Telehealth is "the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration." Videoconferencing, store-and-forward imaging, and remote monitoring are some examples of telehealth applications. Th ough "telehealth" may refer to non-clinical services that are provided remotely, such as training, administrative meetings, and continuing education, some individuals may use the term "telemedicine" to describe the use of telecommunications technologies in clinical situations that include patient diagnosis, prescriptions, and treatment at a distance. The 114 th Congress has witnessed the introduction of a number of telehealth-related pieces of legislation that address a wide range of issues that have the potential to impact access to, along with the cost and quality of care under various federal programs, including Medicare. In recent years, the federal government has embarked on various initiatives to increase access to telehealth services (as well as to improve the underlying technological infrastructure that supports telehealth) at more than 20 federal agencies. Examples of this agency activity include: The Department of Veterans Affairs (VA) supported more than 2.1 million telehealth visits to veterans in FY2015. The Department of Defense (DOD) reported more than 34,000 telehealth visits and store-and-forward consultations at military installations in more than 30 countries and territories in FY2013. The Centers for Medicare and Medicaid Services (CMS) (of the Department of Health Human Services (HHS)) reported a total of $17.6 million in Medicare (Part B) payments to providers for 192,692 telehealth visits in CY2015. Trends in telehealth access, utilization, and innovation indicate that sustained interest is likely among health insurance plans, institutions, and major decisionmakers. For example, market analysts predict that: Private insurers are likely to increase the number of plans that include telehealth services for their enrollees. Institution-to-institution contracts could lead to greater willingness by patients to pay out-of-pocket for telehealth services they perceive to be convenient and valuable. Examples of these contracts are an arrangement between a large hospital and a rural hospital to provide neurologist services via telemedicine, or an arrangement between a clinical consulting group for a second opinion and an academic medical center or hospital wherein the members of consulting groups provide subspecialty consulting to the physicians at the hospital. Alternative payment models for reimbursement and coverage are likely to expand during 2016. Though providers are using telehealth to overcome barriers to health care access created by geography and time, the evidence-base for its use, including issues related to cost and quality, are strong in some areas and weak in others. For example, the Agency for Healthcare Research and Quality (AHRQ) reports that there is evidence that telehealth is effective for certain types of chronic conditions (such as diabetes, heart disease and conditions such as behavioral health). Also, AHRQ describes how telehealth applications may lead to improvements in health outcomes, and reductions in health care costs, such as fewer hospitalizations and fewer emergency room visits, but these findings have not been tested for all telehealth settings. On the other hand, more robust evidence is not yet available in relation to telehealth and various medical specialties according to AHRQ and the Institute of Medicine (IOM). Among the questions that are in need of more evidence: What is the patient telehealth experience regarding safety, effectiveness, timeliness, and overall access to health care? Which cost and quality measures support telehealth applications in primary care and urgent care populations, and which are cost drivers for public health insurance programs, such as Medicare and Medicaid? This report describes telehealth activities at selected federal agencies, and the evidence available to assess telehealth through the lenses of health care access, cost, and quality. In this report, a ccess refers to telehealth tools and systems that address behavioral, social and, environmental determinants of health and deliver high quality care; cost is associated with telehealth interventions that impact the cost of health care for individuals, families, employers, and government; and quality is associated with telehealth initiatives that improve the overall quality of care by resulting in health care that is more patient-centered, reliable, accessible and safe. Telecommunications systems along with federal and state licensure policies also impact access, cost and quality, but their discussion is beyond the scope of this report (telecommunications issues are briefly discussed in Appendix D ). Current laws, policies, and guidance present a range of descriptions for telehealth and the related term telemedicine, reflecting a need for clarity and distinction. For example, the Office of the National Coordinator for Health Information Technology (ONC) distinguishes between telemedicine and telehealth, with telemedicine being a function of interactions that involve clinical decisionmaking. The Agency for Healthcare Research and Quality (AHRQ) makes a distinction among technologies that support telehealth, noting that the technologies are not treatments in and of themselves but are the means for delivering health care in different formats, such as remote patient monitoring, videoconferencing, Internet applications, and devices. Within the VA, the Veterans Health Administration (VHA) notes that telehealth technologies may include single or combined uses of: videoconferencing, mobile technologies, store-and forward technology (or asynchronous communication). CMS, under the Medicare program, acknowledges that some health plans under its Medicare Advantage (MA) program conduct health services by telephone, over the Internet, or via telemonitoring for selected Medicare beneficiaries. Under the Medicaid program, states use the terms "telemedicine" or "telehealth" interchangeably. Some state laws explicitly define the terms, and place restrictions within the definition, such as the exclusion of email, phone, or fax from the definition. Other states may use "telehealth" to reflect a broader definition, and use "telemedicine" to define the delivery of clinical services. These and other distinctions are important not merely for semantic reasons but because they have implications for federal policies that impact access, cost and/or quality. For example, the Medicare statute delineates boundaries for "telehealth" reimbursement, and the regulation specifies the conditions under which Medicare makes a payment to a provider for services delivered via telehealth technologies. An acknowledgment of these differences, which may or may not result in uniformity, may be significant for policy decisions that involve telehealth and telemedicine. FedTel, a workgroup supported by the Health Resources and Services Administration (HRSA), consists of 26 federal agencies that invest in, or maintain an interest in, various telehealth activities. This section describes telehealth at three federal agencies that are directly involved with telehealth and patient care, and one agency that oversees the nation's largest program for health insurance financing. As noted earlier, issues such as the telecommunications infrastructure that supports the delivery of telehealth services (see Appendix D ) or legal matters such as state licensure portability for providers of telehealth services, while important, are beyond the scope of this report which is focused solely on health policy, financing, and service delivery related matters. Various federal agencies use telehealth services to help in providing direct patient care. For example, the VA, DOD, and the Indian Health Service (IHS) provide health care via telehealth to veterans, military beneficiaries, and underserved tribal populations, respectively. This section summarizes examples of telehealth activities in these three federal agencies with substantial telehealth experience. A major caveat analysts of telehealth raise is that it may not be appropriate for all consumers or providers in situations where certain clinical, technological, and environmental factors dictate prudence on the part of the provider. For example, in its Practice Guidelines for Live, On Demand Primary and Urgent Care , the American Telemedicine Association (ATA) urges providers to "exercise their professional judgment when deciding whether or not to use telemedicine, taking into account the patient condition, mitigating circumstances, available resources, and their own comfort level and expertise in using telemedicine." For example, where diagnostic interventions cannot be supported by high quality evidence, providers "shall use their professional judgment, experience and expertise in making such decisions. Conditions for use of telemedicine are likely to change to reflect new evidence from future research and the evolution of the enabling technology." In addition, some physical environments do not support telehealth visits, specifically where there is a lack of privacy, inappropriate lighting, or other distractions. The ATA encourages providers to follow these practice guidelines and guidelines published by other organizations, including governmental agencies and professional entities. The VA operates the largest integrated health care delivery system in the United States. It administers health services through 151 Medical Centers, 300 Vet Centers, 820 Community-based Outpatient Clinics (CBOCs), 135 Community Living Centers, 6 Independent Outpatient Clinics, and 103 Residential Rehabilitation Centers throughout the 50 states, U.S. States territories, and the Philippines. In FY2015, the VA employed 298,546 medical care and research professionals. In FY2015, the VA served some 6.8 million unique patients, dependents, and survivors. Telehealth technologies used in VA health care include the following: Clinical Video Telehealth (CVT) (or live-video) which allows VA health care access through live-video consultations representing 44 clinical specialties. Live-video is a tool that allows health providers to diagnose, monitor, and treat conditions in veterans who may be located hundreds of miles away at a VA community-based outpatient clinic, thus eliminating the cost and inconvenience of travel. Home Telehealth technologies, which allow health providers to provide monitoring services to veterans with chronic conditions, such as chronic heart failure, diabetes, chronic obstructive pulmonary disease, depression, or post-traumatic stress disorder. Store-and-Forward (asynchronous) telehealth, which allows for the capture and storage of clinical information (e.g., data, sound, image, video) commonly used in radiology, dermatology, and ophthalmology.