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Financial Impact of Telehealth: Rural Chief Financial Officer Perspectives

Publication
Article
The American Journal of Managed CareDecember 2022
Volume 28
Issue 12

Interviews with chief financial officers of rural hospitals revealed that they perceived telehealth to have some financial advantages; however, they did not believe that telehealth improved their hospitals’ financial situations.

ABSTRACT

Objectives: To explore the perceived impacts of a variety of telehealth services on hospital finances and assess how hospital administrators make decisions about adopting telehealth programs.

Study Design: From October 2021 to January 2022, we conducted semistructured interviews with chief financial officers (CFOs) of rural hospitals.

Methods: Recruitment occurred in collaboration with 6 rural health collaboratives and hospital associations that facilitated CFO peer-learning groups. We used inductive and deductive approaches informed by a health care innovation adoption model to identify themes in the qualitative data.

Results: Twenty rural hospital CFOs and other hospital administrators from 10 states participated in interviews. Seventeen (85%) represented critical access hospitals and 3 (15%) represented short-term acute care hospitals. Although CFOs believed telehealth has some financial advantages (eg, can help to avoid patient transfers), they did not believe that telehealth improved their hospitals’ financial situations. CFOs, rather, seem motivated to implement telehealth services to improve quality of care and address patients’ needs. CFOs reported that limited reimbursement, low volumes, preference for in-person care, and insufficient broadband were key challenges to telehealth’s financial viability.

Conclusions: Understanding how CFOs think about the return on investment of telehealth can inform efforts to promote telehealth utilization in rural communities and to develop policy solutions to make telehealth more sustainable. CFOs may benefit from guidance on promising practices and cost-effective implementation strategies. Policy makers could take steps to improve telehealth’s financial attractiveness (eg, through payment parity, subsidies to improve technology infrastructure).

Am J Manag Care. 2022;28(12):e436-e443. https://doi.org/10.37765/ajmc.2022.89279

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Takeaway Points

Telehealth has been promoted as a solution to the financial challenges facing rural hospitals; however, interviews with chief financial officers (CFOs) did not support that assertion.

  • Although CFOs believed telehealth has some financial advantages, they did not believe that telehealth improved their hospitals’ financial situations.
  • CFOs may benefit from guidance on promising practices and cost-effective implementation strategies.
  • Policy makers who are interested in expanding telehealth to increase access to care could take steps to improve its financial attractiveness (eg, through payment parity, subsidies to improve technology infrastructure).

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Telehealth is promoted as a solution to the financial challenges facing rural hospitals and a means of preventing hospital closure.1 For example, a Health Resources and Services Administration–sponsored Toolkit for Critical Access Hospitals asserted that telehealth decreases staffing costs and increases hospital revenue by reducing transfers to other hospitals.2 Despite these potential advantages, adoption of different telehealth services (eg, telestroke, tele–intensive care unit [tele-ICU], telehealth for outpatient specialty consults) varies significantly across rural hospitals. A 2019 study from prior to the COVID-19 pandemic showed that 46% of rural emergency departments (EDs) did not have telehealth services and that cost was the biggest barrier to implementation.3

A hospital’s decision to invest in new medical technologies is a complex one; adoption decisions are typically made by hospital leadership including clinicians and chief financial officers (CFOs). The more costly a proposed innovation, the more scrutiny it will receive,4 as hospital leaders weigh a variety of factors, including the likely return on investment.

Despite the critical role of perceived financial impact on the decision to implement telehealth, no prior research has explored the perspectives of rural hospital administrators on the business case for telehealth. Research on telehealth has historically focused on the experiences and attitudes of clinicians and patients,5-9 and although these stakeholders are critical, these parties do not typically have insight on the financial impacts or sustainability of telehealth programs in rural areas. Understanding how CFOs think about the return on investment of telehealth can inform efforts to promote telehealth utilization and to develop policy solutions to make telehealth more sustainable. We conducted interviews with rural hospital CFOs to understand the perceived impacts of a variety of telehealth services on hospital finances and how hospital administrators make decisions about adopting telehealth programs.

METHODS

Conceptual Framework

Our approach to data collection and analysis was informed by Flessa and Huebner’s health care innovation adoption model.10 In this framework, we assume that a hospital CFO is in a position to be an administrative promoter of telehealth adoption. CFO support for a new telehealth service is influenced by many factors including the inclination to innovate (which depends in part on tolerance for risk) and the perceived financial impacts, including impact on revenue and costs. Further, the model suggests that CFOs will support an innovation only if they perceive system deficiencies. Because many rural hospitals face continued financial losses, we argue that many rural hospital CFOs will agree that change is necessary, and this will increase their support of telehealth. However, rural hospitals also have a number of characteristics that decrease the likelihood that they will embrace new innovations. For example, literature suggests that hospitals with less competition and fewer patients with private insurance are less likely to implement innovations.4

Study Sample

From October 2021 to January 2022, we conducted semistructured interviews with CFOs of rural hospitals. To recruit, we contacted 16 state-level organizations (rural health collaboratives and hospital associations) that hosted peer-learning networks in which CFOs met regularly to share resources. Six agreed to share recruitment materials and background on the study with participating CFOs via email and in standing meetings. CFOs were asked to contact the study team if they were interested in participating. Some organizations advertised the study to all CFOs in their networks, whereas others selected a subset. The organizations that selected a subset were asked to advertise the study to CFOs who varied with respect to rural location (rural vs frontier), hospital type (critical access hospital vs short-term acute care hospital), financial health, and types of telehealth programs. This instruction helped to support maximum diversity sampling. The only inclusion criterion was that each CFO represented a rural hospital.

We invited every CFO who contacted the study team to participate, and we continued to recruit until we reached thematic saturation, defined as the point at which new interviews did not uncover new themes.

Data Collection

Interviews were conducted via videoconference and followed a semistructured protocol. Topics included (1) basic hospital information (eg, location, payer mix); (2) existing telehealth programs in the ED, inpatient, and outpatient settings; (3) perceptions about the financial impact of each program; (4) drivers of financial impacts; (5) the role of telehealth in strategic planning efforts; and (6) policy and other barriers to the financial sustainability of telehealth. Two members of the study team (L.U.-P. and J.L.S.) trained in qualitative research conducted the 60-minute interviews, and study staff recorded and transcribed the interviews. Each participant received a $150 gift card for their time, and they provided verbal informed consent to participate. The RAND Institutional Review Board approved this study.

Analysis

We coded interview transcripts using qualitative research software (Dedoose version 9.0.17 [SocioCultural Research Consultants LLC]). We developed a hierarchically organized codebook to summarize themes and identify patterns. We used standard qualitative analysis techniques consisting of both inductive and deductive approaches to identify and characterize instances of themes arising from the domains in the conceptual framework interview guide, as well as unanticipated themes that emerged. The lead author (L.U.-P.) coded all transcripts, refining the codebook as she worked and adding relevant probes to interviews in progress.

We defined a theme as a concept noted by at least 2 participants. When identifying themes, we not only considered cohesiveness and prevalence across participant responses, but also incorporated perspectives that were inconsistent (ie, negative case analysis). We achieved consensus regarding the characterization of themes through interactive discussions among the research team.

To improve internal validity and transferability, we conducted respondent validation. We presented preliminary findings to 14 CFOs in a group meeting hosted by one of the participating organizations. Respondents largely affirmed the findings and provided additional context for certain points.

RESULTS

Twenty CFOs and other hospital administrators from rural hospitals in 10 states participated in interviews. Seventeen (85%) represented critical access hospitals and 3 (15%) represented short-term acute care hospitals. Sixteen (80%) represented hospitals with 25 or fewer beds, and 10 (50%) represented hospitals that operated at a financial loss in the prior 3 years (Table 111).

Most CFOs reported having multiple telehealth programs at their hospitals including inpatient services, ED-based services, and outpatient services. The most common inpatient or ED program was telestroke and the most common outpatient service was tele–behavioral health. For inpatient or ED telehealth, the rural hospital generally served as the hosting site and connected patients to remotely located specialties. For outpatient telehealth, the hospitals sometimes served as the hosting site and at other times as the distant site (eg, rural health clinic providers employed by the hospital delivered telehealth visits to patients in their homes).

Most CFOs believed that telehealth was a loss leader or had a neutral impact on hospital finances. All but 1 hospital in the sample operated multiple telehealth programs; however, CFOs reported that they were more motivated to implement telehealth to improve quality, and in some cases to keep up with competitors, rather than to improve their financial position.Although participants provided a few examples of select telehealth services that resulted in direct financial advantages, they provided more examples of telehealth programs that did not. Further, although participants felt that some specific services could have benefits, when reflecting on telehealth more broadly across multiple inpatient and outpatient services, CFOs were not enthusiastic about telehealth’s direct financial advantages. Table 2 features relevant quotes. According to a CFO from Iowa, “All these telehealth models that we’re talking about are just new expenses brought on to the hospital without any kind of return on investment at all.…Now, all those things are a little harder…to get your arms around the exact dollar amount. But [telehealth results in] major, major improvements in the quality of our care, the safety of our care.” A CFO from Oregon stated, “[Telehealth] is probably a little bit of a loss leader, but I think that we are a community health care provider that is really honestly more concerned about offering services.”

Further, telehealth was not featured prominently in strategic planning. Only a handful of CFOs discussed their long-term plans for telehealth. A CFO from Washington stated, “We have not specifically discussed telemedicine as part of our strategy plan moving forward.…We’re trying to remodel our hospital. So, a lot of our thought process is going toward that right now.” A CFO from West Virginia said, “[Telehealth] is not a big focus. I don’t see specific initiatives for next year for that, but…one of our [priorities], of course, is lowering the cost of health care.” A CFO from Wisconsin explained, “In our last strategic planning cycle, we weren’t focused at all on telemedicine…; we were still really focused on getting [more patients and providers].” When telehealth was discussed as part of a strategic plan, the focus was on increasing specialties via telehealth and growing remote patient monitoring programs.

Despite this general belief that telehealth was not profitable, CFOs did identify several direct and indirect financial benefits of select services. Table 3 [part A and part B] lists financial benefits and illustrative quotes. Just under half of interview participants reported that inpatient and ED-based telehealth programs help avoid patient transfers, allowing the hospital to retain more patients. Given that hospitalizations bring in a lot of revenue, some hospitals used telehealth as a strategy to increase inpatient volume and, by extension, their financial position. The next most commonly cited financial benefit applied to outpatient telehealth. Here, several CFOs believed that telehealth visits for primary care and specialty care may not generate much revenue on their own, but they can drive more profitable ancillary services (eg, laboratory testing). A handful of participants identified additional benefits. First, if a hospital can prevent transfers through inpatient telehealth and offer more complete services through outpatient telehealth, it can reduce the risk that it will permanently lose patients to competitors. Second, starting an inpatient telehealth program (eg, telehospitalist) is less expensive than having a full-time, in-person provider and can reduce both direct labor costs and costs of recruitment. Third, during the pandemic, telehealth helped to sustain some outpatient practices because in-person visit volume dramatically declined.

CFOs were asked to explain the disconnect between a general belief that telehealth is a loss leader and these positive financial impacts. First, they clarified that telehealth requires substantial initial investments in the technology, and the downstream financial benefits are hard to quantify and are not always realized. A CFO from Iowa explained that some benefits “do not show up on a spreadsheet.” Further, CFOs pointed out that the utilization of the telehealth service is often not high enough to have significant downstream impact. Lastly, a belief that in-person care is generally superior to telehealth and should be provided when possible may have influenced their perceptions about financial advantages. The same CFO from Iowa explained, “That personal connection has been a cornerstone of how care is provided [in rural communities]…[it involves] actually touching [the] patient.”

CFOs mentioned several factors that prevented telehealth from being more profitable, including low reimbursement, the fact that services are often low volume, and lack of broadband. Several participants pointed out that reimbursement was too low for telehealth, particularly for outpatient rural health clinic visits. A few mentioned that with telehealth services, non–critical access hospitals may forgo the facility fee (ie, a fee that health care organizations can bill for a patient’s use of hospital facilities and equipment). Further, within rural health clinics, telehealth visits have extra technology costs and are reimbursed less. According to a CFO from Maine, “The rate that we get for a telemedicine visit is a quarter to a third of what we get paid for an in-person visit…But we still have to have all the staff, we still have to bill…[and] register the patient [and]…do everything just like the patient was coming in the building. So, there’s really not a lot of cost savings, but they don’t allow us reimbursed cost on those visits. We only get fee schedule reimbursement. And the way that the cost reporting works, it actually pulls cost away from our other functions for those visits.”

Cost-based reimbursement from Medicare for critical access hospitals reduces some of the financial risk associated with implementing telehealth because most costs are supported; however, not all costs related to telehealth implementation are allowable. A CFO from Maine explained, “Certain things with telemedicine are allowable. [With our] e-hospitalist [program], one of [the] most expensive telehealth services that we’re doing…we don’t receive any support for that as it relates to cost-based reimbursement.”

Further, CFOs pointed out that frequently, the low rate at which telehealth services are utilized means they cannot be profitable. This is the case because of both the fixed, limited demand for services in a small community and rural culture, in which in-person connection is valued.

Finally, limited broadband in rural communities has discouraged hospitals from growing outpatient telehealth programs that serve patients in their homes. Also, limited broadband requires that hospitals invest more in infrastructure when establishing inpatient programs. A CFO from West Virginia explained, “I think [outpatient telehealth is] an opportunity for us to expand, but I do feel like we’re going to be limited because of the location. We’re at the mercy of someone having internet or having the capability. We’re not projecting increased volumes because of those limitations.” A CFO from Wisconsin explained how broadband can be challenging for inpatient programs as well: “If you’re going to provide a tele-ICU solution, you’re going to have to make sure that you have some significant redundancies in your [information technology] infrastructure…[and] anytime you’re putting in fiber infrastructure, it is a really expensive venture for a small critical access hospital.…I guess that’s one major risk that I see in rural telemedicine, especially when you’re talking [about] more critical levels of care: You just can’t afford to have it go down. Having significant downtime is just not an option. That part is a little scary, because you don’t have your specialists here on site.”

Participants also expressed a variety of views about how competition posed challenges for their telehealth offerings. One CFO from West Virginia pointed out that her hospital was concerned that if it aggressively pursued telehealth for outpatient specialty care, patients who prefer in-person care would go elsewhere for care. A CFO from Oregon echoed a similar concern: “If you’re doing telemedicine [for outpatient specialty care], you don’t have to go to our hospital. You can go to those tertiary facilities that are offering the telemedicine.”

CFOs identified several policy barriers that affected telehealth financial viability, including lack of payment parity, uncertainty about the reimbursement environment, and the requirement that critical access hospitals maintain an average length of stay of less than 96 hours. Several CFOs mentioned that lack of payment parity for telehealth and in-person visits, especially for rural health clinic visits, was a barrier to the growth of telehealth programs. As stated earlier, Medicare reimburses less for rural health clinic telehealth visits, and as an additional challenge, telehealth visits are carved out of cost-based reimbursement, so they involve additional accounting challenges. An important reason why lack of parity is a concern is that there is fixed demand for outpatient visits in many rural communities. As such, replacing an in-person visit that generates more revenue with a telehealth visit that generates less revenue is problematic. A CFO from Washington state explained, “[Telehealth] was a glaring concern, because [the reimbursement for] itwas approximately $110 less than what we normally get reimbursed for an in-person visit. And since we are kind of volume based, the providers…can do quite a few more telehealth visits, if that’s what they’re doing. But we have such a small volume in general that they’re replacing all the in-person visits…[and] there’s not enough [patients] to have [providers] double up on total visits.” Several CFOs also pointed out that uncertainty about the reimbursement environment and how reimbursement will change as the pandemic evolves has prevented them from optimizing telehealth services and making them as efficient as possible. A CFO from Illinois stated, “We just haven’t felt comfortable enough to aggressively look at that service optimization.”

Finally, a few CFOs mentioned that the requirement that critical access hospitals maintain an average length of stay of less than 96 hours was a barrier to the growth of their inpatient and ED-based telehealth programs. The concern was that with a program like tele-ICU, hospitals would keep higher-acuity patients with longer inpatient stays. However, there was not universal agreement on whether this rule posed a significant threat to the growth of telehealth. A CFO from California explained, “At the critical access hospital, the average length of stay has to be less than 96 hours…So, if we’re doing telehealth, we are able to treat things that are going to [increase] their length of stay.…Ordinarily, if you didn’t have telehealth, you would discharge them.” In contrast, a CFO from Maine pointed out, “It’s the overall average for your entire population. But I don’t think the one rare [telehealth] patient here or there would impact my average length of stay.”

When asked about lessons learned and advice to other rural hospitals, several CFOs suggested that rural hospitals pursue grants to cover technology costs, choose a distant site that is not in a position to cannibalize your business (ie, don’t partner with a local organization that could be a source of competition for patients), and consider hidden costs when starting programs (eg, ensure that whatever system you implement captures data elements required for external reporting so that additional funds are not needed to develop solutions after the fact).

DISCUSSION

Telehealth has been promoted as a solution to the financial challenges facing rural hospitals; however, discussions with CFOs in our study did not support that assertion. Although CFOs believed that some select telehealth services had financial advantages, they did not believe that telehealth overall improved their hospitals’ financial situations. CFOs, rather, seem motivated to implement telehealth services to improve quality of care and address patients’ needs. Limited reimbursement, low volumes, preference for in-person care, and insufficient broadband are key challenges to telehealth’s financial viability. Given CFOs’ lack of enthusiasm for the direct financial benefits of telehealth, we were surprised that so many hospitals in our sample had multiple, robust telehealth programs.

CFOs in our sample identified many of the same financial advantages that other literature has discussed, including increased local revenue for ancillary services, reduced labor costs (eg, from sharing distant site personnel with other facilities), and fewer transfers.1,2,12,13 Our results are consistent with those of a study by Haque et al, which also identified somewhat negative views about the financial impact of telehealth. Similar to our findings, hospital staff from frontier critical access hospitals reported that the high upfront costs for equipment combined with low use would likely lead to a negative impact on financial performance.14

Limitations

A key limitation is that CFOs who agreed to participate in this study may have more interest in telehealth and/or more extreme views of (both in support of and against) telehealth.

CONCLUSIONS

Our study findings imply that CFO perceptions regarding financial impacts will be a barrier to the continued growth of rural telehealth. Although we explored perceptions of the financial impact rather than quantitative data on actual impacts, we argue that CFO attitudes are highly relevant to decisions to invest in telehealth.

It is possible that telehealth does have financial advantages that CFOs have not yet observed directly. If so, they could benefit from guidance on promising practices and examples of successful programs that could in turn influence their perceptions and increase their support for telehealth. This might include a focus on more cost-effective implementation strategies. A 2015 study by MacKinney et al showed that a tele-emergency program can generate a $187,614 profit in a high-revenue/low-expense scenario and a $69,588 loss in a low-revenue/high-expense scenario.15

Another possibility is that the financial benefits of telehealth to rural hospitals are exaggerated. If telehealth really “doesn’t pay” in the majority of cases, then policy makers who are interested in expanding telehealth to increase access to care should take steps to improve its financial attractiveness (eg, through payment parity, subsidies to improve technology infrastructure). Further, policy makers can work to finalize permanent, postpandemic telehealth policy. CFOs may be reluctant to optimize telehealth services and thus achieve these services’ true potential until there is a clear signal as to what reimbursement for different telehealth services will look like in coming years.

Acknowledgments

Recruitment for interviews would not have been possible without the support of numerous organizations, including but not limited to California Hospital Association; Healthcare Education Foundation of West Virginia; Iowa Hospital Association; Mid-Atlantic Telehealth Resource Center; Oregon Association of Hospitals and Health Systems; Rural Maine Health Collaborative, LLC; Rural Wisconsin Health Cooperative; South Central Telehealth Resource Center; and the Washington Rural Health d/b/a Rural Collaborative.

Author Affiliations: RAND Corporation, Arlington, VA (LU-P), and Boston, MA (JLS); Massachusetts General Hospital (KSZ, LS), Boston, MA; Harvard Medical School (KSZ, LS, AM), Boston, MA; Beth Israel Deaconess Medical Center (AM), Boston, MA.

Source of Funding: This research was supported by a grant from the National Institute of Neurological Disorders and Stroke (R01NS111952).

Author Disclosures: Dr Zachrison received funding from the Massachusetts General Hospital Executive Committee on Research to study adoption of telehealth in and innovations in telehealth use by US emergency departments related to COVID-19. Dr Schwamm reports the following relationships relevant to research grants or companies that manufacture products for telemedicine, thrombolysis, or thrombectomy: scientific consultant regarding trial design and conduct on late window thrombolysis and member of steering committee for Genentech (TIMELESS NCT03785678); user interface design and usability to LifeImage (privately held teleradiology company); stroke systems of care to the Massachusetts Department of Public Health; member of a data safety monitoring board for Penumbra (MIND NCT03342664); principal investigator, multicenter trial of stroke prevention for Medtronic (Stroke AF NCT02700945); principal investigator, StrokeNet Network, NINDS (New England Regional Coordinating Center U24NS107243); coinvestigator, The Impact of Telestroke on Patterns of Care and Long-Term Outcomes, NINDS (R01NS111952); and coinvestigator, REACH-PC telepalliative care trial, PCORI (NCT03375489). Dr Mehrotra has consulted for NORC, Pew Charitable Trust, Sanofi, and the State of Massachusetts and has received grants from the National Institutes of Health, The Commonwealth Fund, and Arnold Ventures. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (LU-P, JLS, LS); acquisition of data (LU-P, JLS, AM); analysis and interpretation of data (LU-P, JLS, KSZ, LS, AM); drafting of the manuscript (LU-P, KSZ, JLS); critical revision of the manuscript for important intellectual content (LU-P, JLS, KSZ, LS); obtaining funding (AM); and administrative, technical, or logistic support (JLS).

Address Correspondence to: Lori Uscher-Pines, PhD, MSc, RAND Corporation, 1200 S Hayes St, Arlington, VA 22202. Email: luscherp@rand.org.

REFERENCES

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2. Schadelbauer R. Anticipating economic returns of rural telehealth. The Rural Broadband Association. March 28, 2017. Accessed August 1, 2022. https://www.ntca.org/ruraliscool/stories-innovation/anticipating-economic-returns-rural-telehealth

3. Zachrison KS, Boggs KM, Hayden EM, Espinola JA, Camargo CA Jr. Understanding barriers to telemedicine implementation in rural emergency departments. Ann Emerg Med. 2020;75(3):392-399. doi:10.1016/j.annemergmed.2019.06.026

4. Wernz C, Zhang H. Medical technology investment decision-making at US hospitals: a comparative case study of four organizations. Paper presented at: 51st Hawaii International Conference on System Sciences; January 2-6, 2018; Waikoloa Village; HI. Accessed August 1, 2022. https://scholarspace.manoa.hawaii.edu/handle/10125/50276

5. Donelan K, Barreto EA, Sossong S, et al. Patient and clinician experiences with telehealth for patient follow-up care. Am J Manag Care. 2019;25(1):40-44.

6. Powell RE, Henstenburg JM, Cooper G, Hollander JE, Rising KL. Patient perceptions of telehealth primary care video visits. Ann Fam Med. 2017;15(3):225-229. doi:10.1370/afm.2095

7. Fischer SH, Ray KN, Mehrotra A, Bloom EL, Uscher-Pines L. Prevalence and characteristics of telehealth utilization in the United States. JAMA Netw Open. 2020;3(10):e2022302. doi:10.1001/jamanetworkopen.2020.22302

8. Polinski JM, Barker T, Gagliano N, Sussman A, Brennan TA, Shrank WH. Patients’ satisfaction with and preference for telehealth visits. J Gen Intern Med. 2016;31(3):269-275. doi:10.1007/s11606-015-3489-x

9. Uscher-Pines L, Sousa J, Raja P, Mehrotra A, Barnett ML, Huskamp HA. Suddenly becoming a “virtual doctor”: experiences of psychiatrists transitioning to telemedicine during the COVID-19 pandemic. Psychiatr Serv. 2020;71(11):1143-1150. doi:10.1176/appi.ps.202000250

10. Flessa S, Huebner C. Innovations in health care—a conceptual framework. Int J Environ Res Public Health. 2021;18(19):10026. doi:10.3390/ijerph181910026.

11. Cost reports. CMS. Updated October 19, 2022. Accessed November 5, 2022. https://www.cms.gov/research-statistics-data-and-systems/downloadable-public-use-files/cost-reports

12. National Rural Health Resource Center. Critical access hospital telehealth guide. Northwest Regional Telehealth Resource Center. February 2022. Accessed August 1, 2022. https://nrtrc.org/resources/downloads/CAHTelehealthGuide.pdf

13. Dudas LM, Bardes JM, Wagner AK, White T, Wilson AM. Cost effective virtual intensive care unit expanding capabilities in critical access hospitals. Am Surg. Published online December 27, 2021. doi:10.1177/00031348211062653

14. Haque SN, DeStefano S, Banger A, Rutledge R, Romaire M. Factors influencing telehealth implementation and use in frontier critical access hospitals: qualitative study. JMIR Form Res. 2021;5(5):e24118. doi:10.2196/24118

15. MacKinney AC, Ward MM, Ullrich F, Ayyagari P, Bell AL, Mueller KJ. The business case for tele-emergency. Telemed J E Health. 2015;21(12):1005-1011. doi:10.1089/tmj.2014.0241

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