Licensure: A key barrier to telehealth access has been the prohibition of physicians from practicing in states in which they are unlicensed, thus preventing a doctor in one state from treating a patient in another state with telehealth technologies. The Federation of State Medical Boards created the Interstate Medical Licensure Compact to facilitate multistate physician licensing and 21 states have joined with support from their state legislatures.6 “Research is needed to better understand the relationship between facilitating interstate licensure and quality-of-care outcomes to protect against any adverse consequences,” the authors of the present report wrote.

Liability: According to the Physician Insurers Association of America, liability carriers typically consider each telehealth provider on a case-by-case basis, based on factors such as practice specialty and volume of telehealth services. Following reimbursement limitations, Dr Lipoff notes that liability and state licensure issues are the 2 main barriers in telehealth. Further evidence is needed to clarify any differences between quality and safety risks associated with telehealth services compared with in-person care.

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Human factors: Pointing to lessons learned from electronic health record (EHR) implementation, the authors emphasize that user-centered “design that facilitates the integration of telehealth into workflows and clinical routines is essential, especially with respect to remote physical examination.” Usability for telehealth consumers is equally important, and ease of use for both providers and consumers should be considered in future research.

Device interoperability and data integration: Although data from telehealth clinical tools, such as remote monitoring devices and apps, should ideally be well integrated into EHRs, this is not yet the standard. Professional groups including the American Telemedicine Association have called for EHRs to begin incorporating these data, and research to inform these endeavors is essential.

Privacy and security: The anticipated increase in data integration will necessitate even more stringent privacy and security measures, and standardized state and federal guidelines for these efforts will be needed. “It has also been suggested that a comprehensive regulatory framework enforced by a single federal entity will be required to increase and maintain patient and provider trust and to fully realize the benefits of telehealth.” Studies to guide these endeavors should be a priority, according to the authors.

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Performance measurement: Metrics regarding the cost-effectiveness and quality of telehealth services is an important consideration for users, investors, and policymakers. The Telehealth Framework to Support Measure Development is currently underway; the 1-year project aims to elucidate telehealth metrics and establish priorities and principles for telehealth measurement.7 The authors of the report note that, “performance measurement requires an evidence basis and is a critical priority that must be addressed.”

Patient engagement and the evolving patient-physician relationship: As consumers, aided by telehealth delivery and devices, become more involved in the management of their own health care, the patient-physician relationship will inevitably change. For example, providers will be charged with guiding patients in the use of these tools, and evidence-based data are necessary to facilitate these actions.

“Clinicians deserve access to a more complete body of evidence on telehealth care as they make important decisions with, and on behalf of, their patients,” the authors concluded.


  1. US Department of Health and Human Services. Report to Congress: E-health and telemedicine. Published August 12, 2016. Accessed January 15, 2018.
  2. Health policy brief: telehealth parity laws. Health Affairs. Published August 15, 2016. Accessed January 15, 2018.
  3. Totten AM, Womack DM, Eden KB, et al. Telehealth: mapping the evidence for patient outcomes from systematic reviews. Technical Brief No. 26. Rockville, Maryland: Agency for Healthcare Research and Quality. Accessed January 15, 2018.
  4. Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-1592.
  5. American Medical Association. Ethical practice in telemedicine. Accessed January 15, 2018.
  6. Federation of State Medical Boards. Understanding the Medical Licensure Compact. Accessed January 15, 2018.
  7. Telehealth framework to support measure development 2016–2017. National Quality Forum. Accessed January 15, 2018.