A telehealth platform integrated with an interoperable electronic health record (EHR) system can contribute directly toward achieving the often-discussed “quadruple aim” [1]—better health outcomes, improved patient experience, lower costs, and improved clinician experience. This paper develops a telehealth success model and discusses three critical components: (1) health information quality, (2) EHR system quality, and (3) telehealth service quality to ensure effective health care service delivery, reduce professional burnout, and enhance access to care.

Despite the benefits of telehealth in rural health, mental health, and Veterans Administration health services, disparities continue to exist in access to care. Patients without internet service, appropriate devices, or digital literacy skills experience greater challenges in accessing care via telehealth. The COVID-19 pandemic has also caused substantial financial strain on hospitals, and it is uncertain if the current reimbursement and payment model for telehealth service/devices and regulation flexibility for virtual consulting will continue after the pandemic is over.

To help integrate telehealth into clinical practice and improve patient care, health policy at the systemic level should accelerate the uptake of telehealth. On the industry level, hospitals should identify adoption strategies for different types of telehealth services and evaluate telehealth products for health care delivery. On the physician level, health providers should offer the same level of care and follow the same treatment guidelines for telehealth services as with in-person visits and ensure that their practices are compliant with applicable regulations.

Telehealth has become a rapidly growing sector of health care delivery systems. Previous studies show evidence that telehealth tools and services increase the overall effectiveness of physicians in (1) counseling patients with chronic conditions, (2) psychotherapy support for behavioral interventions, and (3) remote monitoring of patients [2].

The shortage of health providers and increasing consumer demand (from the aging population and people diagnosed with chronic diseases) were key factors in expanding the scope and scale of telehealth services [3]. The 2019 annual report of the Association of American Medical Colleges projected a shortfall of 40,000 to 122,000 physicians in the United States over the next decade, with a shortage of 29,000 to 42,900 doctors in 2020 [4]. To use telehealth as a new strategy to stretch the physician supply, the Interstate Medical Licensure Compact standardized licensing requirements that allow physicians to practice in multiple states and provide remote digitalized services [5]. To further remove regulatory and reimbursement barriers to telehealth services, telehealth parity laws require commercial health insurers to provide equal coverage for telehealth and in-person services in 38 states and the District of Columbia [6]. By January 2017, all state Medicaid programs reimburse teleradiology, 49 cover tele–mental health services, and 36 states cover various remote telehealth services [2].

The COVID-19 pandemic accelerated the adoption of telehealth tools and services. Amid the pandemic, some hospitals are seeing 500 to 600 patients per day via video or telephone visits [7]. To enable providers to use telehealth services, Medicare implemented temporary payment flexibility to allow more beneficiaries to benefit from virtual care services and more providers to be eligible to bill for telehealth services at the same payment rate as they would receive for in-person services [8]. The Centers for Medicare and Medicaid Services (CMS) added 135 allowable services, including emergency department visits; initial nursing facility and discharge visits; home visits; and physical, occupational, and speech therapy services [9]. With these initiatives, US provider systems are rapidly deploying digitalized services for two main goals:

This paper applies a conceptual model (Figure 1) based on Delone and McLean’s [11] model of information systems success to assess the impact of hospital medical record interoperability on telehealth service outcomes. As framed by Delone and McLean [11], a sustainable information system depends on positive results from the quality of information, service, and systems, as well as interrelated measures of user satisfaction, use, and net benefits.

Device interoperability and data integration are key aspects of telehealth delivery. Hospital interoperability (Figure 2) covers three types of information exchange: (1) sending, receiving, and incorporating health records that support electronic referral loops; (2) electronic access for both physicians and patients to their health information; and (3) public health surveillance that collects and integrates health-related data to assist planning, implementing, and evaluating public health practice [12].

For value-based care to achieve and protect patient safety, the EHR system needs to deliver accurate and clinically appropriate data across care settings to both physicians and patients. Studies suggest that hospital sharing of diagnostic data with providers within their system is associated with lower patient mortality, and the hospital interoperability level is associated with improved process quality related to conditions of acute myocardial infarction, heart failure, and pneumonia at acute care hospitals [13-15].

However, establishing a telehealth platform in a short period of time amid pandemic conditions could put health information—patient names, address, dates, diagnoses, and more—at higher risks to safety and security [16]. The introduction of increasingly complicated technology into already complex work environments may trigger various unintended interactions that undermine or outweigh the potential benefits of the new technology [17]. Moreover, with an exponential growth in clinical data, it becomes critical to code symptoms (eg, allergies) and medications correctly to ensure patient safety and care quality [18].

Integrating telehealth programs into a hospital’s existing EHR system infrastructure helps maximize the benefits of telemedicine, as providers and staff already have experience working with the baseline system [19]. Over 95% of US hospitals reported using a certified EHR platform [12]. However, many hospitals run separate systems for doctors, labs, radiologists, and remote monitoring devices; the technical and data incompatibilities between different vendors make data sharing more vulnerable to cybersecurity threats [20]. Suboptimally integrated systems also added clerical burdens on physicians that can help lead to professional burnout. For every hour of clinical work, physicians spent 2 hours on EHR-related tasks, threatening the capacity and performance of the health system [21].

In 2020, the US Office of the National Coordinator for Health Information Technology (ONC) established requirements for a secure standards-based application programming interface (API) to support each individual patient’s access and control of their electronic health information [22,23]. The increasing data volumes, new data types, and various data sources collected from telehealth services can make it difficult and labor-intensive to match or identify the correct patient between systems [24]. Thus, a wide-scale adoption of common standards would drive data sharing and make integration more consistent and efficient, thereby providing clinically useful information and mitigating physician burnout [25].

Advanced interoperability—especially at semantic and organizational levels—can enable telehealth to expand access, exchange information, and provide user-centered services to both physicians and patients [26]. Current telehealth services use devices such as wearable monitors, smartphones, mobile apps, video, email, and web portals to deliver three types of care: (1) remote monitoring of patients and collecting vital signs and health data for care plan management, (2) counseling and interacting with patients at home, and (3) triaging patients to screen them to reduce exposures to viruses and thereby free up hospital resources during emergencies [27].

Although most hospitals in the United States have adopted interoperable EHR systems, there is little evidence about whether small, rural, and safety net hospitals are keeping up [66]. Compared to more technologically advanced hospitals, smaller and rural hospitals have limited broadband access [59], less interoperability and health care IT management experience [67], and staff with less technological familiarity [68,69]. Because of the uneven adoption of telemedicine services, some small clinics and postacute care facilities are unable to receive or share patient data [70,71].

Substantial disparities in access to telehealth services also remain [72]. Evidence suggests geographical disparities, profit-based discrimination, technology deployment cost, and socioeconomic factors played key roles in the telehealth use gap [59,72,73]. Moreover, people 65 years and older, with disabilities, experiencing poverty, and who are non-White are less likely to use telehealth services because of lower smartphone or computer ownership, limited (home) broadband internet access, and low digital literacy [36]. A recent study of 134,225 completed primary care visits also reported that early adopters of online scheduling were more likely to be young, White, and commercially insured [74].

To ensure that EHRs cooperate effectively in an interoperable structure, substantial governmental regulation has been put into place. In the United States, CMS and the ONC regulate EHR privacy, security, and standards for hospitals or health providers and health IT developers [75,76]. In July 2021, the Interoperability and Patient Access final rule began to require CMS-regulated payers to remove industry siloes and support Patient Access API, Provider Directory API, and Payer-to-Payer Data Exchange to achieve greater semantic interoperability within the health care system while complying with existing Health Insurance Portability and Accountability Act (HIPAA) requirements [75,77]. On the technical level, CMS adopted Health Level 7 Fast Healthcare Interoperability Resources Release 4.0.1 to standardize implementing privacy and security features for provider organizations [78].

In the European Union, to facilitate cross-border EHR interoperability, the General Data Protection Regulation established explicit rules to process and protect patient health data [79]. On the technical level, the eHealth Digital Service Infrastructure has enabled provider organizations to exchange patient summaries and e-prescriptions [78]. In the Asia-Pacific region, Singapore, Japan, and Australia have instituted regulations on software qualification, software as a medical device, and presubmission consultation by regulatory authorities to facilitate EHR interoperability [80-82]. In Singapore, for example, the National Electronic Health Record system sets technical standards (including architecture, security, and operations) for the digital health market and monitors user functionality and risk to protect data security [83].

Studies suggest that telehealth programs paired with the right EHR system enhance care access, increase patient satisfaction, and reduce medical spending [84,85], and by improving clinician experience, the integrated system can contribute to achieving the quadruple aim.

To help integrate telehealth into clinical practice and improve patient care, on a systemic level, health policies should accelerate the uptake of telehealth, including tele–mental health, to improve care quality, cost-effectiveness, and value of care [86]. Federal and state governments can use disruptive reimbursement and funding strategies on training primary and mental health care providers, workforce, licensure, and cultural sensitivity for long-term telehealth practice [34,87]. Regulators also need to assess and set standards for malpractice liability and protect patient safety and confidentiality that may result from telehealth deployment [88].

On an industry/organization level, hospitals need to identify strategies to adopt and integrate different types of telehealth services, and evaluate telehealth products for health care delivery [66,70]. Future studies are needed to provide evidence on telehealth practice guidelines and service models.

On the physician level, clinicians who provide telehealth should offer the same level of care and follow the same treatment guidelines they would follow for in-person visits [89]. Moreover, physicians should closely follow HIPAA rules, state laws, and medical board definitions to ensure their practices are compliant with applicable regulations while implementing telehealth [57].