To address the threat of COVID-19, lawmakers in March relaxed regulations preventing medical providers and patients from connecting through technology. Under the CARES Act, telemedicine expanded rapidly, introducing many patients and providers to new ways of interacting. Many realized that telemedicine works. It’s both convenient and efficient. It’s not for everything, but it’s capable of a much larger role, especially in underserved rural areas lacking specialty care.

The Helmsley Charitable Trust’s Rural Healthcare program has invested over $100 million in the expansion of telemedicine and views its increased use as a win for healthcare providers and patients.

“What the promise of telemedicine allows is that it doesn’t matter what your zip code is,” said Kevin Kincaid, CEO of Knoxville Hospital & Clinics in Knoxville, Iowa. “You have the same access to a provider.”

The question turns now to what will happen once the threat of COVID-19 wanes. How much will remain of the recent changes to regulations and reimbursement practices that allowed telemedicine to expand?

“Telemedicine is out of the barn,” said Dr. Jennifer McKay of Avera McKennan Hospital & University Health Center in Sioux Falls, S.D. If regulations and reimbursement don’t adapt, she said, health care will be harmed.

Telemedicine exists in many forms. Some behind-the-scenes forms have proven themselves. Telemedicine established itself in radiology long ago, Kincaid said. It’s accepted.

Telemedicine also extensively augments rural emergency services. At Madelia Community Hospital in Madelia, MN, an agricultural community of 2,500 people, the use of emergency telemedicine through Avera eCARE has grown since it arrived in 2012, said OR/ER Supervisor Jen McLaughlin.

“When we know a severely injured patient is coming in, we push our easy button and connect with e-emergency,” she said. It allows Madelia’s nurses to focus on patients while the folks at eCARE arrange for patient transfers and handle documentation.

With eCARE, “We have access to experts at our fingertips,” McLaughlin said. In her rural area, where she knows nearly everyone who walks through the door, it’s also helpful to have input from those not emotionally invested.

McLaughlin foresees telemedicine expanding in rural areas, especially in behavioral health, hampered by a severe shortage of providers.

While telemedicine may have become integral to healthcare’s inner workings, the wariness of providers and especially patients slowed expansion into direct patient care.

The technology needed for the expansion existed. In rural areas, much was funded by The Leona M. and Harry B. Helmsley Charitable Trust, Kincaid said.

Community health systems have operated on the thinnest of margins for a decade, Kincaid said, so without Helmsley’s capital assistance, the rural expansion of telemedicine wouldn’t have been possible.

“That investment,” he said, “is changing the landscape of rural healthcare.”

Healthcare leaders, meanwhile, increasingly accepted that telemedicine would grow in importance with the further evolution of hospital care into clinical care.

Prior to COVID-19, Kincaid said, “I was going to a lot of conferences around the country, and the whole idea of virtual acute care and virtual primary care was taking hold.”

Participants envisioned parents dialing in to ask whether they could take a recovering child to daycare. Knoxville’s hospital developed the processes and policies necessary to implement virtual acute care.

Providers, however, retained a slight preference for seeing patients in front of them, Kincaid said. Rural patients were outright skeptical of telemedicine.

“Most people in our area didn’t want it,” Kincaid said. “They would rather get out of their pajamas and bring their child to the hospital.”

It was what they were accustomed to, he said, and they liked it.

Suddenly, COVID-19 came along and shut down access between providers and patients, also halting provider reimbursement. The CARES Act then expanded telemedicine to restore both.

“Providers were saying ‘Thank God we have this,’” Kincaid said

Patients gained real-life experience, and many came away thinking, “That was pretty good. Pretty handy,” Kincaid said.

Kincaid recalled feeling skeptical about entering his credit card number for his first online purchase, but how it quickly became part of daily life.

Technology has integrated with education, finance, retail and government, he said, but healthcare was left behind.

“Now is the time to finally advance that technology that every other industry has,” Kincaid said.

McKay said the data demonstrates telemedicine’s potential for rural areas.

“Was telemedicine the reason we did not see the (COVID-19) surge we expected in South Dakota?” she asked. “The answer is yes.”

Data from a rural gestational diabetes program, meanwhile, shows it eliminated 55,000 miles of travel for participants. “Lost days of work were in the 300 to 400 range,” McKay said. “It’s a smarter use of resources for sure.”

As the CEO of a rural hospital, Kincaid said, he’s a “core believer that somebody who chooses to live in a rural area should have the same access to care as somebody in a metro area — in emergency care, in specialty care. But in much of country, that’s just not the case. It’s an access issue the more rural you get.”

Every American citizen should have equal access to expertise, he said.

“Telemedicine is a huge piece of being able to fulfill that promise,” Kincaid said.

What will happen to telemedicine’s expansion as the threat of COVID-19 subsides?

“There’s always in healthcare an urge to go back to where we’re most comfortable,” Kincaid said, but there’s been headway. COVID-19 put a spotlight in the corner of just how much we can do with technology to augment things, not only in providing care but in keeping people well.

And even with its recent advance, telemedicine could still go further.

To catch up with other industries, McKay said, telemedicine must progress in terms of interoperability – “In the same way you can go to any bank in the world and draw from your account, I could put an action plan in place for you from any place you are at from any place I am, using technology.”

Hospital administrators and physicians also ponder their future should telemedicine’s expansion continue.

“As the CEO of a bricks and mortar organization,” Kincaid said, “I think about that question a lot.”

Knoxville is considering a large building project.

“Should I do that?” he asked. “What does virtual med do?”

There’s no way telemedicine will take away the need for hands-on medicine, he said.

“One does not replace the other,” Kincaid said. “It is clearly a complement.”

He once wondered whether a large investment in telemedicine would reduce the need for providers.

“I’m not finding that to be true,” he said. “Our providers in the rural community can do a better job in their craft because of instant access to expertise that they didn’t have before,” he said. “It doesn’t replace the need for hands-on care.”

It could, however, temper the amount of bricks and mortar needed moving forward.

McKay has concerns regarding artificial intelligence.

“What makes medical providers special is our humanness,” McKay said, and technology must be viewed as a clinical tool in the hands of a physician.

“Because I have technology helping me, I feel more like a doctor than I ever have.”