Most public discussion of telehealth assumes a live, real-time video visit, but a distinct and clinically important category — asynchronous, or "store-and-forward," telehealth — involves a patient submitting information (photos, a symptom questionnaire, recorded data) that a clinician reviews and responds to later, without a live simultaneous interaction. This model has a distinct clinical use case, reimbursement structure, and regulatory treatment that differs meaningfully from live video telehealth.
Where Asynchronous Telehealth Fits Clinically
Store-and-forward telehealth works best for conditions where a visual or written record, rather than a real-time conversation, contains the essential clinical information needed for evaluation — dermatology is the clearest example, where a high-resolution photo of a skin lesion combined with patient history often provides a dermatologist sufficient information to render a diagnosis or treatment recommendation without a live visit. Similar store-and-forward models have been used for ophthalmology screening (reviewing retinal images for diabetic retinopathy), radiology (a specialist reviewing images asynchronously), and certain psychiatric intake questionnaires reviewed before a subsequent live visit.
The Reimbursement Structure Is Distinct From Live Video Visits
Medicare and most commercial payers have historically treated asynchronous telehealth reimbursement differently and, in many cases, more restrictively than live video visit reimbursement — Medicare's coverage for store-and-forward telehealth has traditionally been limited primarily to federal telehealth demonstration programs in Alaska and Hawaii, reflecting more caution about asynchronous care's reimbursement parity compared to the more expansive coverage live video telehealth has received, particularly since the pandemic-era flexibility expansions applied primarily to synchronous, real-time visits.
E-Visits and Virtual Check-Ins Occupy a Related But Distinct Billing Category
Separate from formal store-and-forward telehealth, CMS has created specific billing codes for "e-visits" (patient-initiated, portal-based communication with a clinician that requires clinical decision-making, billed based on cumulative time over a period) and brief "virtual check-ins" (a short, patient-initiated check to determine whether an office visit is warranted) — these codes reflect a distinct, growing category of asynchronous or brief clinical communication that is billable, but under specific rules and time thresholds different from either a full synchronous telehealth visit or traditional store-and-forward specialist consultation.
Licensure and Liability Questions Follow the Asynchronous Model Too
Because asynchronous telehealth still constitutes the practice of medicine across whatever state the patient is located in, the same interstate licensure requirements discussed in the context of the Interstate Medical Licensure Compact apply equally to store-and-forward consultations — a common misconception is that because the interaction is not live and real-time, different or more relaxed licensure rules might apply, which is not generally the case under current state medical board interpretations.
Patient Experience Trade-Offs Are Real But Often Underappreciated
Asynchronous telehealth offers genuine convenience — a patient can submit information whenever convenient rather than scheduling a specific appointment time — but it also removes the ability for real-time clarifying questions during the actual clinical review, meaning the clinician is dependent entirely on the quality and completeness of the initially submitted information. Well-designed store-and-forward programs address this by using structured, guided intake questionnaires specifically designed to capture the clinical information a live conversation would otherwise elicit, reducing the risk of an incomplete or ambiguous asynchronous submission leading to a less accurate assessment.
Conclusion
Asynchronous, store-and-forward telehealth serves a genuine and distinct clinical niche, particularly for image-based specialties like dermatology, but operates under a considerably more restrictive and inconsistent reimbursement framework than live video telehealth has received since the pandemic. Specialty practices building asynchronous consultation programs rely on quality diagnostic equipment to capture the clinical information these programs depend on.
