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Introduction
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Understanding Telehealth comes at an opportune time in the continued evolution of the important role telehealth technology can play in enhancing access, supporting clinicians, and improving the patient experience. I applaud the authors for the breadth of topics and issues covered in this publication. It is reflective of the growth of clinical applications that are leveraging this technology to support health care delivery.

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We certainly have a vested interest in this issue at the Federal Office of Rural Health Policy (FORHP) within the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services. FORHP began supporting telehealth projects in the early 1990s as a way to improve access to health care services that were not available locally in rural communities. We have been joined in those efforts by a host of federal partners ranging from the Indian Health Service (IHS) to the Veterans Health Administration (VHA). FORHP's early efforts were focused mostly on supporting demonstration programs, and we were joined in this effort by similar projects funded by the Centers for Medicare & Medicaid Services (CMS, though then known as the Health Care Financing Administration). Our early efforts sought to inform broader policy issues related to reimbursement, safety, quality, and licensure.

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Much has changed in the ensuing years. By the late 1990s, Congress had formally created the Office for the Advancement of Telehealth (OAT), which is located within FORHP, and authorized a range of telehealth programs within HRSA to support the development of telehealth network grants and a nationwide network of telehealth resource centers, as well as the Licensure and Portability Grant program. Around the same time, Medicare began covering a limited range of services that has been steadily growing. At the state level, 48 states and the District of Columbia now provide some form of Medicaid reimbursement for telehealth services.

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Developments that are more recent include a 2012 HRSA-sponsored workshop, convened by the Institute of Medicine (IOM), to determine the role of telehealth in the rapidly changing U.S. health care system. 1 The meeting came at a critical time, with the health care system rapidly evolving from one that emphasizes volume to one that focuses on delivery of high-value care. Throughout the two-day IOM workshop, one common theme was that telehealth can facilitate access for patients to interact with their providers, which reduces barriers to receiving high-value care. This publication will pick up on that specific theme and many other issues raised by the IOM.

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As Understanding Telehealth explores in more detail in the subsequent chapters, telehealth continues to deal with a number of long-standing policy issues such as licensure and reimbursement, as noted in Chapters 2224. Clinicians and state and national licensing bodies continue to wrestle with the challenge of how to ease the regulatory burden of providers who deliver services across state lines via telehealth while still protecting patient safety. We have seen some progress in this area through the OAT Licensure and Portability Grant program, which has provided funding to the Federation of State Medical Boards and the Provincial Boards of Psychology to develop ways to address this challenge.

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Payment for telehealth services has been evolving to reflect this movement toward value by providing payors opportunities to invest in telehealth capabilities outside the traditional fee-for-service payment. Medicare historically has paid for telehealth under limited circumstances, but the statutory authority is limited, as discussed in Chapter 23. Still, incremental progress has been made.

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CMS has undertaken efforts to address reimbursement limitations through alternative payment models such as the recent Next Generation ACO Model, which offers greater flexibility for telehealth reimbursement. 2 The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) also includes incentives for clinicians to coordinate care using telehealth, because they could be “rewarded” for that activity 3 under the Improvement Activities category of the Merit-Based Incentive Payment System in the Quality Payment Program (QPP) that will assess clinicians’ performance and adjust their payments. 4 A recent Medicaid Home Health Final Rule clarified that the Medicaid eligibility requirements for face-to-face encounters include telehealth. 5 Since 2012, the CMS Innovation Center has funded eight states with telehealth activities under its State Innovation Models (SIM) initiative 6 and 22 projects with a telehealth focus under its Health Care Innovation Awards (HCIA). 3,7

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Across HHS, there is increasing adoption of telehealth technology. For example, telehealth activities are woven into many of HRSA's programs beyond OAT. The Bureau of Health Workforce and the HIV/AIDS Bureaus support grant programs that rely on telehealth links to support training and education. The Bureau of Primary Health Care has seen an expanded use of telehealth in community health centers. The Maternal and Child Health Bureau intends to fund several telegenetics grants to serve children with special health needs. 8

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HHS’ Office of the National Coordinator for Health IT (ONC) recently completed an assessment of the various telehealth activities funded by federal agencies, showing a broad range of these activities across the department.

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HHS has made investments in telehealth in a number of its other agencies. For instance, the Agency for Healthcare Research and Quality (AHRQ) recently released an evidence map for telehealth that analyzed which applications showed the greatest promise for improving patient outcomes. 9 The National Institutes of Health (NIH) has supported a number of studies that develop, utilize, or evaluate a telehealth component to show how this technology can help address chronic disease. 10 Also, the Centers for Disease Control and Prevention (CDC) has supported efforts to address public health issues using telehealth, including an e-pathology program to link pathologists to public health providers. 11 The Substance Abuse and Mental Health Services Administration (SAMHSA) has invested in grants to support mental health care coordination through telehealth and other health information technology applications. 12 More recently, the IHS awarded a contract to expand its ability to provide telehealth services in the IHS Great Plains Area, representing frontier areas of the United States. 13

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As the number of federal programs involved in telehealth activities has grown, so has the need for identifying areas of collaboration and the ability to share information. Toward that end, HRSA established the Federal Telemedicine Working Group (FedTel) to summarize key telehealth activities and facilitate information sharing among participants in 26 agencies and departments throughout the federal government, not just HHS. The workgroup holds monthly conference calls and meets semiannually face to face. 14

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The increase in federal activity is not happening in isolation. There is growing interest in telehealth across a broad range of stakeholders. One study estimates that 58% of health care providers used some form of telehealth in 2015. 15 Towers Watson reported that 22% of large employers in 2014 covered telemedicine consultations and that more than 68% planned to do so by 2017. 16 In 2013, the market for telehealth-generated annual revenue was $9.6 billion, a 60% growth from 2012. 17

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Amidst all of this activity, it is clear that the field of telehealth is continually evolving and maturing. It is becoming an increasingly expected part of the health care delivery system and an essential tool for clinicians and patients. It is also important to note that delivering services through telehealth is no longer solely an issue to reach rural communities, as urban patients may also benefit from the flexibility of the technology to more efficiently deliver access and services. Fields like dermatology and mental health are well-established users of this technology.

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With each passing year, however, more clinicians are finding ways to deliver these services via telehealth. This publication includes chapters that examine some of these emerging applications of the technology, including areas such as high-risk obstetrics, direct-to-consumer primary care, and pediatric cardiology, just to name a few.

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This publication's chapters focusing on public policy highlight a range of ongoing policy issues that will need to be addressed. These issues range from ensuring access to robust and affordable broadband services as the backbone for telehealth to the need to find ways to balance the requirement to ensure quality and safety without the regulatory burden associated with licensure for clinicians who deliver telehealth services in multiple states.

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Although policy issues such as reimbursement and licensure continue to pose challenges, other systemic changes in health care delivery may offer a path toward greater integration of this technology into the daily patient experience. The emerging emphasis on creating a value-driven health care system that focuses more on outcomes and quality and less on volume creates a unique opportunity to leverage telehealth technology. The traditional fee-for-service payment structure has never been a particularly good fit for telehealth. New payment models focused on accountable care or global budgeting offer interesting new possibilities for telehealth because the emphasis is more on the outcome and less on the site of service.

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Although this volume-to-value transition has begun, it is still in its early stages. This publication will help inform a growing effort to better understand how telehealth can fit into a value-based system. There is a need to expand the current evidence base for telehealth services. At FORHP, we have taken initial steps in this direction by focusing our TNGP funding not only on enhancing access, but also on gathering data as part of a broader research effort to compare outcomes for patients seen through telehealth compared to patients receiving similar services face to face. The previously mentioned AHRQ Telehealth Evidence Map will be an important tool to better inform future telehealth investments. The ensuing chapters cover these and many other issues and inform much of the current state of how clinicians are using this technology to enhance care for their patients.

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REFERENCES

1. +
The Role of Telehealth in an Evolving Health Care Environment - Workshop Summary. November 20, 2012. http://www.nationalacademies.org/hmd/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx. Accessed December 14, 2016.
2. +
Centers for Medicare & Medicaid Services. Next ACO Model. https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/. Accessed December 14, 2016.
3. +
U.S. Department of Health and Human Services. Report to Congress E-health and Telemedicine. August 12, 2016. https://aspe.hhs.gov/sites/default/files/pdf/206751/TelemedicineE-HealthReport.pdf. Accessed December 14, 2016.
4. +
Centers for Medicare & Medicaid Services. Quality Payment Program. https://qpp.cms.gov/. Accessed December 14, 2016.
5. +
Centers for Medicare & Medicaid Services. Face-to-Face Requirements for Home Health Services; Policy Changes and Clarifications Related to Home Health. February 2, 2016. https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-01585.pdf. Accessed December 14, 2016.
6. +
Centers for Medicare & Medicaid Services. State Innovation Models Initiative. https://innovation.cms.gov/initiatives/state-innovations/. Accessed December 14, 2016.
7. +
Centers for Medicare & Medicaid Services. Health Care Innovations Awards. https://innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/. Accessed December 14, 2016.
8. +
Maternal and Child Health Services Title V Block Grant Puerto Rico . March 16, 2016. https://mchb.tvisdata.hrsa.gov/uploadedfiles/2016/submittedFiles/printVersion/PR_TitleV_PrintVersion.pdf. Accessed December 14, 2016.
9. +
Agency for Health Care Research and Quality. Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews. Technical Brief Number 26. https://www.effectivehealthcare.ahrq.gov/ehc/products/624/2254/telehealth-report-160630.pdf. Accessed December 14, 2016.
10. +
U.S. National Library of Medicine. Telehealth and Telemedicine. https://lhncbc.nlm.nih.gov/project/telehealth-and-telemedicine. Accessed December 14, 2016.
11. +
Centers for Disease Control. Infectious Diseases Pathology Branch. https://www.cdc.gov/ncezid/dhcpp/idpb/epathology/index.html. Accessed December 14, 2016.
12. +
Substance Abuse and Mental Health Services Administration. SAMHSA's Efforts in Health Information Technology. http://www.samhsa.gov/health-information-technology/samhsas-efforts. Accessed December 14, 2016.
13. +
Indian Health Service. Indian Health Service Awards $6.8 Million Telemedicine Services Contract to Avera Health. September 20, 2016. https://www.ihs.gov/newsroom/pressreleases/2016pressreleases/indian-health-service-awards-6-8-million-telemedicine-services-contract-to-avera-health/. Accessed December 15, 2016.
14. +
Doarn C , Pruitt S , Jacobs J ,  et al. Federal Efforts to Define and Advance Telehealth: A Work in Progress. May 1, 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011485/. Accessed December 15, 2016.
15. +
HIMSS Analytics. The Healthcare Information and Management Systems Society. 2015 Telemedicine Study. September 2015. http://www.himssanalytics.org/research/essentials-brief-telemedicine-study.
16. +
Tower Watson. Current Telemedicine Technology Could Mean Big Savings. August 11, 2014. http://www.towerswatson.com/en-US/Press/2014/08/current-telemedicine-technology-could-mean-big-savings. Accesed December 15, 2016.
17. +
Drobac K. 2015: Another Unstoppable Year for Telehealth. Published March 24, 2015. http://www.connectwithcare.org/2015-another-unstoppable-year-telehealth/. Accessed December 15, 2016.

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