Career resources content posted on NEJM CareerCenter is produced by freelance health care writers as an advertising service of NEJM Group, a division of the Massachusetts Medical Society and should not be construed as coming from, or representing the views of, the New England Journal of Medicine, NEJM Group, or the Massachusetts Medical Society

New applications of telemedicine have enabled rural practicing physicians to manage a wide range of acutely ill patients, improve accessibility to specialists, and reduce barriers to care in underserved regions. With advances in technology, plummeting costs, and governmental health care system partnerships, telemedicine is now used by more than half of U.S. hospitals and has reduced rural practice isolation. Be sure that health plan and hospital credentialing, privileging, licensure, and malpractice issues are addressed before practicing telemedicine.

– John A. Fromson, MD*

As telemedicine sites and networks grow, so do novel practice opportunities for physicians in both rural and urban areas

Physicians in many specialties are discovering new avenues for using telemedicine to expand their practice, reach new patients, and potentially improve the care of patients who historically have had poor access to medical services — especially specialty services. The trend of using electronic communication and incorporating sophisticated technology (i.e., connecting physicians and patients, or physicians and their colleagues practicing in a distant location) is proving beneficial for both rural- and urban-based physicians.

By Bonnie Darves

The time-honored image of the country physician toiling into the twilight, taking care of a sick patient in a rustic two-room office, and then trekking 10 miles to the hospital to check in on a seriously ill patient still finds a footing in reality these days. And rural practice still holds a perennial appeal for physicians who want that particular combination of relative autonomy and a broad practice scope in a small-town environment.

At the same time, increased use of telemedicine, which has been formally defined as the use of electronic communication to transmit medical information from one site to another in the delivery of clinical services, and health information technology (HIT) advances is rapidly changing the practice of rural medicine. Physicians who want to balance their medical practice life with operating a 10-acre apple orchard or being able to backpack into a nearby remote wilderness on their rare weekend off, can create such a blended life more successfully, without forgoing the specialty support network they developed during training.

The proximity of specialists and services via teleconferencing, as well as the expanding network of telemedicine sites, connect rural clinics and care settings to academic centers or health systems, which benefits physicians in both rural and urban settings. Telemedicine allows rural primary care physicians (PCPs) to potentially expand their scope of practice by obtaining specialty consults in real time. Telemedicine also potentially enables urban-based specialists to expand their patient base by caring for patients in rural or underserved areas.

James Paul Marcin, MD, MPH, a pediatric critical care physician in Davis, California, cites a recent case that illustrates the reach of telemedicine: A very sick child with severely swollen glands showed up in a rural hospital emergency department (ED), and the covering PCP was uncomfortable handling the situation on his own. “We hooked up the ED physician with one of our pediatric infectious disease experts at University of California-Davis (UC-Davis) Children’s Hospital, who was able to view the child, speak to the parents about possible exposure, and then recommend an appropriate antibiotic,” said Dr. Marcin, director of pediatric telemedicine at the UC-Davis Center for Health and Technology. This exchange enabled the child to be treated at the local hospital rather than being transported to a tertiary center.

In another case, when a child developed potentially life-threatening diabetic ketoacidosis, having the specialist available via telemedicine consult enabled the rural ED physician to safely manage the crisis — one in which time to treatment was a critical factor. “We’ve also helped manage trauma cases in which patients weren’t stable enough for transport, and had good outcomes with those cases,” Dr. Marcin said. “Many of our specialists find it exciting to be able to care for remote patients using videoconferencing, and I personally appreciate the fact that we can touch more lives, and even save lives using telemedicine.”

The Center for Health and Technology at UC-Davis, among the nation’s largest telemedicine operations, is helping to reduce barriers to care in underserved regions of the state. A network that enables connections between rural emergency departments and the university’s specialists — in critical care, dermatology, endocrinology and pediatric audiology, among other areas — is helping rural primary care physicians better care for complex patients or treat challenging conditions more effectively.

Expanding Care to Underserved Patients
Psychiatry, one of the earliest applications of telemedicine, is also one of the fastest growing areas today. For one thing, the national shortage of mental health professionals means that many rural or remote areas have no psychiatry or behavioral health services at all. In addition, two-way videoconferencing technology is, if not ideal, at least an acceptable means of delivering care to patients who have difficulty accessing mental health services.

Terry Rabinowitz, MD, a psychiatrist at Fletcher Allen Healthcare in Burlington, Vermont, was drawn to telemedicine practice for precisely that reason: to help individuals who cannot travel to services. For example, Dr. Rabinowitz, clinical director of telemedicine at Fletcher Allen, affiliated with the University of Vermont, has developed a special practice focus serving nursing home patients.

“It’s very gratifying to care for these patients, because rural nursing-home residents are a truly underserved population,” Dr. Rabinowitz said. He spends a half-day every other week treating these patients for common conditions such as depression and cognitive impairment, to mild schizophrenia. “One of the best things I have discovered in this work is that older patients actually love this [telemedicine] modality, and they’re very appreciative of the fact that it enables them to receive the services,” Dr. Rabinowitz said. “I’ve never encountered a patient who was reluctant to try it.”

For residents who are training in psychiatry, or for practicing psychiatrists seeking a change of pace, telemedicine offers many potential practice opportunities. “The resident who is coming out of fellowship who wants to live in a rural area but whose patient base is in the city, could set up the equipment and still treat those patients,” Dr. Rabinowitz said, or develop an additional patient base in the rural area. Likewise, a young physician who wants to spend more time at home with a new child could practice “telemedically” part time.

“There are lots of ways that young physicians, in psychiatry and in many other specialties, could use telemedicine to their advantage — especially to deliver care to patients who might not be able to access care otherwise,” he said.

Telehealth Extending Reach of Specialty Services
Another rapidly growing telemedicine practice area is specialist-driven “telestroke” services, which are proving invaluable to rural-practicing physicians who must manage stroke patients when they present to the emergency department. In the wake of new guidelines issued early this year by the American Heart and Stroke Association, which call for greater use of telemedicine to support regional networks of stroke centers and community hospitals, many health systems are expanding stroke services to position neurologists devoted primarily to performing telestroke consultation.

Karen Rheuban, MD, medical director of the Office of Telemedicine at the University of Virginia, cites telestroke services as a key area where telemedicine can make a major difference in outcomes. “For the rural patient who has had a stroke, arranging transport can take several hours, when ‘time is brain,’ ” Dr. Rheuban, a pediatric cardiologist, explained. “Many small emergency departments are staffed by family practice physicians who might not be comfortable administering thrombolytic agents such as tPA (tissue plasminogen activator).”

That could mean, for transported patients, that by the time they receive care in a larger facility, they might be outside the therapeutic window for the drug. The availability of the university’s telestroke program has increased the rate of tPA administration from zero to more than 17 percent of stroke patients evaluated in rural hospitals, Dr. Rheuban notes.

The UVA Health System also provides telemedicine services in psychiatry, high-risk obstetrics, ophthalmology, endocrinology, hepatology, gastroenterology, and pediatric cardiology and other subspecialties, among other areas, and is constantly expanding its services and its geographic reach. The health system’s telemedicine network now encompasses 108 sites.

“Telemedicine allows practitioners almost anywhere in the state to access many of the specialty care services they might have had if they practiced in an academic setting,” Dr. Rheuban said. “In many cases, telemedicine enables patients to stay within their local community or hospital setting without having to travel. And it provides an opportunity for our university physicians to serve patients who might not be able to receive treatment otherwise.”

That’s a boon not only to patients but also to local hospitals and physicians who, with the help of telemedicine-enabled specialty services, may be able to manage a broader range of acutely ill or complex patients than they could in the past, Dr. Rheuban explained. She cites the examples of two university’s other telemedicine services, high-risk obstetrics management, which has significantly reduced pre-term births in rural patients, and teleophthalmology. In the latter case, ophthalmologists at the academic center teleconference with rural primary care physicians to perform retina examinations in diabetes patients using telemedicine technology.

“There are applications for telemedicine in most of the medical specialties, and I think we will see continued innovation and developments in the next several years, in bringing more specialty services to the community level,” Dr. Rheuban predicted, especially as health care organizations and states work collaboratively to reduce care disparities.

Telemedicine’s Continuing Evolution
Although telemedicine as a mode of care delivery isn’t new — it has been around in some form for nearly 40 years — it has grown rapidly over the last decade, in part because of technology advances, especially in the area of HIT. Telemedicine is now used in more than half of U.S. hospitals, primarily to extend specialty care services to remote or underserved areas, and a growing number of federally qualified health centers are incorporating telemedicine capabilities. The federal Office for the Advancement of Telehealth (OAT) reports that more than 200 telemedicine networks are now operating, and that the number of U.S. telemedicine service sites recently topped 3,500.

Several factors have contributed to the growth spurt, according to Sherilyn Pruitt, MPH, director of OAT. “During the past decade, technology advances have affected the way the entire health care system operates, including telemedicine. Telecommunications technology costs have decreased substantially compared to a decade ago, which has increased adoption and use of telemedicine by rural-practicing physicians,” Ms. Pruitt explained. Physician access to telemedicine and HIT have also improved the financial aspects of rural practice, Ms. Pruitt notes, while simultaneously reducing geographical barriers to care. In most cases, telemedicine services are underwritten or supported by large health care organizations, such as academic medical centers or integrated health systems, frequently in concert with federal or state government entities.

The government is doing its part to make telemedicine more feasible economically for both rural physicians and the “hubs” to which they connect. The Office of Rural Health Policy supports community based programs that include grants to rural communities that focus specifically on HIT and workforce development — the Rural Health Information Technology Network Development and the Rural Health Workforce Development grant programs. In addition, the Rural Health Care Services Outreach grant program supports networks that provide services to rural communities via telehealth technologies. These resources are helping rural physicians and communities expand their telemedicine and telehealth capabilities to serve a broader range of patients, particularly those in remote areas. (See Resources sidebar.)

In addition, reimbursement for telemedicine services has been improving. Medicare has approved payment for an increasing range of telemedicine-delivered services provided the care meets its criteria, and in recent years several commercial insurers have developed payment structures for physicians and other providers who deliver care using telemedicine. A handful of states, including New Mexico, Nevada, Oklahoma, Oregon, Texas, Virginia, and Vermont, have legislatively mandated commercial coverage for telemedicine services, and several others have proposed similar legislation, according to a recent update from the American Telemedicine Association in Washington, D.C.

The Patient Protection and Affordable Care Act (ACA) is expected to further boost telemedicine usage as more Americans obtain coverage and certain provisions, including one that calls for use of telehealth to improve treatment for chronic conditions. In addition, nearly a dozen physician specialty societies have developed telemedicine practice guidelines to date, and several others are in the process of creating such guidance.

Reducing Rural Practice Isolation
Wilbur Hitt, MD, an Arkansas obstetrician-gynecologist, has experienced the benefits of telemedicine and the challenges of rural practice first-hand — as both a recipient and, later, of telemedicine specialty consults.

Just after completing his training, he set up practice in the remote city of Hot Springs, more than an hour from the state’s capital of Little Rock. “I loved living in Hot Springs but practicing there had its challenges. I was so busy that I had little time to interact with colleagues about interesting cases, so I found myself on the phone a fair amount with my former professors when challenging situations came up,” Dr. Hitt said.

A few years into his practice, Dr. Hitt started operating a telemedicine site at his practice, which enabled him to consult with specialists at the University of Arkansas for the Medical Sciences. “I thought there would be an impersonal nature to the interaction, but I found out pretty quickly that wasn’t the case,” he said. Patients appreciated not having to travel an hour or more for an appointment, and they were highly receptive to the technology. “With a bit of extra training, our ultrasound technicians we were able to send high-definition video, and we were get an immediate read and consult with the maternal-fetal medicine physician,” Dr. Hitt said.

Now director of the general OB/GYN division at the University of Arkansas for the Medical Sciences, Dr. Hitt finds himself at the other end of the spectrum — providing telemedicine gynecology consults and real-time to rural physicians who are dealing with potentially complex cases. Today, UAMS operates a robust telemedicine in OB-GYN as well as many other specialties.

Dr. Hitt and his colleagues, for example, provide remote colposcopy interpretation in real time provide remote colposcopy interpretation in real time to rural-practicing primary care clinicians at 10 sites throughout the state. “We were able to extend our reach and give those providers more confidence. Putting in a speculum and visualizing the cervix isn’t difficult, but interpreting what you’re seeing is where we pick it up so that those physicians can provide the service.” Dr. Hitt explained.
The arrangement also professionally benefits the telemedicine-practicing specialist, Dr. Hitt observed. “One thing about doing 40 to 50 colposcopies in a six-hour timeframe is that you get pretty good at it,” he said. “I feel that I am providing a high-level service, and this has allowed me to be a statewide provider of health care services.”

Dr. Hitt is convinced that telemedicine pays off in less measurable ways, too, for rural-practicing physicians in any specialty. “Telemedicine fosters a collaboration that reduces the feelings of isolation that physicians may experience when they go to practice in a small town,” he said. “With telemedicine, it’s like having one foot in the city but being able to live and practice out in a rural area. It’s also reassuring to know that you’re on the right track with the treatment plan and are staying current.”

As an indicator of telemedicine’s expansion in terms of physician practice opportunities, Specialists on Call, a Virginia-based provider of telemedicine services that specializes in neurology and psychiatry, and now operates in more than 300 U.S. hospitals, recently launched a “tele-intensivist” service line to expand on traditional e-ICU capabilities. In addition, the online professional networks like Medscape and QuantiaMD, which connect physicians with their peers or experts in a wide range of medical specialties for the purpose of sharing insights or seeking advice on challenging cases, are constantly expanding and in some cases incorporating telehealth technologies.

“These online communities give rural physicians access to expertise and a sounding board they didn’t have in the past, which also reduces the isolation factor,” said Ken Simone, DO, a Bangor, Maine, family medicine physician and longtime rural hospitalist practitioner who also consults with hospitals on rural practice staffing issues.

John Haynes, MD, Louisiana, family medicine physician who has practiced for decades in the tiny town of Vivian (population 2,000), exemplifies the evolving intersection of traditional rural practice and technology. Although he practices typical rural medicine — on a particular day he handles everything from atrial fibrillation to pneumonia, and an asthma exacerbation to a cesarean section birth — he is increasingly connected via technology to specialists at the medical school in Shreveport. “We have a hand-in-glove relationship with the specialists in Shreveport, and it’s made a big difference being able to, for example, have the radiologist read an uploaded image and give me a report within the hour,” he said. “That has really changed things for those of us who want the variety that rural practice provides but also want to be connected to the specialists.”

Practical and Licensure Considerations
Although physicians do not need special credentials to practice in a telemedicine arrangement, several factors warrant special attention. First, they must follow all appropriate state requirements and regulations for telemedicine practice, and should also be conversant with and adhere to the Joint Commission standards for telemedicine.

In addition, as with any practice expansion or modification, health plan and hospital credentialing and privileging issues might come into the picture as telemedicine-practicing physicians begin to serve a larger patient base or consult to rural hospitals. The Centers for Medicare & Medicaid Services, for example, has recently allowed for hospital credentialing and privileging by proxy for certain telemedicine services, but it’s important to check with individual institutions to determine their particular requirements.

Some states are considering special reciprocal licensing agreements, or compacts, for physicians who are based in one state but want to offer telemedicine services in an adjoining or other state. But as this is a fast-evolving area, physicians seeking telemedicine practice opportunities should ensure they stay abreast of licensure issues where they plan to provide services. The American Telemedicine Association (see Resources) provides frequently updated information on telemedicine-related licensure and regulatory matters.

“There are different elements of issues that physicians need to be cognizant of, and of course it’s important for physicians to let their malpractice insurers know if they’re considering telemedicine practice,” Dr. Rheuban advised. “But once you’ve adhered to all of the requirements, telemedicine offers a new opportunity. Why not use technology to provide care, or develop new patient populations that you can serve?”

American Telemedicine Association
(202) 223-3333

HRSA Office for the Advancement of Telehealth

National Rural Health Association


*Dr. Fromson serves as the editor for Career Resources and is Vice Chair for Community Psychiatry, Brigham and Women’s Hospital; Chief of Psychiatry, Brigham and Women’s Faulkner Hospital; Associate Professor of Psychiatry, Harvard Medical School.