The meteoric upsurge in adoption of telemedicine due to the pandemic, and an increasing demand for patient convenience, has rendered telemedicine a useful and necessary adjunct for practicing medicine and delivering care in the 21^st century. Its accessibility and effectiveness are reason enough for providers to embrace it in order to supplement in-person visits and consultations. However, certain economic barriers, government regulations, malpractice risks, lack of propitious reimbursement models, individual resistance to change in care-delivery and organizational processes, etc., are some of the challenges faced while employing this technology and oftentimes deter physicians from trying it at all.

These barriers are discussed as follows:

Credentialing and Physician Licensing

Practitioners who wish to provide consultations and other clinical services beyond immediate geographical state borders and expand their patient pool must meet certain licensure standards and comply to regulations that may vary considerably from state to state. In some cases, physicians might require a full medical license in the state they operate in as well as the state where the patient resides, and might have to disburse an extortionate fee to continue cross-state practice. The requisite to uphold multi-state license and the mandatory adherence to regulatory policies for practicing telemedicine across state lines can sometimes subdue the convenience of telemedicine. But the inter-state licensing indenture, formulated by the Federation of State Medical Boards, allows ease of portability of licensure for physicians and physician assistants. This indenture does not, however, apply to nurse practitioners (NPs) who are licensed under State Boards of Nursing. But since some requirements have provisionally changed because of Covid19, NPs should check with their respective Nursing Board for updated information about regulations regarding telemedicine practice.

In addition, the time and costs to process telemedicine credentialing can get tremendous and complicated. Some even suggest that the monetary resources required to approve physician credentials for practicing telemedicine could instead be used to train practice staff and onboard patients.

Misdiagnosis and Malpractice Risks

Applying current principles of malpractice risks to telemedicine does not suffice because existing policies, regarding informed consent, practice standards, provision of liability insurance coverage, etc., may not include telemedicine in the scope of coverage, particularly while providing cross-state services.

Moreover, inadequate understanding and disruption of service during failure of technological systems, poor Internet bandwidth and remote monitoring devices, ineffective patient-provider communication, etc., are some of the challenges that can potentially compromise the accuracy and reliability of the collection of patient data and consequently lead to misdiagnosis, incorrect interventions and malpractice. Practitioners can fairly hedge the forestated data inaccuracies by maintaining certain standards and acceptable formats while sharing medical images and associated clinical information. One such standard is regulated by the Digital Imaging and Communications in Medicine format, which standardizes format quality for medical images and data required for clinical use and interpretation.

Lack of Reimbursement Models

Another major obstacle to the widespread adoption of telemedicine is insufficient capital expenditure and reimbursements from Medicare, several state Medicaid programs, and commercial insurance plans. When reimbursement is limited, patients in the affected regions are under-served. Like licensing laws, reimbursement models vary considerably across states. Practitioners need to be aware of the most up-to-date policies and laws and meet certain criteria in order to receive reimbursement. Unlike Medicare, Medicaid programs are subject to state telehealth laws and the reimbursement from services, such as real-time video consultation, remote patient monitoring, etc., is largely dependent on individual state policies and Medicaid coverage.

To counteract these complications, expand coverage and improve reimbursements, The Bipartisan Budget Act was signed into law by then President in 2018, in addition to the Centers of Medicare and Medicaid’s decision to include the coverage of remote patient monitoring for patients with chronic conditions and those whose morbidity could be reduced by timely interventions.

Internal Resistance to Change in Clinical Processes

Human factors that can potentially hinder the widespread adoption and implementation of telemedicine are the resistance to change based on existing opinions about telemedicine, lack of the level of individual competence and skills required in the information field to carry the practice of telemedicine confidently, added workload, etc. These subjective disinclinations can be alleviated by providing incentives and proper training.

Provider Patient Encounters; Privacy and Confidentiality

Telemedicine encounters are generally less effective compared to in-person visits. Therefore, some states require physical evaluation or, depending upon morbidities and patient condition, at least one face-to-face episode of care before physicians make prescription using telemedicine. Some state policies even restrict providing services on controversial medical procedures, like medication-induced abortions, through telemedicine.

Aside from being less effective, telemedicine encounters are also more vulnerable to security risks. This aspect greatly hinders the adoption and implementation of telemedicine. Although most platforms are adequately encrypted and pursuant with HIPAA, but are still not 100% immune to cyber-attacks and data breaches. Providers must use systems that comply with state and federal laws, such as HIPAA, the Health Information Technology for Economic and Clinical Health, and the Children’s Online Privacy Protection Act protect medical, that offer protection for health information that is collected by all covered entities.

In addition to complying with legal regulations, it is important for providers to be cognizant of and observe the “telemedicine etiquette” when working from home or performing E-visits at their practice location.