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Telehealth is the delivery of health-related services and information via telecommunications technologies. Telehealth could be as simple as two health professionals discussing a case over the telephone or as sophisticated as doing robotic surgery between facilities at different ends of the globe.
Telehealth is an expansion of telemedicine, and unlike telemedicine (which more narrowly focuses on the curative aspect) it encompasses preventative, promotive and curative aspects. Originally used to describe administrative or educational functions related to telemedicine, today telehealth stresses myriad technology solutions. For example, physicians use email to communicate with patients, order drug prescriptions and provide other health services. One of the most significant increases in telehealth usage is the home monitoring of conditions by patients whose clinical trials in the UK have shown to improve mortality by around 47%, however the case for telehealth is still being actively debated, with a study on a separate US project showed remote telemonitoring was associated with increased mortality in vulnerable patients.
- 1 Clinical uses
- 2 Nonclinical uses
- 3 Modes
- 4 Benefits
- 5 Criticism
- 6 Reimbursement for Telehealth in the United States
- 7 The state of the market
- 8 See also
- 9 References
- 10 Further reading
- 11 External links
- Transmission of medical images for diagnosis (often referred to as store and forward telehealth)
- Teleconference between patient and healthcare provider for assessments and history taking
- Groups or individuals exchanging health services or education live via videoconference (real-time telehealth)
- Transmission of medical data for diagnosis or disease management (sometimes referred to as remote monitoring)
- Advice on prevention of diseases and promotion of good health by patient monitoring and followup.
- Health advice by telephone in emergent cases (referred to as teletriage)
- Distance education including continuing medical education, grand rounds, and patient education
- administrative uses including meetings among telehealth networks, supervision, and presentations
- research on telehealth
- online information and health data management
- healthcare system integration
- asset identification, listing, and patient to asset matching, and movement
- overall healthcare system management
- patient movement and remote admission
In store-and-forward telehealth, digital images, video, audio, observations of daily living (ODLs), and clinical data are captured and "stored" on the client computer or mobile device; then at a convenient time they are transmitted securely ("forwarded") to a clinic at another location where they are studied by relevant specialists. The opinion of the specialist is then transmitted back. Based on the requirements of the participating healthcare entities, this roundtrip could take between 1 minute to 48 hours. In the simplest form of telehealth application, basic vital signs like blood pressure, weight, pulse oximeter, and blood sugar values are monitored and trended for long term chronic care. In many specialties, such as dermatology, radiology and pathology, an immediate response is not critical, making these specialties conducive to store-and-forward technologies. Automated screening and diagnostic tele-audiology is fast becoming another specialty conducive to store-and-forward audiology.
In real-time telehealth, a telecommunications link allows instantaneous interaction. Videoconferencing equipment is one of the most common forms of real-time (or "synchronous") telemedicine. Peripheral devices can also be attached to computers or the video-conferencing equipment which can aid in an interactive examination. With the availability of better and cheaper communication channels, direct two-way audio and video streaming between centers through computers is leading to lower costs.
Examples of real-time clinical telehealth include:
- Telebehavioral Health—includes telepsychiatry
Remote patient monitoring
In remote monitoring, the patient has a central system that feeds information from sensors and monitoring equipment, e.g. blood pressure monitors and blood glucose meters, to an external monitoring center. This could be done in either real time or the data could be stored and then forwarded. 
Examples of remote monitoring include:
- Home-based nocturnal dialysis
- Cardiac and multi-parameter monitoring of remote ICUs
- Disease management including COPD, Chronic Heart Failure, Diabetes, Coagulation, Arthritis, Depression, Obesity
Telehealth also provides opportunities for health care professionals in remote locations to receive training. In the United States, the Extension for Community Healthcare Outcomes or ECHO project uses a telehealth platform to help urban medical center specialists train primary care doctors in rural settings. The training allows these general practitioners to provide specialty care, especially chronic condition services, that would otherwise be unavailable to patients in these areas.
Electronic consultation (E-Consult), a TeleHealth modality, is a mechanism that enables primary care providers (PCPs) to obtain specialists' inputs into a patient's care treatment without requiring a patient to go in for a face-to-face visit.
Telehealth adds a new paradigm in healthcare, where the patient is monitored between physician office visits. This has been shown to significantly reduce hospitalizations and visits to the Emergency Room, while improving patient's quality of life. Telehealth also benefits patients where traditional delivery of health services are affected by distance and lack of local specialist clinicians to deliver services. In 2003, the University of Arkansas for Medical Sciences implemented a telehealth program to enhance access to care for high-risk pregnant women living in rural areas. The Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS) program provides real-time telehealth consultation among patients, their local physicians, and medical center specialists through a statewide telemedicine network. The program has reduced the state's 60-day infant mortality rate by 0.5 percent by increasing the number of low birthweight infants delivered at a medical center. In Alaska, the Alaska Federal Health Care Access Network (AFHCAN) connects approximately 180 Alaska Native community village clinics, 25 subregional clinics, 4 multiphysician health centers, 6 regional hospitals, and the Alaska Native Medical Centerin Anchorage. More than 3,000 providers have engaged in 160,000 telehealth clinical consultations since 2001. It is estimated that in 2012, the AFHCAN telehealth program saved the state of Alaska $8.5 million in travel costs for Medicaid patients alone.
The UK's Department of Health's Whole System Demonstrator (WSD) launched in May 2008. It is the largest randomised control trial of telehealth and telecare in the world, involving 6191 patients and 238 GP practices across three sites, Newham, Kent and Cornwall. Three thousand and thirty people with one of three conditions (Diabetes, Chronic Heart Failure and COPD) were included in the telehealth trial. The trials were evaluated by: City University London, University of Oxford, University of Manchester, Nuffield Trust, Imperial College London and London School of Economics.
- 45% reduction in mortality rates
- 20% reduction in emergency admissions
- 15% reduction in A&E visits
- 14% reduction in elective admissions
- 14% reduction in bed days
- 8% reduction in tariff costs
Another UK trial of telehealth, this time for patients suffering from infertility, demonstrated a reduction in the cost of care of approximately 95%. The remote patient monitoring product and service used cost $800 per patient, compared to $15,000 as the average cost of a cycle of in-vitro fertilization (IVF), and showed (for suitably selected patients) the same pregnancy rate.
The rate of adoption of telehealth services in any jurisdiction is frequently influenced by factors such as the adequacy and cost of existing conventional health services in meeting patient needs; the policies of governments and/or insurers with respect to coverage and payment for telehealth services; and medical licensing requirements that may inhibit or deter the provision of telehealth second opinions or primary consultations by physicians.
There may also be some significant carbon reductions for the NHS to be gained from developing Telehealth and therefore reducing the need to travel (often, in the case of patients, by car) as well as encouraging healthy, sustainable behaviour through monitoring and improved communications and reducing the requirements to expand sites to meet increases in Healthcare demands.
In Australia, during January 2014, Melbourne tech startup Small World Social collaborated with the Australian Breastfeeding Association to create the first hands-free breastfeeding Google Glass application for new mothers. The application, named Google Glass Breastfeeding app trial, allows mothers to nurse their baby while viewing instructions about common breastfeeding issues (latching on, posture etc.) or call a lactation consultant via a secure Google Hangout, who can view the issue through the mother's Google Glass camera. The trial was successfully concluded in Melbourne in April 2014, and 100% of participants were breastfeeding confidently. Small World Social Breasfteeding Support Project
Although several studies have demonstrated a positive impact from the use of telehealth and remote patient monitoring, there are dissenting studies.
A US study of 205 elderly patients with a high risk of hospitalisation showed a significant increase in the mortality rate over 12 months, with rates over 12 months for the telemonitoring group at 14.7%, compared with 3.9% for the usual care group (Source: Arch Intern Med 2012, online 16 April, and Pulse, April 20, 2012 - Telemedicine trebles death rate in elderly patients).
As a result, there is controversy in the UK regarding the government's determination to proceed with Telehealth despite conflicting findings from the studies undertaken.
Reimbursement for Telehealth in the United States
Reimbursement by Medicare
Reimbursement for Medicare-covered services must satisfy federal requirements of efficiency, economy and quality of care. Since 1999, Medicare and Medicaid reimbursement for all kinds of telehealth services have expanded, requirements of providers have been reduced, and grants have been given to support telehealth program adoption.
For 2014, the Center for Medicare Services (CMS) does cover telemedicine services as long as the services fall into either Category 1 or Category 2. As of now, these categories are defined as such:
- Category 1: Services that are similar to professional consultations, office visits, and office psychiatry services that are currently on the list of telehealth services. The request is evaluated based on the similarities between the services already eligible for reimbursement, and that of the requested service.
- Category 2: Services that are not similar to the current list of telehealth services. The assessment will be based on whether the service is accurately described by the corresponding code when delivered via telehealth, and whether the use of a
telecommunications system to deliver the services produces a demonstrated clinical benefit to the patient. Supporting documentation should be included.
Medicare Telehealth Coverage Areas
There are several conditions to Medicare telehealth coverage. The first being that the consumer, or individual receiving telehealth services must be physically located in an "originating site" that is eligible for Medicare coverage.
State specific Medicare Reimbursement
States have the option/flexibility to determine whether or not to cover telemedicine under the Medicaid assistance program. They may also decide:
- What types of telemedicine to cover
- Where telemedicine will be covered throughout the state
- How telemedicine services are to be covered/reimbursed
- What types of providers/practitioners can be covered/reimbursed
- How much to reimburse for telemedicine services (as long as payments do not exceed Federal Upper Limits)
Individual states are encouraged to use flexibility granted by federal law to create payment methodologies that incorporate telemedicine technology. For example, sates can reimburse the practitioner at the distant site an reimburse a facility fee to the originating site. States can also reimburse support costs like technical support, transmissions charges, and equipment. Add-on costs like those can be incorporated into the fee-for services rate or separately reimbursed as an administrative cost by the state.
If a state decides to cover telemedicine, but not to cover certain areas or certain practitioners, then the state must be responsible for assuring access and covering face to face visits by recognized providers in those parts of the state where telemedicine is not available.
Reimbursement by Private Payor
Currently, 21 States have a previously enacted Legislated Mandate for Private Coverage:
The state of the market
Projections for the growth of the telehealth market are optimistic, and much of this optimism is predicated upon the increasing demand for remote medical care. According to a recent survey, nearly three-quarters of U.S. consumers say they would use telehealth. At present, several major companies along with a bevy of startups are working to develop a leading presence in the field.
In the UK, the Government's Care Services minister, Paul Burstow, has stated that telehealth and telecare would be extended over the next five years (2012–2017) to reach three million people.
- Ontario Telemedicine Network
- List of video telecommunication services and product brands
- American Telemedicine Association
- National Rural Health Association
- Connected Health
- Remote therapy
- Health in Everyday Living Robert Wood Johnson Foundation primer.
- Vavilis, S., Petković, M., & Zannone, N. (2012). Impact of ICT on home healthcare . In ICT Critical Infrastructures and Society (pp. 111-122). Springer Berlin Heidelberg.
- Andreas Pierratos, MD. Nocturnal hemodialysis: dialysis for the new millennium Canadian Medical Association Journal, November 2, 1999; 161 (9), 2 November 1966.
- "Focusing on Priority Populations: An Interview With Cecilia Rivera Casale, Senior Advisor for Minority Health, AHRQ". Agency for Healthcare Research and Quality. 2013-04-017. Retrieved 2013-08-27. Check date values in:
- Overview for Healthcare Professionals, L.A. Care Health Plan. (2012).
- "Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Areas". Agency for Healthcare Research and Quality. 2013-05-08. Retrieved 2013-05-10.
- "Telehealth Improves Access and Quality of Care for Alaska Natives". Agency for Healthcare Research and Quality. 2013-05-22. Retrieved 2013-05-22.
- "Whole Systems Demonstrators An Overview of Telecare and Telehealth". 2009-06-11.
- Chausiaux, O., Hayes, J., Long, C., Morris, S., Williams, G. and Husheer, S. 2011. Pregnancy Prognosis in Infertile Couples on the DuoFertility Programme Compared with In Vitro Fertilisation/Intracytoplasmic Sperm Injection. European Obstetrics & Gynaecology, 2011;6(2):92-4.
- "http://www.inquisitr.com/1224638/google-glass-connects-breastfeeding-moms-with-lactation-help/". Inquisitr. Inquisitr. Retrieved 12 June 2014.
- "Exclusive Clips Google glasses help breastfeeding mums". Jumpin Today Show. Mi9 Pty. Ltd. Retrieved 12 June 2014.
- "Breastfeeding mothers get help from Google Glass and Small World". The Sydney Morning Herald.
- "Turns Out Google Glass Is Good for Breastfeeding". Motherboard Vice Media Inc. 21 April 2014. Retrieved 1 May 2014.
- "Survey: Consumers Keen on Telemedicine". Retrieved 2010-04-26.
- UK Department of Health Whole System Demonstrator Programme - Headline Findings December 2011 Results from clinical trial carried out by the UK Government's Department of Health
- Telemedicine,Telehealth, and the Consumer Online introduction and primer to telehealth and telemedicine from the Telemedicine Information Exchange
- Norris, A. C. (2002). Essentials of Telemedicine and Telecare. West Sussex, England; New York: John Wiley & Sons, Ltd. ISBN 0-471-53151-0.
- Maheu, Marlene M.; Whitten, Pamela; & Allen, Ace (2001). E-Health, Telehealth, and Telemedicine: A Guide to Start-up and Success. San Francisco: Jossey Bass. ISBN 0-7879-4420-3.
- Olmeda, Christopher J. (2000). Information Technology in Systems of Care. Delfin Press. ISBN 978-0-9821442-0-6
- Telehealth Technical Assistance Manual - A document to assist in the planning of telehealth and telemedicine projects for rural community and migrant health centers and other health care organizations. By Samuel G. Burgess, Ph.D. October 2006
- Teleneurology and requirements of the european Medical Devices Directive (MDD) - Telemedical Systems and regulatory affairs for Europe, by Dipl. Ing. Armin Gärtner
- Barriers to Telemedicine: Survey of Current Users in Acute Care Units
- 2013. Gilman, M., & Stensland, J. Telehealth and Medicare: Payment Policy, Current Use, and Prospects for Growth.
- Norwegian Centre for Integrated Care and Telemedicine
- Office for the Advancement of Telehealth (established by the Health Resources and Services Administration)
2013. Gilman, M., & Stensland, J. Telehealth and Medicare: Payment Policy, Current Use, and Prospects for Growth. CMS HRSA NCSL