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The Sustainability of Telemedicine Business Models in Rural America BUSI511: Healthcare Administration Faizan Malik December 1, 2023 Respectfully Submitted to: Professor Curry

Telemedicine Sustainability 2 Abstract Telehealth has emerged as a pivotal tool in healthcare, especially highlighted during the COVID- 19 pandemic, where it played a crucial role in maintaining healthcare services. Despite its potential to address healthcare disparities, particularly in rural America, telehealth remains underutilized. This disparity raises questions about the relevance and adaptability of telehealth business models beyond the pandemic. As we continue to navigate the post-pandemic landscape, it is essential to evaluate whether these models can effectively meet the evolving needs of rural healthcare and bridge the existing gaps in access and utilization. The future of telehealth in these settings depends on its ability to adapt and remain a viable solution for healthcare challenges.

Telemedicine Sustainability 3 Introduction Telemedicine, defined as the employment of electronic information and communication technologies to deliver and facilitate healthcare services across geographical distances (Haleem et al., 2021), has been a critical component of modern healthcare and gained unprecedented prominence during the COVID-19 pandemic, demonstrating its ability to sustain healthcare delivery amidst global disruptions. It emerged as a vital resource, targeted for the underserved and those in rural areas, offering a glimmer of hope in bridging longstanding healthcare disparities. However, despite its potential, telehealth's utilization in these rural settings has been surprisingly limited. This raises pivotal questions about the ongoing relevance and sustainability of current telehealth business models in a post-pandemic world. To address concerns of sustainability, it's crucial to understand the multifaceted nature of telehealth, its challenges, and opportunities in rural America, and to contemplate its future trajectory in a rapidly evolving healthcare landscape through a comprehensive analysis of telehealth’s impact, its underutilization in rural areas, and the need for adaptable, resilient business models to ensure its continued efficacy and relevance in addressing rural healthcare needs. History of Telemedicine Understanding the dynamic of the telemedicine business within the context of sustainability in rural America begins with understanding how such healthcare delivery practices came into existence. Gogia (2020) delves into the practice of telemedicine over the years, tracing its evolution from the 1970s with the development of satellite technology, through the 1980s and 1990s as personal computers, the internet, and disaster response integration enhanced its accessibility, to its expansion in the 2000s for in-home patient care, its application in developing countries in the 2010s, and its pivotal role during the COVID-19 pandemic in the 2020s (Gogia

Telemedicine Sustainability 4 (2020). Arguably the biggest driver of widespread telemedicine utilization has been the advancements and increased accessibility to the associated technologies. These have included increased bandwidth and improved internet connectivity for high-quality telemedicine services, the development of new mobile health devices and wearable sensors for remote patient data collection, and the use of artificial intelligence and machine learning to analyze patient data for personalized care recommendations and enhanced care delivery efficiency (Waller & Stotler, 2018). As technology advanced and became more accessible, and adoption of telemedicine services began to increase, many benefits of telemedicine were presented to the healthcare community, for both providers and their patients. Providers saw benefits of increased access to patients, especially in rural or underserved areas, improved patient outcomes through remote monitoring and timely interventions, reduced healthcare costs due to a decreased need for in- person visits, and enhanced job satisfaction and work-life balance, whereas patients received improved access to healthcare, particularly for those with mobility limitations or transportation difficulties, reduced travel time and costs, enhanced convenience and flexibility, and improved patient-provider communication and engagement (Hjelm, 2017). Hjelm (2017) also provides insights into the subsequent drawbacks of telemedicine utilization including the potential for reduced reimbursement rates for healthcare providers and a sense of technology dependence for patients, who may become overly reliant on telemedicine and neglect the importance of in- person care for certain conditions (Hjelm, 2017). Arguably the most disconcerting aspect throughout the history of telemedicine is that, despite its development to aid those in rural areas with limited healthcare access, it remains significantly underutilized in these such when compared to its adoption in more urbanized areas

Telemedicine Sustainability 5 Although there are numerous factors to the underutilization of telemedicine in rural areas, arguably one of the strongest is related to the technology required to support such healthcare delivery. Baker and Stanley (2018) outline the technical requirements for telemedicine delivery, which include a secure, high-speed internet connection essential for real-time video conferencing; a clinical telemedicine cart equipped with necessary devices and medical peripherals for patient-provider interaction; patient access software for secure and user-friendly access to appointments and records; and access to IT professionals for setup, maintenance, and troubleshooting of the telemedicine system (Baker & Stanley, 2018). These, however, are the most basic of requirements, with Baker & Stanley (2018) also recommending that telemedicine programs incorporate robust security measures for HIPAA compliance, assess network bandwidth to prevent bottlenecks, establish redundancy and backup systems for continuity, and conduct regular maintenance and updates to keep pace with evolving technologies (Baker & Stanley, 2018). From the patient’s perspective, technology requirements often include reliable broadband for consistent telemedicine, low-bandwidth tools for limited internet access, device distribution, and training programs, multilingual services for diverse linguistic needs, and telemedicine-equipped community centers for those without personal technology access. (Baker & Stanley, 2018). In the context of technical requirements, one variable that is often unaccounted for is the end-user experience, resulting in systems that are not tailored to the needs and expectations of the user, both the healthcare provider and their patients. This end-user experience is often the key driver in successful telemedicine implementation, with a study performed by Klaassen et al. (2016) emphasizing that understanding and applying various usability methods is essential for meeting the diverse needs of different end-user groups and applications in telemedicine, such as those in more rural settings (Klaassen et al., 2016). These variabilities in

Telemedicine Sustainability 6 end-user needs often result in telemedicine technology lacking critical functionalities for those in rural areas, such as offline mode or the telemedicine delivery system that does not require real- time internet connectivity (Chandwani & Dwivedi, 2016). Offline mode functionality removes the need for broadband internet access to utilize telemedicine, an issue often faced in more rural areas. Technical Requirements and Current Offerings The advancements in telemedicine technology discussed earlier have provided both healthcare providers and their patients with multiple avenues for telemedicine delivery. Many are familiar with the more traditional offerings of telemedicine which leverages technology like video conferencing, digital data exchange, and remote monitoring tools to facilitate patient care, consultation, and medical procedures remotely. While many are familiar with traditional telemedicine offerings, which use technology such as video conferencing, digital data exchange, and remote monitoring tools for patient care and consultations (Gogia, 2020), the scope of telemedicine extends further to include safety and security monitoring through devices like gas sensors and flood and fire detectors, health parameters and vital signs monitoring, including heart rate, blood pressure, body temperature, and glucose levels, as well as support through information and communication technology, encompassing teleconsultations, SMS reminders for appointments and medications, and educational text messages (Magdalena, 2015). The COVID- 19 pandemic brought an increase in telemedicine utilization, both in urban in rural areas, but significantly more so in urban areas of the United States. A study performed by Chu et al. (2021) found that although usage significantly increased in both urban and rural settings, it increased significantly more in urban areas (220 visits per 1000 urban patients) when compared to rural areas (147 visits per 1000 rural patients) (Chu et al., 2021). Despite the variety of offerings

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