-2 pandemic crisis, the US Congress toppled a multitude of telemedicine regulations, and telemedicine expanded rapidly. Although the acute pandemic crisis may be entering its long tail, telemedicine will remain a permanent fixture in routine American health care. How will this serve us as practitioners and patrons of medicine? The experiences of the last several years can help us forge our path forward into a future with virtual health care.

Definitions of Telemedicine and Telehealth

The definitions of these two terms depend upon whom you ask and what you read, as there are currently more than one hundred different peer-reviewed definitions. 1 A general consensus shared by most is that telemedicine refers to providing clinical services (either in real time or asynchronously) between patient and clinician and/or between clinician and clinician when the two parties are physically remote from one another using some form of information-communication technology. The term telehealth is a larger umbrella term encompassing other remote health-related services, such as administration, continuing medical education, and/or provider training.

Telemedicine in the United States before March 2020

Before March 2020, telemedicine use in the United States was on a steadily increasing trajectory, but its absolute integration remained low, and the logistics were complex. 2 , 3 Patients and providers who desired to use it navigated inconsistent and often inadequate reimbursement for services, restrictions on where each party must be located and what sort of technology interface they must use, and privacy regulations that necessitated costly investments in secure telecommunication technology. Providers were (and often still are even in a postpandemic landscape) limited from treating traveling patients by interstate licensing restrictions, and juggled miscellaneous rules about prescriptions, types of visits, and types of patients that were or were not acceptable for telemedicine. 4 Despite these hurdles, 76% of US hospital systems used some form of telemedicine as of 2018, with radiology, psychiatry, and cardiology noted as the highest users of the modality. 5 Systems factors, such as technology capability of the electronic medical record and other characteristics driven by reimbursement policies (such as rural location), influenced which hospitals or clinics were more likely to offer telehealth, 6 , 7 further limiting which patients had the option of using this service.

Of the patients who were able to access telemedicine before March 2020, their overall impressions were positive. 8 , 9 , 10 , 11 , 12 , 13 In a systematic review on the topic, the most frequently cited factors associated with patient telehealth satisfaction included improved outcomes (defined a variety of ways owing to heterogeneity of the 44 included studies), preferred modality over face-to-face visits, ease of use, low cost, improved communication, and elimination of travel time. 9 Patients also expressed some concerns about telemedicine, such as data security. 14 The telemedicine appointments assessed in these studies were almost entirely video-conferencing rather than telephone-only owing to reimbursement restrictions on the latter.

Clinicians had a more variable opinion of telemedicine, perhaps driven by inexperienceas most were not using it before the pandemicand those who did use it still conducted most of their visits in person. About half of clinicians surveyed in one setting (respondents largely consisting of psychiatry providers) who were actively using both telehealth and office visits in their practices were concerned that the personal connection through telehealth was inferior to office visits. 11 Approximately one-third of those clinicians also stated that the overall quality of the visit was better in person. Family medicine providers (N = 1630) surveyed about the reasons behind their nonuse of telehealth were more likely than current users to feel it was an inefficient use of their time, and to express concerns about the overall quality of care and the liability potential. Nonusers were also more likely to cite lack of training, equipment costs, liability concerns, and inadequate reimbursement as barriers to telehealth. 15

COVID-19 drives telehealth expansion and gives new insights on patient and provider use

The widespread recognition of SARS-CoV-2 in the United States by March 2020 upended many of the prior barriers to telemedicine. Patients who would have had in-person office visits for their needs were isolating, quarantining, sheltering under health orders, or fearful to venture out. In early March 2020, Congress made major alterations to Medicare restrictions on where telemedicine must originate, what would be reimbursed, and what platforms could be used ( Table 1 ). This paved the way for similar relaxations on interstate practice and privacy regulations, and reimbursements for telemedicine improved dramatically. State and private payors promptly followed Medicare’s lead in a collective effort to keep health care channels open and practices solvent. 2

Table 1

Comparison of Centers for Medicare & Medicaid Services telehealth regulations before and after March 2020

In response, practices greatly expanded telemedicine services during the long months of shelter in place and recurrent surges of COVID-19 infections, and patient use of telehealth services blossomed. A national study including 36 million working-age individuals with private insurance claims data showed that telemedicine encounters increased 766% in the first 3 months of the pandemic, from 0.3% of all interactions in March to June 2019, to 23.6% of all interactions in the same period. 16 This is in line with research by the Doximity online medical networking service, which counts 1.8 million physicians (about 80% of the US physician workforce) among its membership, estimating with private claims data that approximately 20% of all US health care visits in 2020 were conducted by telemedicine. 17 However, even as telemedicine skyrocketed, medical care in general across the United States showed a sharp decline that could not be made whole despite best efforts. One estimate using claims data from 16.7 million Medicare Advantage and commercial insurance patients estimated that total outpatient visits plummeted by 30% of usual volume between January and June 2020, and that telemedicine only compensated for about two-thirds of this loss. 18 Physicians across the nation were severely impacted between reduction in overall visit volume, increased spending on personal protective equipment, and pervasive staffing challenges. Eighty percent of physicians surveyed by the American Medical Association reported a persistent reduction in income (average reported decrease of 32%) at 5 months into the pandemic. 19

Even as isolation precautions have relaxed and shelter-in-place orders are past, telehealth is showing some staying power. FAIRHealth, 20 which manages a large national database of both private and Medicare claims data, shows that although in-person care is still chosen most of the time, the overall percentage of telehealth claims has ballooned from 0.1% in 2019 to hover just around 5% at the close of 2021 ( Fig. 1 ).

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Telehealth claims (as a percentage of all claims) in the United States from 2019 to 2021, based on FAIRHealth reported claims data, which includes participating Medicare and private insurance plans.

Discussion: telemedicine during and after COVID-19

Who is using telemedicine now.

Although disappearing regulations have somewhat leveled the playing field for all to participate, there are still various factors that predict which physicians and which patients are more likely to engage in telemedicine. What we know about physicians accessing telemedicine comes from studies of large academic practices, claims data from commercial insurance, and research from Doximity.

According to available data, the number of physicians reporting telemedicine as an active skill has doubled as of 2020, from 20% to just less than 40% of the Doximity survey. 17 A physician most likely to be practicing telehealth today treats patients who have chronic diseases, such as in endocrinology, gastroenterology, rheumatology, nephrology, cardiology, and psychiatry, whereas physicians in dermatology, orthopedic surgery, or optometry are least likely to report telemedicine use (note: these references did not distinguish between subspecialists who treat chronic disease and primary care physicians who may treat the same conditions). 17 , 18 , 21 Telemedicine practitioners tend to identify as female more often than male and are between 40 and 60 years of age. 17 They live predominantly in large metropolitan areas or on the East Coast. 17 , 18 The clinician demographics are likely influenced by the inherent demographics of the high-telemedicine specialties.

As telehealth rapidly evolves, it is important to note what has changed (and what has not) now that insurance type, physical location, and technology platform should present fewer barriers for all to use telemedicine. Historically, it has been challenging to describe the typical “telemedicine user,” because telemedicine use was such a small proportion of care before the pandemic. What has been reported about the demographics of telemedicine users before 2020 reflects what would be expected of those select patients that either were granted access (eg, large academic centers, Veterans Administration health system, integrated health systems) or purchased access (eg, through direct-to-consumer telemedicine services). In contrast, some patients who might be expected to frequently use telemedicine (including those who live far away from in-person care, such as large areas in the middle of the United States) were often effectively excluded owing to lower rates of household internet access. Others who suffered from the digital divide included households of lower socioeconomic status and patients with disabilities. 22

With the advent of the pandemic in 2020, reimbursable telemedicine services expanded to include telephone-only visits and removed geographic barriers and platform restrictions. Interestingly, this has not addressed the inequities in telemedicine use as much as one might predict. Studies inclusive of March to August 2020, which examined demographics of new telemedicine users, show a surprisingly similar picture to the prepandemic period: patients who use telemedicine still tend to be white, younger, wealthier, and more urban-dwelling than non-telemedicine-using peers. 16 , 23 , 24 , 25 , 26 This demographic discrepancy becomes even more apparent when examining video telemedicine users compared with telephone (audio-only) users. 23 , 24 , 26 Although this picture of the typical telemedicine user may reflect the larger troubling patterns of inequitable access to medical care in general in our country, these data should still guide us as we move into a more telemedicine-dependent future. Our most vulnerable, marginalized, and chronically ill patients will need additional attention and funding dollars to understand all their barriers (digital and otherwise) to this type of care that we hope could address their care gaps, and to prevent telemedicine from becoming yet another wedge to widen medical disparities in our country.

Despite the observed differences in utilization, telemedicine visits did globally increase for all types of patients compared with rates in 2019 and prior, especially among those with chronic illnesses. 17 Perceptions of telemedicine care from this much larger sample of users continue to be positive overall whether they are new to telemedicine or experienced. One survey of 800 patients at Penn Medicine in the first half of 2020 reported that 67% of respondents considered their video or telephone visit “as good or better” than a standard in-person visit. 27 A similar survey of 1011 University of Michigan Medicine patients in early 2020 showed similar degrees of high satisfaction between first-time users and repeat patient users of telemedicine. 28 In addition, although telemedicine use varies significantly based on certain demographics (as described above) because of either preference or barriers, those who use it across different demographics can have a similar experience. A nationally representative sample of US households (N = 3454) surveyed on telemedicine use during the pandemic affirmed that telemedicine use differed significantly based on race, household income, insurance status, and presence of high-speed internet (in keeping with the literature cited above), but that those who did use telemedicine even in lower-income households or non-white households seemed equally satisfied with their experience. 29

What Do We Know About Conditions that Are Evaluated by Telemedicine?

In the literature to date, telemedicine is most often evaluated by examining patient acceptance of care using technology, patient and clinician satisfaction with the visit, and patient perception of care they received. Studies examining patient-oriented health outcomes or economic impact on individuals and systems are less common and are needed to delineate how telemedicine can be best used for future medical care.

Before the COVID-19 pandemic, research on telemedicine health care outcomes had some inherent challenges. Patients using telemedicine were a self-selected audience with the inherent differences that accompany this, and telemedicine is a broad category that encompasses many different intervention types ranging from simple telephone encounters to highly intensive encounters involving facilitators or digital examination equipment, such as stethoscopes or otoscopes able to transmit audio-visual information to a remote provider. Likewise, it is challenging to compare outcomes between telemedicine and face-to-face care in a prepandemic world where clinicians might prioritize in-person encounters for more high-risk or medically complex individuals when there is no limitation or disincentive for doing so.

Despite these challenges, there is now more literature to support telemedicine as a viable alternative to in-person care in certain situations. One of the more comprehensive looks at this topic was a systematic review of telemedicine practice in primary care before the pandemic, including 81 studies conducted both domestically and abroad. 30 The results from this study have been supplemented by other publications conducted during the pandemic, and general conclusions about patient outcomes for different categories of careare summarized below.

Acute care using telemedicine

Telemedicine has been studied in various acute conditions as compared with usual care, including uncomplicated cystitis, upper respiratory tract infections (URI), pharyngitis, and low-back pain. Results of these studies are heterogenous. Some suggest that telemedicine care for conditions such as URI and low-back pain can result in similar or improved clinical outcomes for patients, with “clinical outcomes” usually defined narrowly as a single categorical item (such as appropriate vs inappropriate use of antibiotics for a given diagnosis). In a nurse-administered telephone or a Web-based protocol for URI and sinusitis treatment, overall antibiotic administration with telemedicine for viral URI was less than usual care, and first-line antibiotics were more often prescribed for cases of sinusitis meeting clinical criteria. 31 , 32 In an evaluation of care administered by Teladoc, a direct-to-consumer telemedicine consultation service, telemedicine consultations did not order imaging for low-back pain (appropriately so) at about the same rate as in-person evaluations. 33

Other studies in direct-to-consumer telemedicine differ, suggesting that patients who received telemedicine may be more likely to receive inappropriate antibiotics than when seen in face-to-face care 33 , 34 , 35 and are less likely to receive an appropriate rapid strep test for evaluation of pharyngitis. 33 The variations in medication use and diagnostic testing seen in these studies may be explained by the context of a direct-to-consumer telemedicine encounter. The typical model for direct-to-consumer telemedicine is a single encounter between a clinician and patient who have no preceding relationship, and the clinician is often limited by lack of on-site testing, no means to bring patient in for a face-to-face examination, and little way to ensure the patient will access follow-up care if they get worse. Telemedicine outcomes may look different when delivered within a context where physicians and patients know one another, a consistent medical record is available, on-site testing may be achievable, and there is more readily accessible follow-up care. An observational study in this type of setting (a large integrated health system) analyzed more than 1 million visits: telephone, video, and office visits, for any type of initial concern (excluding routine physical examination) during a 2-year period. Patients initiated scheduling of the visit modality themselves via a Web-based scheduling portal. The investigators found that rates of overall prescribing of medication or imaging (across all diagnoses as well as a subanalysis of visits only for URI symptoms) were actually lower for telemedicine (telephone or video) as opposed to in-person care, and that the need for emergency department (ED) or hospital visit within 7 days following the index visit did not differ between telemedicine and in person. 36 This suggests that clinicians using telemedicine may be less likely to overprescribe or overuse testing as a precautionary measure when they have some prior knowledge of the patient and when they feel confident that follow-up care is available should things get worse.

This study also demonstrates that when examined in a very large sample and over a broad array of diagnoses, assessment and treatment via telemedicine seem no more likely to result in acute decompensation requiring emergency room services or hospitalization than traditional in-person care. However, emergency and hospital care is an uncommon outcome to begin with; in this study, overall rates of ER visits within a week of index visits were approximately 1% across all visit types, and hospitalizations were less than 0.5%. Future studies may do well to see if this conclusion holds true when telemedicine care is used for specific diagnoses (dizziness, abdominal pain, dyspnea) that may be more challenging to assess, or for different types of telemedicine users that may have communication barriers.

For acute skin concerns, tele-dermatology is already used in multiple countries for routine dermatologic management, to consult on patients in remote locales, or for medical support in nursing homes or home care settings. 37 However, most studies to this point have not examined a specific comparison with usual (in-person) consultation. Tele-dermatology may serve an intuitive role as a follow-up method once a diagnosis has been established, to triage whether an in-person consultation is needed, or to guide primary physicians on the best next steps in management for routine conditions.

Chronic care using telemedicine

Telemedicine has been studied for many chronic conditions, such as asthma, chronic obstructive pulmonary disease (COPD), depression, diabetes, hypertension, hyperlipidemia, and heart failure. Some of the most robust evidence for improved patient outcomes with telemedicine care comes from pharmacist-based telemedicine interventions. A systematic review of 34 studies looking at chronic disease management using pharmacist-delivered telemedicine care protocols examined outcomes for different conditions (hypertension, diabetes, anticoagulation, depression, hyperlipidemia, asthma, heart failure, HIV, posttraumatic stress disorder, chronic kidney disease, stroke, COPD, and smoking cessation). 38 The investigators noted the heterogeneity of studies and for this reason did not perform a data synthesis to quantify collective results and instead performed a narrative review. Most included studies (N = 25) examined telephone-only interventions as opposed to more technology-intensive ones, and studies were included in the final review if they used a comparison (ie, face-to-face, usual care, or no intervention) and if they evaluated as outcomes either chronic disease management (ie, achievement of laboratory values specific to therapeutic goals), patient self-management (ie, self-monitoring blood pressure or demonstration of inhaler use), or adherence (ie, patient self-report or pharmacy records showing medication fills). Results showed good success for telemedicine interventions, with 23 out of 34 studies logging positive improvements in disease management, self-management, or adherence measures. Another 10 studies reported neutral outcomes (noninferior to the comparison), and only one study concluded any sort of negative outcome for the telemedicine group. A scheduled model of care, described as pharmacists delivering telemedicine interventions to patients at predetermined times, was the most common and the most successful delivery system for improved outcomes as opposed to a responsive/reactive model (pharmacist reaching out to patient when being prompted to do so by a health system alert). Similar benefits of pharmacist-led virtual care have been documented as health systems rapidly transitioned chronic disease care to virtual visits during the pandemic. 39

One notable aspect of this systemic review is the increased success of scheduled telemedicine care as opposed to a more responsive/reactive model, affirming that a high degree of reinforcement and support is beneficial for chronic disease management in general whether in person or otherwise. Shifting some of this care to telemedicine could conceivably lower overall system costs through reduced overhead and possibly improved patient outcomes (if evidence cited above proves accurate) but would likely require upfront investment in clinicians or other personnel to support the consistent, high-frequency visits. The overall impact on physician and practice revenue is also unclear, as reimbursement for telemedicine may become less favorable when the pandemic wanes.

Other small studies show some benefit of telemedicine for other chronic conditions. One study demonstrates that telemedicine intervention delivered over an extended period (ie, 24 months) can be as successful as in-person care for weight loss of primary care patients, with either telemedicine or in-person treatment groups achieving equivalent weight loss and more so than the “no-treatment” arm. 40 Telemedicine also shows some promise with management of chronic musculoskeletal pain; patients who participate in a 12-month telemedicine intervention with algorithmic guide to pharmacologic management had improved pain scores at 1 year as compared with usual care. 41

Despite the promise of evidence above, conclusions about telemedicine effectiveness overall can be difficult to determine, as the types and intensity of interventions vary drastically from study to study. In the case of asthma care, for example, one frequently cited telemedicine study entitled “Telemedicine is as effective as in-person visits for patients with asthma” concludes that children in the telemedicine group and children in an in-person visit group had similar degrees of asthma control over a 6-month study period. 42 However, the intervention described in the article is a highly intensive “Remote Presence Solution” involving a digital stethoscope and otoscope and a high-resolution camera situated at the patient's home site. Therefore, broad conclusions about equivalency of care must be interpreted in the context of the intervention being delivered (and whether it is feasible in most practices) as well as the outcome of interest, all of which tend to be variable across telemedicine literature. A more recent narrative review on the topic of asthma care via telemedicine looked at a variety of interventions ranging from telephone-only follow-ups to the Remote Presence Solution described above, and concluded that data remain limited for clinical outcomes on this condition. 43 In addition, many studies in this review that used a telemedicine intervention combined it with a school-based care program, making it difficult to conclude what effects (if any) might be due to the telemedicine itself.

Similar challenges in drawing firm conclusions have been noted in a recent umbrella review of systematic reviews regarding telemedicine interventions for diabetes care, cholesterol, and hypertension. 44 Although the investigators concluded that telemedicine may improve outcomes for patients with diabetes and there are trends favoring certain subgroups in other conditions, the overall quality of the current evidence is low or very low because of potential bias in study design, heterogeneity in subgroups, imprecision of results or small effect sizes (due to small sample sizes), publication bias, and underreporting of relevant information, such as the treatment of dropout or missing data. Larger, more robust studies that address specific questions on clinical outcomes of telemedicine-supported chronic disease care as pandemic-era data come to publication are eagerly awaited.

Impacts on systems and resource utilization

Using telemedicine for select cases of both acute and chronic disease management may decrease the need for some routine face-to-face visits. In addition, there is interest in whether early triage and intervention for patient concerns via telemedicine could decrease face-to-face visits in urgent care and ED settings. A study by Reed and colleagues 36 showed that over a very large sample of appointments (more than one million visits for all types of complaints performed via telephone, video, or office visits), short-term hospital and ED utilization did not differ between patients who used telemedicine and patients who scheduled in-person visits. This preliminarily suggests that when patients are free to choose their own mode of care within a clinical context that has consistent physicians and ready follow-up care, telemedicine may be a reasonable initial alternative to in-person care and may not lead to increased emergency care. Further research in the same setting as the Reed study showed that e-visits for patients who met specific, low-risk criteria for one of five different complaints (eg, URI, emergency contraception, conjunctivitis, pharyngitis, and urinary tract infections) had overall low rates of in-office follow-up (about 13.5% of the entire cohort), and less than 1% used emergency services. 45 The e-visits took about two to three minutes of clinician time, suggesting this could be a very cost-effective and efficient intervention for common low-acuity complaints.

Even asynchronous patient-physician communication could be a timely way to reduce the need for more intensive care. Patient access to physician-patient messaging through a secure portal may not decrease face-to-face visits overall, 46 , 47 but for those with multiple chronic conditions (in this study defined as diabetes plus another chronic condition, such as asthma, coronary artery disease, congestive heart failure, or hypertension), it can decrease ED and hospital utilization. 47 This may be particularly significant during times when hospital care is severely overburdened, such as flu seasons, pandemics, or natural disasters. However, increased care burden may fall on outpatient clinicians handling the message volume and could contribute to fatigue or burnout over time if not addressed.

A key health outcome for telemedicine visits that has not been well studied is the diagnostic accuracy of telemedicine evaluation compared with standard care, and the association of delayed diagnosis and adverse health outcomes with each modality. Delayed diagnosis is a frequent allegation in malpractice claims, and to date, the medical-legal footprint of telemedicine has been very small. 48 The medical-legal implications of telemedicine are limited at the time of this publication and will certainly be an area of future research.

Summary and future directions

As we prepare to enter a future with widespread telemedicine, we should consider what will be gained and what may be lost. The benefits of telemedicine after its pandemic renaissance are apparent now more than ever: convenient and timely access to care that overcomes geographic barriers, reduced burden on medical infrastructure (e.g., traffic, facilities’ wear, perhaps reduced staff needs), and minimal exposure to infectious diseases for all participants. However, concerns still exist that something may be lost if telemedicine becomes standard practice for all. Many telehealth investigators and enthusiasts assert that telemedicine should play a role as an adjunct rather than a replacement for in-person care. 48 This is certainly the most likely scenario, because pandemic restrictions have lessened at the time of authorship of this article, and it remains unclear whether payment parity and other legislation supporting telemedicine care will remain in effect long term. It seems clear thattelemedicine is likely to remain pervasive in some fashion, and this author’s review of telemedicine both prepandemic and during the pandemic shows that it is widely agreeable to those who use it and it can stand alongside standard care for a variety of acute and chronic medical conditions, with the opportunity for more research ready to be explored in the future.

Going forward, many questions remain ripe for study on what makes for an effective telemedicine encounter. The relative importance of a physical examination in general and for what types of concerns will need to be considered, as well as to what extent patient-provided vital signs and physician-directed virtual examinations can fill this need. Beyond the physical examination, it is not clear whether patient-clinician relationships, rapport, and trust will suffer through the loss of nonverbal communication and therapeutic touch. Technology challenges from all directions, including poor reception, blurry screen resolution, or choppy Internet connections, may impair the telemedicine rapport. Questions on the impact of telemedicine to specific aspects of the physician-patient relationship deserve further study, as patient adherence and outcomes are known to be heavily influenced by physician communication techniques. 49 , 50 , 51 , 52 Perhaps tried-and-true patient communication techniques that have been successfully used in traditional practice to improve patient care 53 can translate relatively easily into telemedicine care and show similar benefits.

It will be to everyone’s benefit to understand how to participate in telemedicine care most effectively,as telemedicine is projected to remain more widely available to Americans moving forward. It is time for all of us to become adept at the twenty-first-century house call.

Clinics care points

• Telemedicine use between physicians and patients of all types has greatly expanded with the arrival of the COVID-19 pandemic. It is predicted to remain more prevalent in future US health care.
• Patients who are older, are non-white, live in a rural area, or are from a lower socioeconomic group continue to use telemedicine at lower rates. Some of this inequity is due to inconsistent technology access, but more research is needed in this area.
• Telemedicine is generally well liked by patients who use it, both before and during the pandemic.
• Research supports a role for telemedicine in both acute care and chronic disease management and suggests that it is noninferior to in-person care for health outcomes in certain conditions, such as uncomplicated upper respiratory tract infection, urinary tract infection, low-back pain, initial dermatologic concerns (with the help of high-definition photography), and chronic disease management (with the strongest evidence to date being for diabetes care). Telemedicine may also decrease, or at least not add to, short-term hospital and emergency department utilization.
• Systems-level interventions are needed to solidify telemedicine as a fixture in American health care and ensure more equitable access to it, including more universal service and payment parity, expanded broadband and digital technology access to patients and practices, and the allowance of audio-only telemedicine visits as an acceptable alternative to video.
• Clinicians have cited lack of training as a barrier to practicing telemedicine, and more robust training is needed at the undergraduate and graduate medical education levels. The Association of American Medical Colleges has released telehealth competencies to guide these efforts, and the Society of Teachers of Family Medicine has spearheaded the development of a national telemedicine curriculum.
• Areas of future study should include the development of telemedicine best practices for common acute and chronic conditions and examination of how they affect patient-oriented health outcomes, assessment of physician communication techniques that are suited to remote and audio-only care, study of the economic impact of providing telemedicine care either as adjunct to or in place of in-person care, and the provision of telemedicine access to less represented groups.

Medicare Part B (Medical Insurance) covers certain telehealth services.

Your costs in Original Medicare

After you meet the Part B deductible , you pay 20% of the Medicare-approved amount for your doctor or other health care provider's services.

For many telehealth services, you'll pay the same amount that you would if you got the services in person.

To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:

Other insurance you may have
How much your doctor charges
If your doctor accepts assignment
The type of facility
Where you get your test, item, or service
The type of provider

Telehealth includes certain medical or health services that you get from your doctor or other health care provider who's located elsewhere (or in the U.S.) using audio and video communications technology (or audio-only telehealth services in some cases), like your phone or a computer. You can get many of the same services that usually occur in-person as telehealth services, like psychotherapy and office visits.

Through December 31, 2024, you can get telehealth services at any location in the U.S., including your home. After this period, you must be in an office or medical facility located in a rural area (in the U.S.) for most telehealth services.

You'll still be able to get certain Medicare telehealth services without being in a rural health care setting, including:

Monthly End-Stage Renal Disease (ESRD) visits for home dialysis.
Services for diagnosis, evaluation, or treatment of symptoms of an acute stroke wherever you are, including in a mobile stroke unit.
Services to treat a substance use disorder or a co-occurring mental health disorder (sometimes called a "dual disorder"), or for the diagnosis, evaluation or treatment of a mental health disorder, including in your home.
Behavioral health services, including in your home.

Things to know

Medicare Advantage Plans and some providers, like ones who are part of certain Medicare Accountable Care Organizations (ACOs) may offer more telehealth benefits than Original Medicare. For example, these benefits might be available no matter where you're located, and you might be able to get them at home instead of going to a health care facility. Check with your plan to find out what benefits they offer. If your provider participates in an ACO, check with them to find out what telehealth benefits might be available.

Is my test, item, or service covered?

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Telemedicine and E-Visits: An Update

The state of telemedicine and remote patient monitoring.

As cardiac disease, diabetes, and other chronic illnesses rise worldwide, and as the population ages and the U.S. faces a predicted physician shortage, many health systems and health plans have embraced telemedicine as an option to grow their markets and continue care to patients remotely.

A study on health insurance claims from across the country found that between 2016 and 2017 telehealth claims increased by 53%-more than both urgent care centers (14%) and retails clinics (7%) combined.

“From a business perspective, if I can keep you healthier and more compliant with your physician recommendations, hopefully your health outcomes are going to be more positive. That means where we can potentially reduce readmission disease exacerbations and emergency room visits,” says Marya Vande-Doyle, director of workplace wellness and telemedicine for Excellus BlueCross BlueShield (BCBS). The health plan recently reported that nearly 15,000 telemedicine claims were filed in 2018. “We see telemedicine as a way to ensure that members feel like they have access to care wherever they go.”

Combined with market factors, CMS also accepted five new reimbursement codes in 2019 allowing for providers to be paid for remote patient monitoring, e-visits, and e-consults.

But even with a ripe market and more CMS support, experts believe that healthcare organizations still have a long way to go before telemedicine and e-visits are commonplace. Zynn says state regulations can still be a hurdle to telehealth adoption.

Related article: Telehealth Program Reduces Readmissions

“If you asked anybody in the industry, they would say licensing and changes in the regulations at the state level are probably the biggest hurdle or hindrance to faster growth,” says David Zynn, president of Infectious Disease (ID) Connect, a telemedicine company recently spun off from the University of Pittsburgh Medical Center (UPMC).

Currently, 29 states are a part of the Interstate Medical Licensure Compact , which provides streamlined licensure for physicians who offer telemedicine services through multiple states.

“In the next five years, we'll lose the term ‘tele’ because it will just be healthcare,” says Zynn. You will make an appointment to see your doctor and either go to the hospital or get that service via telemedicine. You will also get follow ups via telemedicine. So, it’s more efficient, more effective, and better for the patient.”

Using telehealth to expand specialists’ reach

UPMC saw telehealth as an opportunity to offer its expertise in infectious disease to communities across the country. The hospital launched a telemedicine company, ID Connect, to help other hospitals improve outcomes and reduce transfers for patients who need infectious disease treatment.

Currently, the program is being used by several other hospitals and outpatient clinics, with plans to expand in the upcoming months. A shortage of physicians who specialize in infectious disease, coupled with the constantly-evolving nature of the field were other catalysts to UPMC’s decision to create a technology company focused on providing services more broadly.

ID Connect incubated at UPMC for the past five years, and Zynn says that through that trial they were able to prove that telemedicine could contribute to a decrease in antibiotic misuse , patient hospital stays, and mortality. Currently, 12 doctors are providing services on the platform to other doctors who need assistance or second opinions, and to patients who are recommended to a specialist.

“Our doctors schedule tele-physical exams and we train our customers to use a tele-presenter. It is still is a very comprehensive exam, with questions, history, and a physical exam. The tele-presenter also has a video, so that our doctors can see and hear everything as if they were physically present,” Zynn says. “Our doctors can diagnose, treat, order labs and prescriptions, all documented in the EHR. They will follow up with that patient to make sure everything is working out as planned. They can make any changes to the diagnosis or treatment plan if necessary. And upon discharge, a telehealth appointment would be part of the discharge order and follow up.”

Zynn says that because there are more than 4,000 hospitals with 300 beds or less, it is increasingly important for smaller providers to have easy and affordable access to specialists. The U.S. could be short up to 122,000 physicians by 2032, with possibly half of them projected to be specialty care providers, according to a 2019 report from the Association of American Medical Colleges.

“I’ve talked to our customers and the number one thing that we bring to them is, without our service, they would have to transfer a lot of patients out to a larger tertiary. That’s not good patient service,” Zynn says. “It's not good for the local hospitals because they lose that patient. You don't want to take someone who is very sick with an infection and transport them from one facility into another. That alone is a tremendous opportunity to improve care.”

Health plans increasing telehealth outreach

Health plans are also seeing positive impacts to increased telehealth adoption. A recent claims review from Excellus BCBS in New York found that telehealth services have tripled in the past two years. The health plan’s review found that nearly 15,000 telemedicine claims were filed in 2018, up from 5,100 in 2016.

A survey of more than 2,000 Excellus BCBS members conducted in 2019 found that more than half of members knew about telemedicine and 43% said they would consider using it in the future. Though only 5% reported using telemedicine services, 93% who used it rated their experiences favorably.

An increase in community outreach and provider education are factors that led to the increase in telemedicine claims, Vande-Doyle says.

“We provided a public service campaign to help spread awareness using local media and partnering with community events, to help the community understand what a telemedicine visit is,” Vande-Doyle says.

Related article: New Payer-Technology Partnerships Could Be Telehealth’s Future

The second approach Excellus BCBS took was to work with network partners, health systems, and primary care providers based in the community and the local and state medical society to share why telemedicine is important. Excellus BCBS services Medicare, Medicaid managed care, commercial, and employer-based health plans.

“A vast majority of our population is located in either health professional shortage or metropolitan shortage areas as designated by HHS. We recognize that for those members it's very difficult for them to travel during a snow storm or find a caregiver to drive them to a doctor's appointment. We reached out to the medical community understanding these common challenges and how can we increase awareness of telemedicine,” Vande-Doyle says.

The Excellus BCBS survey results found that 78% of telehealth services were related to heart disease, hypertension, skin disorders, diabetes, and pneumonia. Another 22% of services were related to behavioral health, including anxiety, depression, attention and bipolar disorders. Behavioral health visits via telehealth were the fastest growing areas of treatment, according to the claims review.

“In order to be successful, we have to ensure that our providers feel comfortable in offering telemedicine. We have to encourage our providers to innovate. And at the same time, we have to share what we're learning,” Vande-Doyle says. “It's not focused on one specialty, healthcare provider, or one visit type. Telemedicine is for all types of applications. It's part of a solution of increasing access to care and using our healthcare services.”

More efficient pharmaceutical services

In the last decade, PipelineRx has grown its telepharmacy business to serve more than 600 hospitals and provider organizations, with 150 telepharmacists working from a call center or remotely. Brian Roberts, CEO of PipelineRx , says that remote dispensing and medication management, along with counseling patients and providers delivers education and efficiency that is lacking in the healthcare system.

“Telepharmacy increases access to facilities or organizations that either can't afford or can’t find the right pharmacy personnel. We can provide that remotely so that everybody has 24/7 care,” Roberts says. “I can take one telephone pharmacist working from home or from our call center, and they can cover between four and seven facilities at the same time. You can bring the overall cost of managing those facilities down by using telepharmacy.”

Roberts says that telepharmacy can allow on-staff pharmacists the ability to focus less on administrative tasks and work more closely with patients.

“We provide increased safety because a telepharmacist has his or her head down focusing on processing orders and making sure that the prescriptions are right,” Roberts says. “We actually counsel the patient during and after discharge to help them understand their medications and how adhere to their program.”

As rural pharmacies close across the country, and the importance of prescription drug management continues to rise, Roberts says telepharmacy can fill gaps in continuity of care.

Related article: FCC considers $100 million for rural telehealth program

“Transitions of care are such a big problem for the U.S. When a patient gets out of the hospital, information stops. If they have to pick up medications at the pharmacy, 40% of patients who leave the hospital either have a wrong prescription or they never pick up their medications,” Roberts says. “That 40% causes readmissions, it causes people to get sicker. We really like the impact that we can have by following patients out of the four walls of the hospital and allowing for the data streams to continue to follow them.”

The nationwide network developed through telepharmacy also allows for better tracking of medication abuse and misuse, Roberts says.

“Our data analytics and our pharmacists identify those that have a history of drug abuse or have been identified as a person who could be of high risk,” Roberts says. “We have access to see patient records across multiple settings and multiple hospitals. So, we can actually identify those who have gone to different hospitals trying to get opiates or other drugs.”

Donna Marbury is a writer in Columbus, Ohio.

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How to Code for Telehealth, Audio-Only, and Virtual-Digital Visits

Learn how to accurately get paid for telemedicine services with medical codes for telehealth, audio-only, and virtual-digital visits.

Looking for additional telemedicine coding resources?

Coding for Telehealth Visits

Note: These tables are informational, not advisory. The AAFP recommends that physicians verify each payer's policy and ask patients to verify their coverage ahead of appointments.

How do I code a new or established patient telehealth office visit that uses audio-video communications technology?

* Elevance's  policies vary by state; contact your provider-relations representative.

Coding for Audio-only Visits

How do i code an audio-only visit for a new or established patient .

CPT Codes: 99441-99443

Audio-only scenario notes

Medicare requires audio-video for most office visit evaluation and management (E/M) services (CPT codes 99202-99215) telehealth services. Audio-only encounters are allowed for certain services. Eligible services may be found on the Medicare Telehealth Services list. Medicare allows audio-only telehealth services for office visit E/M services (CPT codes 99202-99215) for the treatment of mental health conditions.

UHC states they will consider payment for eligible audio-only services listed in Appendix P of the CPT book. Eligible services must be reported using either POS 02 or 10 and include the -93 modifier. CPT codes billed with modifier -93 that are not in Appendix P will not be considered for payment.

Private payers vary on covered telehealth services. Check with your provider relations representatives for each payer’s telehealth policy and covered telehealth services.

CMS will cover telephone evaluation and management (E/M) services (CPT codes 99441-99443) through the end of calendar year 2023. Other services that may be provided via audio-only are available on the Medicare Telehealth List.

Telephone E/M services are provided to a patient, parent, or guardian and do not originate from a related E/M service within the previous seven days and do not lead to an E/M service or procedure within the next 24 hours or soonest available appointment.

The following codes may be used by physicians or other qualified health professionals who may report E/M services:

99441: telephone E/M service; 5-10 minutes of medical discussion
99442: telephone E/M service; 11-20 minutes of medical discussion
99443: telephone E/M service, 21-30 minutes of medical discussion

Telephone E/M services should not be reported when the time spent on the telephone is captured in other services reported, such as:

if CPT codes 99421-99423 have been reported by the same physician in the previous seven days for the same problem,
when CPT codes 99339-99340 and 99374-99380 are used for the same call,
during the same month with CPT codes 99487 and 99489, and
when performed during the same service period at CPT codes 99495-99496.
Self-funded plans can develop their own policies and may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state-level. The AAFP recommends reaching out to your provider relations representatives or Medicare Administrative Contractors (MACs) to verify policies.

Coding for Virtual-Digital Visits

How do i code an e-visit (cpt 99421-99423) for an established patient .

CPT Codes: 99421-99423

How do I code a virtual check-in (HCPCS codes G2012 and G2010) for an established patient?

HCPCS Codes: G2012, G2252, G2010

Virtual/Digital Scenario Notes

Patient consent is required and may be obtained either before or at the time of service.
Virtual check-ins and e-visits must technically be initiated by a patient; however, physicians and other providers may need to educate beneficiaries on the availability of the service prior to patient initiation.
There are no POS or modifier requirements for virtual check-ins or e-visits. Use the POS used for typical services.

Virtual Check-in (HCPCS Code G2012, G2252)

These are brief conversations with a physician or other clinician to determine if an in-person visit is necessary.
The communication cannot be related to a medical visit within the previous seven days and cannot lead to medical visit within the next 24 hours (or soonest appointment available).
Physician or other clinician may respond to patient by telephone, audio/video, secure text messaging, email, or patient portal.
HCPCS code G2010 can be used when a captured video or image (store and forward) is sent to the physician. The physician must follow up with the patient within 24 business hours. The consultation must not originate from an evaluation and management (E/M) service provided within the previous seven days or lead to an E/M service within the next 24 hours (or soonest available appointment).

E-Visits (online digital evaluation and management services)

These are non-face-to-face, patient-initiated communications with the physician through an online patient portal. The communications can occur over a seven-day period, and the exchange must be stored permanently.
Cumulative time includes review of the initial inquiry, review of patient records pertinent to the assessment of the patient’s problem, personal interaction with clinical staff focused on the patient’s problem, development of management plans (including generation of prescriptions or ordering of tests), and subsequent communication with the patient. Communication can occur through online, telephone, email, or other digitally supported communication

Physicians and other clinicians who may independently bill Medicare for E/M services can use the following codes:

99421: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
99422: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
99423: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

E-visits should not be billed on the same day the physician reports an office visit E/M service (CPT codes 99202-99205 and 99211-99215) for the same patient. Additionally, e-visits should not be billed when using the following codes for the same communication:

99339-99340
99374-99380
99487 and 99489
99495-99466

Introduction
Article Information

The plots show estimates and 95% CIs from ordinary least squares linear regression models adjusting for daily visit volume, and physician and calendar day fixed effects. N = 67 894 for all outcomes except next-day documentation time (n = 47 297). Estimates and 95% CIs for 100% telemedicine days do not reach statistical significance and exhibit wide variation due to relatively few observations; thus, they were omitted for readability.

a Reference category is zero telemedicine visits.

Data Sharing Statement

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Apathy NC , Zabala G , Gomes K , Spaar P , Krevat SA , Ratwani RM. Telemedicine and In-Person Visit Modality Mix and Electronic Health Record Use in Primary Care. JAMA Netw Open. 2024;7(4):e248060. doi:10.1001/jamanetworkopen.2024.8060

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Telemedicine and In-Person Visit Modality Mix and Electronic Health Record Use in Primary Care

1 National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, DC
2 Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC
3 Department of General Internal Medicine, Georgetown University School of Medicine, Washington, DC

Telemedicine use increased substantially during and after the COVID-19 pandemic 1 and has the potential to provide low-acuity medical services at lower costs. 2 However, telemedicine also levies new costs on clinicians. 3 Telemedicine requires shifting care delivery workflows, as it rarely includes clinical support staff but can involve levels of patient complexity similar to in-person visits. 4 , 5 This may increase administrative and electronic health record (EHR) burden for clinicians and increase cognitive costs as clinicians switch modalities. In a recent study, 6 greater weekly telemedicine visit share was associated with increased EHR time, including after-hours time, mostly spent in documentation. Our study aimed to address 2 gaps: first, whether day-to-day changes in telemedicine share demonstrate a similar association with EHR time; and second, what changes occur in domains of EHR use not examined in previous studies (eg, medical record review, orders).

This cross-sectional study combined visit modality data with EHR active use data capturing time spent by primary care physicians (PCPs) in the Cerner EHR system from December 2021 through June 2023 at MedStar Health, a large multispecialty health system in the mid-Atlantic region. We calculated PCPs’ daily telemedicine share as the percentage of the day’s visits conducted via telemedicine and categorized this variable into 5 levels. Because we used deidentified data, this study was deemed exempt and not human participant research by the Georgetown University–MedStar Health Institutional Review Board; we followed the STROBE reporting guideline.

Telemedicine visits were identified via registration and scheduling records. We analyzed 5 measures of active EHR time for each PCP-day: total EHR time, documentation time, medical record review time, order time, and next-day documentation time (only for PCP-days with a consecutive qualifying PCP-day). We calculated descriptive statistics and ran ordinary least squares linear regression models, adjusting for visit volume and physician and calendar-day fixed effects. These models estimate the marginal within-clinician association between each telemedicine share level and our outcomes relative to zero-telemedicine days while adjusting for common temporal trends. We used R statistical software, version 3.6.3 (R Project for Statistical Computing) (tidyverse, fixest packages) for analyses, using 2-tailed hypothesis tests (α = .05).

The study included 316 PCPs observed across 67 894 PCP-day observations distributed across 5 daily telemedicine share categories (zero daily telemedicine share, 44.7% of all PCP-days; ≤10% share, 17.2%; 11%-25% share, 24.8%; 26%-99% share, 11.1%; and 100% share, 2.2%); mean (SD) overall visit volume, 13.9 (7.2) visits/d ( Table ). All outcomes demonstrated statistically significant differences across telemedicine share levels. The mean (SD) documentation time for PCPs was 71.3 (54.3) minutes on zero-telemedicine days and 87.1 (50.0) minutes on days with up to 10% telemedicine visits. In regression analyses, days with a mix of visit modalities were associated with significantly greater time for EHR, documentation, and medical record review ( Figure ). Compared with zero-telemedicine days, 26% to 99% telemedicine days were associated with 14.8 (95% CI, 7.6-22.0) more minutes of active EHR time (5.6% increase, P < .001), 4.7 (95% CI, 1.2-8.3) additional documentation minutes (6.0% increase, P = .01), and 5.5 (95% CI, 2.8-8.2) additional medical record review minutes (6.2% increase, P < .001). Telemedicine share resulted in a negligible increase in order time and had no association with next-day documentation time ( Figure ).

This cross-sectional study found that, during clinic days with both telemedicine and in-person visits, PCPs had 5.6% to 6.2% more EHR-based work. This work did not spill over into next-day documentation, suggesting that PCPs absorbed added time into their workload on mixed-modality days. However, we found that fully telemedicine days were not associated with EHR-based work, contrary to previous findings. 6 We attribute this difference to the small sample of fully telemedicine PCP-days in our study in comparison with prior work 6 (2.2% vs 16.5% of physician-weeks) as well as higher mean visit volume (13.9 visits/d vs 20 visits/wk) ( Table ). Greater EHR time may be due to increased multitasking during telemedicine visits, as PCPs simultaneously engage with patients and the EHR during telemedicine visits in ways that are not possible in person. This multitasking may feel more efficient and therefore may not register as “burdensome”; further research should explore whether added EHR time associated with mixed-modality days further burdens PCPs. Limitations of our study include our setting of a single health system, lack of information on visit and patient characteristics and on clinicians’ experience with telehealth tools, and lack of clinical outcomes.

Accepted for Publication: January 22, 2024.

Published: April 24, 2024. doi:10.1001/jamanetworkopen.2024.8060

Corresponding Author: Nate C. Apathy, PhD, National Center for Human Factors in Healthcare, MedStar Health Research Institute, 3007 Tilden St NW, Washington, DC 20008 ( [email protected] ).

Author Contributions: Dr Apathy had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Apathy, Gomes, Ratwani.

Acquisition, analysis, or interpretation of data: Apathy, Zabala, Spaar, Krevat.

Drafting of the manuscript: Apathy.

Critical review of the manuscript for important intellectual content: Zabala, Gomes, Spaar, Krevat, Ratwani.

Statistical analysis: Apathy.

Obtained funding: Gomes, Ratwani.

Administrative, technical, or material support: Zabala, Gomes.

Conflict of Interest Disclosures: Dr Apathy reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study; personal fees from the Office of the National Coordinator for Health IT, the American Medical Association, Yale University, and the University of California–San Francisco outside the submitted work. Mr Zabala and Drs Gomes, Krevat, and Ratwani reported receiving grants from AHRQ during the conduct of the study. No other disclosures were reported.

Data Sharing Statement: See the Supplement .

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To pursue reimbursement for telehealth services, or patient “e-visits,” providers have begun billing insurers and patients for interactions through patient portals. However, remote patient care and associated patient portal messages are either rarely billed to Medicare or rarely occur, as these practices make up a very small percentage of services submitted for reimbursement. The findings are published in Health Affairs Scholar . [1] In 2020, e-visits comprised 0.9% of all managed service codes submitted to Medicare at the height of the pandemic, dropping to 0.5% in 2021 and 2022. During that timeframe, only 0.8% of all fee-for-service Medicare beneficiaries were billed for a patient portal message, despite the fact they can stem from both in-person and virtual visits.

The study shows telehealth still remains underutilized, and its findings can “help alleviate concerns regarding the potential overuse of portal message and e-visit billing," the study authors, led by Terrence Liu, MD , of Sutter Health , wrote. However, the research is incomplete, as the authors lacked access to numbers reflecting the total number of e-visits or messages sent through patient portals, many of which may not have been billed or recorded.

Details on patient communications may not have been recorded because of disparate or inadequate technology at provider practices, combined with relaxed regulation during the pandemic that allowed for consumer-level tools to be used to interact with patients.

Perhaps unsurprisingly, of patient messages billed to Medicare, nearly a third required significant provider time to read or respond to—upwards of 21 minutes. Primary care providers were the most likely to charge a patient for messages, as they comprise more than half of all telehealth and e-visits.

While patients leveraged e-visits for a variety of reasons—especially when in-person visits were challenged by the pandemic—hypertension was the number one patient diagnosis, recorded at 21% of all care incidents. Diabetes and COVID-19 were distant seconds at around 2% of diagnoses each.

The full study findings are available at the link below.

Cardiologist salary update: compensation jumps to $525k per year, no. 3 among all specialties, physician plaintiff: ‘i shouldn’t have to risk losing my license—or getting jail time’ over telehealth visits, hims & hers, hartford healthcare partner for in-person care access, amazon expands telehealth presence, offers primary care for $9 a month, telehealth helps health system manage dramatic rise in patient referrals.

1. Liu, T., Zhu, Z.., Holmgren, J., et al. (April 3, 2024) “National Trends in Billing Patient Portal Messages as E-Visit Services in Traditional Medicare.” Health Affairs Scholar .

Chad Van Alstin Health Imaging Health Exec

Chad is an award-winning writer and editor with over 15 years of experience working in media. He has a decade-long professional background in healthcare, working as a writer and in public relations.