Social distancing measures instituted during the COVID-19 pandemic challenged the usual way of operating in primary care. To continue delivering medical services, physicians had to transition quickly to forms of remote interaction with patients. Use of technology appeared to be the answer. And it gave clinicians the ability to do what many had long hoped for: offer patients the option of telehealth.
The terms telemedicine and telehealth have similar definitions and are commonly used interchangeably. We think most practices probably would have adopted telehealth earlier were it not for reimbursement barriers. In this article, we adopt the World Health Organization’s definition of telemedicine as: “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”1
To provide family medicine clinicians with evidence-based recommendations about telehealth, we conducted a critical review of the literature published through April 30, 2021. The scope of this review includes studies found using the PubMed and Google Scholar databases. In addition, we used the keywords “telehealth,” “telemedicine,” “family medicine,” and “primary care.” We divided this review into 6 sections, including focus areas on implementation in primary care, remote diagnostic accuracy, conditions lending themselves to telehealth, physician and patient perceptions, disparities in telehealth, and finally, the conclusions.
Telehealth implementation in primary care
Telehealth in various forms had been around for years before the pandemic, mainly in the form of commercial telehealth businesses. Telehealth was being used in rural and remote areas where it could be difficult to see a primary care provider—let alone a specialist. The family medicine department of the University of Colorado was an early adopter of telehealth and had navigated this transition since 2017, with clinical champions guiding the process. By 2019, 54% of their clinicians were conducting telehealth encounters.2
However, telehealth implementation elsewhere was not accepted so readily. Before the pandemic, a cross-sectional study of more than 1.1 million patients in Northern California showed that 86% preferred in-person care over video.3 Even as the pandemic began and social distancing measures were implemented, a quality improvement project at a family medicine residency clinic in Florida documented that clinicians still preferred telephone interviews despite the capacity for video visits.4 And many primary care systems were simply unprepared to adopt telehealth technologies.
With time, however, family physicians began to improvise using popular videoconferencing technologies (eg, Zoom) that were readily available and familiar to patients, and medical centers began to repurpose their existing videoconferencing systems.5 The Ohio State University Wexner Medical Center launched a virtual health initiative just before the pandemic struck, at which time fewer than 5% of patient visits were conducted through telehealth. Weeks later, nearly 93% of patient visits were offered through telehealth.6
Reimbursement. Another significant impediment to early telehealth uptake was the late reaction by the Centers for Medicare and Medicaid Services (CMS) in changing the payment system. Hectic expansion of telehealth in response to the crisis pointed to the lack of policies that supported primary care with payments based on outcomes rather than fee-for-service models.7 By the end of April 2020, CMS finally announced that video visits would be reimbursed at the same rate as in-person visits. However, telephone-only visits are still very limited in coverage, and appropriate codes should be verified with payers.
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