INTRODUCTION

Advances in telecommunication and technologies are revolutionizing education and

health services globally, including the provision of nursing services. Decreasing time and distance,
these advances increase access to health and health care, especially to underserved populations and
those living in rural and remote areas. They help to manage the demand for services, ensure more
effective use of human and health resources and facilitate education and research activities.
Today nurse can offer consultation and comfort to patients whether they are in the same
city or thousands of kilometers away. Communication technology also enables nurses to deliver
health care in rural and remote locations, and areas without health care services.
The term “telemedicine” derives from the Greek ‘tele’ meaning ‘at a distance’ and the
present word ‘medicine’ which itself derives from the Latin ‘mederi’ meaning ‘healing’.
Telemedicine is rapidly developing application of clinical medicine where medical
information is transferred through the phone or the internet and sometimes other networks for the
purpose of consulting, and sometimes, remote medical procedures or examination.
First setup of telemedicine Boston Logan Airport to Massachusetts General Hospital in
1967. Dr. Jay Sanders father of telemedicine, MD President and CEO of the Global Telemedicine
Group. It is a phase first coined in the 1970s by Thomas bird, referring to health delivery where
physicians examine distant patients through the use of telecommunication technologies.

DEFINITION OF TELEMEDICINE
“The delivery of healthcare services, where distance is a critical factor, by all healthcare
professionals using information and communication technology for exchange of valid information
for diagnosis, treatment and prevention of diseases and injuries, research and evaluation, and for
continuing education of healthcare providers, all in the interests of advancing the health of
individuals and their communities.” (WHO)

DEFINITION OF TELE HEALTH

- The term telehealth includes a broad range of technologies and services to provide patient
care and improve the healthcare delivery system as a whole.
- Telehealth is different from telemedicine because it refers to a broader scope of remote
healthcare services than telemedicine.
 - Telehealth can refer to remote non-clinical services, such as provider training,
administrative meetings, and continuing medical education, in addition to clinical services.
- According to the World Health Organization, telehealth includes, “Surveillance, health
promotion and public health functions.”
- Telehealth is a subset of E-Health, which includes the delivery of health information, for
health professionals and health consumers, education and training of health workers and
health systems management through the internet and telecommunications.
- Tele-diagnosis: It is the determination of the nature of a disease at a site remote from the
patient on the basis of transmitted tele-monitoring data or closed-circuit television
consultation.
- E-Health: It is the process of providing health care via electronic means in particular over
the internet.
- E-Monitoring: It utilizes home monitoring devices, such as a typical blood pressure
monitor.

DEFINITION OF TELENURSING
Tele nursing is a subset of tele health in which the focus is a nursing practice via
telecommunication. American Nurses Association Tele nursing is defined as the practice of
nursing using protocols through telecommunication technology.
Arkansas Staff Board of Nursing
“Telenursing” can be defined as using telecommunication devices to provide nursing
care, utilizing the nursing process to care for individuals or specific patient populations, such as
isolated groups of people
Telenursing refers to the use of technology for delivering nursing care from a
distance. As technologies like multimedia, imaging, and telecommunications have advanced and
become more affordable, telenursing has become more and more feasible. Its primary benefits are
reduced costs, improved quality of care, and the ability to see more patients more efficiently.
 HISTORY OF TELEMEDICINE
The History of Telemedicine provides a comprehensive and in-depth historical
view of telemedicine from ancient Greece to the present time.
The journey started with ancient societies and the early attempts to establish
rudimentary/primary communication connectivity between settlements when faced with internal
or external threats and subsequently to establish clinical connectivity between patient and
physician/caregiver/priest. Telemedicine provided the tools for connectivity when providers and
recipients of care could not be in the same place and time.
“Necessity is the mother of invention”
In probing the history of telemedicine from the ancient to the present time, authors
discovered continuity and change existing side by side in a dynamic evolutionary process.
Continuity stems from the convergence of medical care delivery and distance communication in
various forms and manifestations, whereas change reflects the never-ending advances in the
character and capability of the technology that enables telemedicine as well as other concurrent
advances in medical science and medical practice.
University of Nebrastea did first documented use of visual telecommunication in
health care in 1959. Under first telemedicine program in December 1988, the site of massive
earthquake in Armenia was linked to medical centers in United States for telemedicine
consultations. The program was extended to Russia to provide telemedicine consultation to burn
victims after a terrible train accident. First internet based telemedicine trials wall conducted in
April 1955 when a Chinese studies zee Ling who was studying in Beijing University fell sick and
her condition could not be diagnosed in china.
1. Telegraphy and telephony was established 1920s
2. Wireless / Radio 1950s
3. TV 1960s
4. Computer and Internet 1990/2000
TELEMEDICINE IN INDIA
- In India, telemedicine practice was initiated at Luck now and Chennai at 1997.
- In Kerala, the first unit of telemedicine was established at medical college Trivandrum in
2003.
- One of the oldest known Telecardiology systems for Teletransmissions of ECGs was
established in Gwalior, India in 1975 at GR Medical College.
- The first Ayurveda telemedicine center was established in India in 2007 by Dr. Partap
Chauhan, Director of Jiva Ayurveda, and a well-known Indian Ayurvedic doctor.
- The integration of e-Health and telemedicine services is being done through the National
Medical College Network (NMCN) by interlinking the Medical Colleges across the
country with the purpose of e-Education and National Rural Telemedicine Network for e-
Healthcare delivery. Considerable amount of effort has already been undertaken to give a
shape to the project.

- ISRO Telemedicine programme started in 2001 has been connecting remote/rural/medical

college hospitals and Mobile Units through the Indian satellites to major specialty hospitals
in cities and towns. ISRO Telemedicine network covers various states/regions including
Jammu & Kashmir, Ladakh, Andaman & Nicobar Islands, Lakshadweep Islands, North
Eastern States and other mainland states. Many tribal districts of Kerala, Karnataka,
Chhattisgarh, Punjab, West Bengal, Orissa, Andhra Pradesh, Maharashtra, Jharkhand and
Rajasthan are covered under Telemedicine Programme.

- Presently, the Telemedicine network of ISRO covers about 384 hospitals with 60 specialty
hospitals connected to 306 remote/rural/district/medical college hospitals and 18 Mobile
Telemedicine units. The Mobile Telemedicine units cover diverse areas of Ophthalmology,
Cardiology, Radiology, Diabetology, Mammography, General medicine, Women and
Child healthcare.
BENEFITS OF TELEMEDICINE
- Telemedicine is an efficient and cost-effective solution to extend quality healthcare
services to remote places where health care delivery is non-existent or practically
inaccessible.
- It also helps increase the overall quality of patient care and satisfaction in healthcare
services. The benefits of telemedicine extend beyond cost and convenience.
1. Increases access to healthcare:
- Telemedicine targets offering healthcare and clinical services to remote patients and
hospitals through the use of technology. Through the concept of telemedicine, patients in
remote locations can more easily access and obtain any kind of clinical services. Moreover,
hospitals in rural regions can be enabled to provide emergency and intensive care services
with the aid of specialized professionals in urban locations.
2. Improves health outcomes:
- Early diagnosis and treatment often provide improved health outcomes. Moreover,
telemedicine offers reduced mortality rates and lesser complications as there is an
immediate transmission of health records and data.
3. Reduces healthcare costs:
- Telemedicine is a cost-effective alternative to hospital stays, they reduce healthcare costs
for patients. Home monitoring programs are better than high-cost hospital visits and stays.
During times of emergencies, high-cost transfers and patient care can be reduced via
telemedicine.
4. Overcome healthcare shortages:
- In India, there is a great shortage for healthcare in rural areas because of irregular
distribution of healthcare providers. Telemedicine helps combat the problem by assisting
healthcare providers in addressing shortages and giving access to healthcare, irrespective
of time and place when needed.
5. Access to specialists:
- Medical specialists located in urban areas can serve patients at rural regions using
Telemedicine technologies. Instead of driving to a medical practice, patients can get
 immediate access to the specialist from anywhere in the world through the concept of
telemedicine. That way, telemedicine serves to significantly increase patient satisfaction.
6. Remote care/monitoring:
- Telemedicine has a strong role in facilitating collaborative care and continuity model. It
creates the possibility of monitoring patient health remotely by collecting and sending
medical data through electronic means for immediate interpretation. Such remote
access/monitoring is greatly beneficial for homebound critical/emergency patients where
constant monitoring is a must.
7. RESOURCE UTILIZATION:
- First benefit of telemedicine is proper utilization of resources.
- In India doctor population ratio is 1:15000 in comparison to 1:500 in developed nations,
and these doctors are not distributed equally.
- 80% Indian population lives in rural and semi urban areas.
- Telemedicine can help in cost effective utilization of meager resources and of the same
time can decrease patient work load on few referral centers.
8. EARLY INTERVENTION:
- One of the most effective means of providing medical intervention is by early detection
and treatment.
- There are factors that inhibit the continuity of care. Issues such as geographic location,
inclement weather, socioeconomic barriers.
- Patient apathy are significant factors that delay and even prevent the specialty care.
- By providing these primary cure sites with the ability to quickly access specialty
consultation services.
- Patients are able to reap the benefits of early intervention while the health care system
maintains quality service and clinical efficiency.
9. AVOIDS UNNECESSARY TRANSPORTATION:
- Local health provides discusses case of a patient on phone with a specialist and it specialist
is not getting clear picture.
- After few questions he will able to send the patient but if by video conferencing he has
clear picture of patient.
- Unnecessary referral and patient transport can be definitely avoided
 - Which Data Can be transferred: Basically four types of data are used in telemedicine.
1. Text for patient notes, generally having a file of less than 10 KB.
2. Audio – electronic stethoscope, with file size of around 10 KB.
3. Still image X-rays which are still images having a size of around 1 MB.
4. Video movie – ultrasound / patient visualization – movie images have a size of 10 MB
or more the patient can be seen by a doctor at a remote place using cameras.
10. COMMUNITY BASED CARE:
- Community based care is another big advantage of telemedicine.
- People like to receive high quality care in their local community.
- This reduces travel time and related stresses associate with many referrals.
11. MEDICAL EDUCATION AND RESEARCH:
- Telemedicine is also useful in medical education.
- When medical students are posted in rural area they can be linked to medical college for
grand rounds and they can also do case presentation to teachers in medical colleges.
- In India Indira Gandhi National Open University (IGNOU) carries out regular monthly
session of teaching of its diploma in maternal and child health (PGDMCH) students.
- Physicians living in different parts of the world also use telemedicine in collaborative
research, they can also share data or can discuss current trends.
 When patient stand seeing of their own day, they stand connecting the data above their
processes. Managing their disease better reduce their utilization of acute care services such as
emergency department visits and hospitalization.
 Saving time achievable because driving time to reach patient residence by significantly
reduced.
 Nurses are able to spend more time on direct patient care.

OBJECTIVE
- Improving patient outcomes
- Increasing patient engagement and satisfaction.
- Improving patient convenience: Telemedicine eradicates the time spent in a crowded room
waiting for the physician, with other coughing patients.
  It helps to save the strength and prevents them from being infected by others. It provides
ease of scheduling.
 Appointment with physician can be set online or through your mobile phone and
consultation can be done via video technology.
 It places the power of health through a click of the mouse or press on your phone.
 It also reduced the burden of traveling. Telemedicine also provides easy access for
immobile patients.
 Patients with complex medical conditions can be given a quality health care from a
specialist in another hospital through the use of telemedicine.
 It provides easy access to quality health care for patients in a very critical condition.
- Providing remote and rural patients with access to care.
- Improving average of limited physician resources
 Reducing Time for Both the Physician and Patient: It enables the patient to save travel
time. Patients who need to travel millions of miles to reach a physical can benefit from
telemedicine. It enables effective communication, examination, and treatment of the
patients in different locations.
 Telemedicine saves the time of physicians.
 They can connect with patients on a more flexible schedule. It also reduces no-shows
because it gives the patient the most convenient way to have an appointment with the
physicians.
 If ever patients missed the appointments, they can easily replace that time by online
scheduling. It also lessens the overhead cost of the physician. Shorter office hours
means saving operating expenses such as salaries, electricity, etc. With telemedicine,
physicians can continue their work at home.
 Saves Cost for Both the Physician and Patient: It eliminates travel expenses. Many
patients do not have the financial capacity to travel for medical treatment.
 However, with telemedicine, they are given a better opportunity to seek medical care.
Telemedicine is helpful for patients with several chronic ailments which require
continuous medication.
 It helps them spend less for hospital bills.
 It would allow them to have the medication at home with quality health care.
  With video calling, it is easier to enhance patient satisfaction through remote quality
health care.
- Reducing hospital readmissions
- Improving specialist efficiency
- Providing access to new specialties
- Provides a 24/7 Quality Health Services: The patient sometimes needs immediate care from
the physician outside the physician’s office hours.
 With telemedicine, the physician can have a quick overview and appropriate advice
that could save the patient’s hassle, time, and money.
 Telemedicine extends the physician’s working hours and increases the physician’s the
availability of urgent service.
- To provide specialized medical advice.
- To monitor patient condition.
- Accessibility of Quality Health Care: Remote regions get a quality patient care without
delay. Clinics in rural areas use video for the interaction between the patient and a specialist
in the city.
 Doctors are also using telemedicine to monitor the situation and provide treatment to
patients in remote areas, at home, and in another hospital or clinic.
- To guide other medical staff about treatment procedure.
- Share patient data among institutions for research purpose.
- Other objectives included reducing emergency department overcrowding, increasing
revenue and supporting research or clinical trials.

NEED OF TELEMEDICINE IN INDIA

- The advances in Medical science, biomedical engineering on one side and
Telecommunication and Information Technology on the other side are offering wide
opportunities for improved health care.
- Health coverage to majority of our population is still a distant dream.
- India is a vast country gifted with rich and ancient historic background and geographically
the nature has provided India with all the varieties like the mountain regions like Ladakh,
 deserts, green planes and far flung areas in the north east and offshore islands of Andaman’s
and Lakshadweep.
- Predominantly rural and distributed in distant geographical locations.
- High cost of health care and lack of investment for health care in rural areas.
- Inadequate medical facilities in rural & inaccessible areas.
- Problem of retaining doctors in rural areas where they are required to serve & propagate
widespread health awareness.
- It is innovative methods of utilization of science and technology for the benefit, of our
society and telemedicine assumes a great significance to revolutionize the health care
system in India.

AIMS/GOAL
- To deliver specialized medical care and advice within reach of patient at distant places.
- To enhance healthcare delivery to medically-underserved populations throughout the state
using telemedicine technologies.
- To maintain a statewide Arizona Telemedicine Network To increase access to medical
specialty services while decreasing healthcare costs
- To use telemedicine outreach programs to encourage physicians, nurses, and other
healthcare professionals to establish and retain practices in underserved rural areas.
- To provide ongoing training for preceptors, medical students, and residents.
- To encourage students from rural communities into the healthcare professions and
encourage their return to these communities upon completion of their educations.
- To improve public health in rural communities by providing current information and
training.
- To have the Arizona Telemedicine Network serve as a test bed to evaluate the effectiveness
of state-of-the-art telemedicine services.
- To increase and promote the use of telecommunications for distance learning in health care.
- To provide health care systems throughout the state with information, training, and
expertise in the field of telemedicine.
- To evaluate telemedicine equipment and telecommunications options and participate in
their development.
 TELEMEDICINE DEVICES
(A). Video Conferencing System
- Roll about systems
- Set top systems
- Desk top system
(B). Peripheral Devices: It can be attached to computers or the video-conferencing equipment
which can aid in an interactive examination. A peripheral device provides input/output (I/O)
functions for a computer and serves as an auxiliary computer device without computing-
intensive functionality. Peripheral devices connect with a computer through several I/O
interfaces, such as communications (COM), Universal Serial Bus (USB) and serial ports.
1. Storage device: Used to store data and programme permanently. For example: hard
drive, flash drive, CD drive etc.
2. Input device: used to enter data and instruction (programme, command) in to the
computer. For example: keyboard, mouse, microphone, scanner, etc.
3. Output device: used to get information from the computer. For example: monitor,
printer, speaker etc.

TYPES
 Real time (synchronous)
1. Video conferencing-television: Communication augmented with sound. Also known as
synchronous video, live video-conferencing is a live, two-way interaction between a person
and a healthcare provider using audiovisual telecommunications technology. This kind of
telehealth is often used to treat common illnesses, to determine if a patient should proceed
to an emergency room, or to provide psychotherapy sessions.
2. Computer conferencing-printed communication through keyboard terminals.

3. Audio-conferencing verbal communication via the telephone with optional capacity for
tele-writing or tele-copying.
 Stored- and- forward telemedicine (asynchronous)
- Store-and-forward telemedicine is also called “asynchronous telemedicine.”
 - It is a method by which healthcare providers share patient medical information like lab
reports, imaging studies, videos, and other records with a physician, radiologist, or
specialist at another location.
- It does not require the presence of both parties at the same time.
- Telemedicine is most beneficial for populations living in isolated communities and remote
region and is currently being applied in virtually all medical domains.
- Store-and-forward telemedicine is an efficient way for patients, primary care providers,
and specialists to collaborate because they can all review the information when it is
convenient for them. The approach gives patients access to a care team that can be
comprised of providers in different locations, even across long distances and in different
time zones.
- Store-and-forward is particularly popular for diagnoses and treatment with certain
specialties including dermatology, ophthalmology, and radiology.
 Remote Patient Monitoring
- Remote patient monitoring, or “telemonitoring” is a method that allows healthcare
professionals to track a patient’s vital signs and activities at a distance.
- This type of monitoring is often used for the management of high-risk patients, like those
with heart conditions and people who have recently been released from the hospital.
- Remote monitoring is also extremely useful for the treatment of a number of chronic
conditions.
- It can be used by diabetics, for example, to track their glucose levels and send the data to
their doctor.
- Elderly patients at home or in assisted living facilities can be conveniently and
inexpensively monitored.

 Mobile health or m-Health

- M-Health uses mobile communications devices, such as smartphones and tablet computers,
and hundreds of software applications for these devices, which can do almost anything
imagined for supporting healthcare.
 Application Adopted
- Most beneficial for populations living in isolated communities and remote regions and is
currently being applied in virtually all medical domains.
- Use a "tele-" prefix;
- Useful as a communication tool between a general practitioner and a specialist available at
a remote location.
- Telepathology
- Telecardiology
- Teleradiology
- Telesurgery
- Teleopthalmology

BARRIERS OF TELEMEDICINE/ TELECOMMUNICATION

- There are still several barriers to the practice of telemedicine. Many countries will not allow
but of country physicians to practice unless licensed in the country.
- Low or small bandwidth.
- Neither telephone lines nor electricity in rural and remote areas.
- Satellite transmission can help but it is very costly.
- Unstable electricity supply.
- Patient’s fear and unfamiliarity.
- Financial unavailability.
- Lack of health infrastructure and services
- Lack of training facilities.
- Low Literacy rate and diversity in languages.
- Quality aspect.
- Government support, legal and ethical issues.
- Privacy and security issues.
FUTURE OF TELEMEDICINE
- Many medical centers in India are now successfully running, telemedicine – projects and
video conference.
- Future of telemedicine in India is definitely bright-with availability of internet everywhere,
with new information's technology policies and with improving telecommunication
network use of telemedicine is going to increase

INDIAN SCENARIO OF TELEMEDICINE

- Now with the availability of internet connection in most cities of India interest in
telemedicine is increasing day by day but still major drawback in India is that
communication network is not suitable for most telemedicine applications.
- ISDN lines are not available in most of the places in India, which is basic requirement for
video conferencing.
- Video conferencing technology will be limited to some big cities and telemedicine
technology that will be used in most of the parts of India will be store and forward
technology.
- It will be like sending radiological images, patients’ records, sounds through e-mail or
modern and getting opinion of experts.
- Many medical centers in India are now successfully running telemedicine projects using
video-conferencing.
- India is an ideal place to use this technology as 80% population in India lives in villages
where treatment is provided by queen and unqualified medical practitioners.

TELEPHONE NURSING
- Telephone nursing care is one application of telehealth.
- This is defined as the practice of telephone based nurse-client communication for the
delivery of professional nursing services over distances.
- As in all nursing encounters, telephone nursing care involves the establishment of a
therapeutic nurse-client relationship facilitated through the nursing process.
- Telephone nursing care can be divided into two services:
 1. Health Advice – Nursing care is provided to address an identified health need(s) such
as: poison control, fever, medication scheduling, wound management or breastfeeding.
Communication is initiated for the purpose of triage, referral, and/or recommendations to
address immediate and/or long term health need(s).
2. Health Information – Nursing care is provided for the purpose of sharing information
about a health issue such as: available health promotion programs, community activities,
locations of health care services, and/or educational resources. Examples include a mother
calling to enquire about an immunization clinic schedule, a teenager looking for
information about sexually transmitted diseases or follow-up with new mothers.
Communication is initiated for the purpose of enhancing the caller’s ability to self-manage
their health issues.
- The nurse must use his/her professional and clinical judgment to determine whether the
telephone caller is seeking advice or information.
- In making this decision the nurse reflects upon his/her clinical knowledge of the health
need/issue of the caller and the perception of the caller’s ability to relay accurate and
comprehensive information.

GUIDELINES FOR TELENURSING

- Nurses and midwives practicing in telenursing shall be registered nurses or midwives.
Enrolled nurses involved by telenursing need to be under the supervision of registered
nurse or midwife.
- Nurses and midwives who are practices telenursing in Australia are effected to practice
with is the frame work of the ANMC National Competences standards of the midwife the
ANMC code of professional conducts for nurses in Australia, code of ethics for nurses in
Australia and other relevant professional standards.
- Nurses and midwives should inform consumers of the telehealth process including other
persons/professionals who may be participations or presence is the telehealth consultations
and urban consent before proceeding.
- Nurses are midwives in televisions have a duty to provide privacy and confidentiality in all
interactions.
- Nurses and midwives practices in telenursing should be aware of both the evidence base
for their practice and the areas or practice need or research.
- Nurses and midwives practicing telenursing should engage in evaluation of their practice
in relations to issue of quality safety and patient outcomes.

ISSUES IN TELENURSING
- Models of Case
- Privatizations
- Work line for nursing staff
- Patient safety
- Cross Border License Issues

CLINICAL FUNCTIONS OF THE TELEHEALTH NURSES

- Tele health nurses are monitoring patients with chronic diseases.
- Helping patterns manage their symptoms and co-ordinations care of patients who require
service from homeruns health professionals.

LIMITATIONS TO SPREAD OF TELEMEDICINE

- Poor patient – Doctor Relationships
- Patient Acceptance
- Fear of Technology
- Low Rates of Utilization
- Infrastructure
- Decrease face –face interaction.
- Security of data.
- Risk of decreasing quality of care.
- Increase liability.
- Concerns with maintaining confidentiality.
- Likelihood of technology failure.
- Dehumanizing effects.
- Knowledge base of nurse.
 - Inability for patient to use equipment.
- Malfunctioning of equipment

CHALLENGES OF TELEHEALTH
1. Payment
- Payment parity — reimbursement and coverage for telemedicine services comparable to
those of in-person services is a big challenge for telehealth.
- There is no guarantee of payment parity between telemedicine and in-person health care.
- Even in the 28 states in which payment parity laws have been passed, no apparatus exists
to enforce it.
- This could potentially defeat the point of telemedicine to reduce health care costs and
expand access to services, and could also discourage providers from offering telehealth
because there is no guarantee of comparable payment.
2. Misdiagnosis
- Misdiagnosis happens often in in-person health care, but the risks increase with telehealth.
Add to this the fact that there is no clear standard of care established by state legislatures,
and quality may be uneven between one provider and the next.
- Misdiagnosis has the potential to drive up overall costs to the general health care system as
well, because misdiagnoses leads to wrong prescriptions and treatments.
- According to the central diagnosis center (CDC), one third of antibiotics prescriptions are
already unnecessary.
- Additionally, if a telehealth service cannot determine a diagnosis, the patient may be
counseled to go to an ER or an urgent care service. If these visits are unnecessary, they
may result in a large cost to both the patient and the system as a whole.
3. Widespread Implementation
- The government has been attempting to address patient demand for telehealth by passing
legislation like CONNECT (Creating Opportunities Now for Necessary and Effective Care
Technologies), which expands the availability of services provided through telehealth
under Medicare.
- The challenges of widespread implementation of telemedicine encompass many different
areas, because “telehealth” can refer to so many different things — from robotics to
 telephone consultations. Some of the responsibility of implementation resides with the
legal system, and rests with the government. Some is institutional, and rests with local
hospitals and health care institutions. Also, some of the challenges are financial, and
require the effective utilization of business strategy and human resources.
4. Telehealth Vendors
- One unique challenge of utilizing telemedical technologies on an extended scale is how to
account for the vendors. Vendors are integral to the process, but they are not held
responsible nor are they compensated for individual cases. Additionally, the line between
provider and care platform is sometimes blurred when it comes to telehealth vendors.
- When health care programs like Medicare reimburse telemedicine services, it’s difficult to
tell exactly what is being paid for, and it’s challenging to determine the exact rates of
payment because the product comprises both the service and the technology. Then there
are questions about whether a health plan should contract directly with a telemedicine
vendor or let the vendor contract with providers, as well as how plans can ensure quality
of services.
 BIBLIOGRAPHY
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