Telehealth has revolutionized the delivery of health care through innovative advances in technology. Telehealth is a mechanism to increase access to preventive and specialty care, address health disparities affecting underserved populations, and potentially reduce health care costs. For rural and underserved regions and communities in particular, telehealth can mitigate transportation barriers to care and address health care provider workforce shortages. Beyond clinical care, telehealth can be leveraged to deliver public health services, health education, and enhance population health. State and territorial health officials (S/THOs) and their agencies can lead state health transformation efforts by leveraging telehealth to improve population health statewide. Furthermore, expanding access to broadband and developing telehealth infrastructure in underserved areas have the ability to improve health equity, allowing these areas to advance telehealth as a modality for providing services and education.
As state and territorial health agencies (S/THAs) expand the use of telehealth across states, several key factors will be critical to success. First, ensuring that a state has adequate telehealth infrastructure, including sufficient broadband access and telehealth networks, is a foundational component of advancing statewide telehealth. Second, collaborative efforts among S/THAs, other state governmental agencies, and partner organizations will be critical to overcome challenges around limited funding and infrastructure. Third, coordinating efforts to reform public and commercial telehealth policies and governance structures can help fully leverage the use of telehealth as a mechanism to expand access to care. Adopting and implementing these strategies can assist public health leaders in expanding the use of telehealth to improve the overall health of the public.
These strategies are described in detail in the following text, preceded by the results of a 2019 telehealth capacity survey fielded by the Association of State and Territorial Health Officials (ASTHO) to all S/THAs (N = 59).
State Telehealth Capacity Landscape
In early 2019, ASTHO administered a survey to S/THAs to understand how telehealth is currently used in each jurisdiction. ASTHO is the national nonprofit organization representing public health agencies in the United States, the US territories and freely associated states, the District of Columbia, and more than 100 000 public health professionals these agencies employ. ASTHO's members include the chief health officials of these jurisdictions who formulate and influence public health policy and ensure excellence in state-based public health practice.
The objective of the survey was to identify common trends among S/THAs and their partner organizations in relation to the utilization, barriers, and achievements seen in telehealth. Survey participants included S/THA senior deputies—public health leaders who provide direct support to S/THOs and keep a pulse on S/THA divisions and programmatic teams—and state-identified telehealth subject matter experts, including telehealth directors, telehealth coordinators, and other agency leaders with oversight of information technology, primary care, and rural health.1 These findings represent 66% (n = 39) of ASTHO's 59 member health agencies. An overview of the survey results is described in the following text, followed by a summary of public health management and practice strategies gleaned from the survey that can be adopted and implemented by S/THAs.
Telehealth Definitions and Survey Summary
The Health Resources and Services Administration (HRSA) defines telehealth as the use of technology to support and promote long-distance clinical health care, health education, public health, and health administration through 4 modalities.2,3 The 4 modalities used to deliver telehealth are outlined in the Table.4
Participating health agencies described telehealth programs in their jurisdiction (n = 90 unique programs), and of the programs described live video was the most widely used telehealth modality in programs (90%). About 25% of the S/THA telehealth programs also use other forms of delivery—store and forward, remote patient monitoring, and mobile health.
Health care and public health providers are the most common priority population for states delivering telehealth services and programs (26%). Other priority groups include maternal/child health, youth, rural residents, and patients with chronic disease. The most common types of telehealth services provided by S/THAs include behavioral health (42%) and specialty care (40%).
The majority of S/THAs (90%) indicated that their agency partners with other governmental state agencies to provide health services, information, or education using telehealth. Sixty percent of the participants indicated that their state delivers telehealth services through a hub-and-spoke model with regional sites or local health departments, and 63% indicated that their agency is participating in or partnering with Project ECHO,* an established telehealth hub-and-spoke model that facilitates connections between primary care and specialist providers in local communities with academic and other subject matter experts.5
Common S/THA telehealth program partners include community-based organizations (53%), local health departments (41%), hospital associations (34%), and federal agencies (17%). Many also work with the HRSA Telehealth Resource Centers (including the National Consortium of Telehealth Research Centers and the National Telehealth Technology Assessment Resource Center) for technical assistance needs and to implement, expand, and deliver services.6,7
More than 60% of S/THAs indicated funding and reimbursement as barriers that inhibit their agencies ability to establish telehealth activities. The majority of S/THAs reported that they are working with their state Medicaid agencies and managed care organizations to increase telehealth reimbursement and adoption. However, more than 30% of S/THAs reported that they are unsure whether their agency is working collaboratively with Medicaid in their jurisdictions to increase telehealth reimbursement and about 20% reported that they are not working with Medicaid.
Most jurisdictions do not have a dedicated telehealth office or program in their S/THA. However, all indicated that there is at least 1 full-time employee in their agency working on telehealth activities or programs, with most indicating either 1 to 3 full-time employees (30%) or 4 to 6 full-time employees (30%). Furthermore, many S/THAs indicated that they do not have a dedicated telehealth office or staff person within their state or territorial Medicaid agency.
Strategies for S/THA Management and Practice to Advance Statewide Telehealth
Building telehealth infrastructure
Prioritizing statewide broadband access
By prioritizing statewide access to broadband, S/THAs can significantly increase access to telehealth services and thereby health care and public health services in underserved and/or rural regions. Although establishing adequate infrastructure for telehealth is no small task, S/THAs can play an important role to ensure that a state has sufficient broadband access in rural and underserved areas and work toward developing a statewide telehealth network. Rural regions continue to face the most significant barriers to accessing broadband.8 These communities also face extreme health professional workforce shortages, which contribute to and reinforce existing health disparities.9 Because of fewer health care personnel in these areas, many rural Americans are forced to travel farther and incur greater costs for clinical services and many delay care, which can lead to worsening health conditions.10 By prioritizing statewide broadband access, including for rural areas, S/THAs can significantly influence access to health care and public health services.
Leveraging federally qualified health centers as hubs of telehealth network
Furthermore, while many health care systems operate siloed regional telehealth networks within a state, S/THAs and other state governmental agencies can leverage local health departments and federally qualified health centers to improve connectivity at a state level. For example, in 2016, the Georgia Department of Public Health completed the development of a telehealth network using a hub-and-spoke model across county health centers in all 159 of the counties.11 Leveraging this infrastructure, Georgia established a robust school-based telebehavioral health program after identifying that about half of the state's counties lacked mental health professionals in 2014. The school-based program allows school nurses to virtually connect children with a behavioral health provider while at school.12 In addition to clinical care, the network is used for educational programs, professional development, and distance learning for health providers. This approach reduces major barriers that often prevent individuals in rural and underserved areas from seeking care, such as a lack of transportation or access to specialty care providers.
Leveraging state partnerships
S/THAs reported that behavioral health agencies, including those with jurisdiction of mental health and substance misuse services, are the most common partners in telehealth activities and programs. Other common interagency partnerships involve collaboration with human and social service agencies, education, justice, aging and seniors, public assistance, and Tribal government agencies. In addition, several state and territorial agencies are working with Medicaid agencies to increase telehealth reimbursement and Medicaid managed care organizations to increase telehealth adoption. However, approximately one-third of S/THAs that participated in the telehealth survey were unsure about the presence of these kinds of partnerships in their jurisdictions.
By leveraging partnerships, S/THAs can enhance program capacity and increase access to resources and services that can aid in the prevention and control of disease. In Iowa, the Department of Health formed a partnership with the University of Iowa Healthcare System to provide an easily accessible way for patients to receive preexposure prophylaxis (PrEP) medication, as well as consultation and education for the treatment of human immunodeficiency virus (HIV) infection, using an in-home telemedical delivery model called TelePrEP. The telehealth service involves pharmacists, physicians, and public health professionals from multiple sectors collaborating to provide fast and efficient care to their patients and increase access to PrEP medications and services. The program combines videoconferencing services between patients and pharmacists with medication delivery by mail to expand HIV prevention across the state of Iowa, especially in rural regions, expanding access for individuals with geographic challenges to care.13 Furthermore, the partnership has the potential to overcome barriers related to stigma as it offers individuals a discrete mechanism of seeking HIV prevention care.
Reform telehealth policy and governance structures
Establishing a clear telehealth governance structure is an important step for S/THAs to advance statewide telehealth. Several states have established a defined telehealth governance structure to enable state and local agencies, as well as outside partner organizations, to collaborate in an aligned manner based on direction and guidance from the state leadership level. For example, Hawaii has a robust telehealth governance structure that supports the collaborative advancement of telehealth in the state. In 2019, the state enacted legislation to create a strategic telehealth advisory council, develop dedicated full-time equivalent staff including a state telehealth and health care access coordinator, and establish a working group tasked with simplifying telehealth administration.14,15 The state's governance structure allows for the S/THA to lead the coordination of multisector telehealth efforts across public and private stakeholders.
Beyond developing dedicated telehealth staff, there are several strategies that S/THAs can take to advance telehealth governance in their states. As shown in the Figure, most states (83%) provide S/THA representation on a telehealth council, board, or other planning entity (A. Kearly, J. Oputa, P. Harper-Hardy, unpublished data, April 2019). Furthermore, S/THAs develop funding opportunities or contracts that include opportunities for telehealth and develop workforce training opportunities on telehealth for providers. Other reported S/THA telehealth governance activities include leading telehealth policy development, monitoring telehealth usage, and analyzing data to understand statewide trends, coordinate interagency telehealth agreements between governmental agencies and health care systems, and provide funding for pilot programs and broadband access.
Having a clear telehealth governance structure can also lead to more efficient collaboration around telehealth reimbursement policy reform. The current telehealth reimbursement landscape varies across states and creates a confusing environment for individuals who use telehealth and for the health systems that provide care across multiple states. There is significant variation regarding the types of telehealth modalities that are covered under public and private payers. According to the Center for Connected Health Policy, telehealth modalities differ greatly among states due to differences in reimbursement laws.16 As of 2019, 50 states and District of Columbia reimburse for live video through their Medicaid programs, whereas only 21 reimburse for remote patient monitoring and 11 reimburse for store and forward.16 Medicare only reimburses for live video, although “store and forward” is reimbursed in Alaska and Hawaii.15
Looking Ahead: The Future of S/THAs, Role in Advancing Telehealth
S/THAs continue to use telehealth as an innovative mechanism to expand the delivery of health care services and public health programs. As commonly reported challenges—including the lack of funding and infrastructure—continue to be barriers to advancing telehealth efforts, partnerships between S/THAs and other state agencies and organizations will continue to serve an important role in overcoming these challenges. As S/THAs continue to enhance telehealth across states, leveraging the strategies described earlier—state partnerships, building capacity for telehealth networks and infrastructure, and improving telehealth policy and governance structures—will be critical to success. Supporting these efforts can help public health achieve its purpose to improve health outcomes for all individuals and advance the population's health.
1. Senior Deputy final video. YouTube. https://www.youtube.com/watch?v=TiWnzsePPzQ&feature=youtu.be
. Published April 25, 2019. Accessed September 20, 2019.
2. Health Resources and Services Administration. Increasing access to behavioral health care through technology. Meeting summary. https://www.hrsa.gov/sites/default/files/publichealth/guidelines/BehavioralHealth/behavioralhealthcareaccess.pdf
. Published Febr-uary 2013. Accessed September 20, 2019.
3. Health Resources and Services Administration. Telehealth programs. https://www.hrsa.gov/rural-health/telehealth/index.html
. Published August 2019. Accessed September 20, 2019.
5. Model | Project ECHO. The University of New Mexico Web site. https://echo.unm.edu/about-echo/model
. Accessed September 20, 2019.
6. National Consortium of Telehealth Research Centers. National Consortium of Telehealth Research Centers Web site. https://www.telehealthresourcecenter.org
. Accessed September 20, 2019.
7. Home | National Telehealth Technology Assessment Resource Center. National Telehealth Technology Assessment Resource Center Web site. http://www.telehealthtechnology.org/
. Accessed October 7, 2019.
8. The drive to quality and access in rural health. Health Aff Blog. October 17, 2018.
9. Centers for Medicare & Medicaid Services. Rural health strategy guide. https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Rural-Strategy-2018.pdf
. Published 2018. Accessed September 20, 2019.
10. Rural Health Information Hub. Healthcare access in rural communities introduction. https://www.ruralhealthinfo.org/topics/healthcare-access
. Published January 18, 2019. Accessed September 20, 2019.
11. Association of State and Territorial Health Officials. Enhancing systems to improve health outcomes. http://www.astho.org/Prevention/UHF-Health-Rankings/Case-Study-GA
. Accessed September 20, 2019.
12. The Office of the National Coordinator for Health Information Technology. Using health information exchange to enhance care for children in rural communities. https://www.healthit.gov/sites/default/files/ga_brightspot_08012016_508_compliance.pdf
. Published August, 1, 2016. Accessed September 20, 2019.
13. Shafer C. TelePrEP launches in Iowa to increase PrEP access! PrEPIowa.org. https://www.prepiowa.org/single-post/2017/06/20/TelePrEP-Launches-in-Iowa-to-Increase-PrEP-Access
. Published June 20, 2017. Accessed September 20, 2019.
14. Relating to Telehealth of 2019, Senate Bill 1246, 116th Cong (2019). https://www.capitol.hawaii.gov/measure_indiv.aspx?billtype=SB&billnumber=1246&year=2019
. Accessed September 20, 2019.
15. mHealthIntelligence. Hawaii adds Telehealth Advisory Board, coordinator to spur adoption. mHealthIntelligence Web site. https://mhealthintelligence.com/news/hawaii-adds-telehealth-advisory-board-coordinator-to-spur-adoption
. Published May 3, 2019. Accessed September 20, 2019.
16. Center for Connected Health Policy| The National Telehealth Policy Resource Center. State telehealth laws and reimbursement policies. https://www.cchpca.org/sites/default/files/2019-05/cchp_report_MASTER_spring_2019_FINAL.pdf
. Published Spring 2019. Accessed September 20, 2019.
* The Project ECHO hub-and-spoke model links expert specialist teams at an academic “hub” with primary care clinicians in local communities as the “spokes” of the model.