Justin Fulcher — technology founder, co-founder of the telehealth startup RingMD, and former senior advisor to the Secretary of Defense — has watched telehealth move from a concept the medical establishment treated with institutional caution to a permanent feature of how healthcare is delivered around the world. He did not watch it from a distance. He was building inside it from the beginning.
When Fulcher launched RingMD at twenty-one, telemedicine had been technically feasible for decades. The technology could serve patients remotely at scale. The conditions required to make that viable inside real healthcare systems were a different problem entirely. What followed was a decade of slow, uneven progress, one forcing event large enough to move the entire sector, and a period of integration that is still underway. Fulcher’s perspective on that arc — from the early friction of operating a telehealth startup across twenty-two countries, to the post-COVID moment the industry finds itself in now — offers a direct account of what changed, what didn’t, and what the industry still has left to prove.
What Held the Sector Back
Telehealth had been tried for decades, but it only succeeded when the conditions required to carry it (technical, institutional, and operational) finally aligned. For most of the 2010s, they didn’t.
The most decisive structural limiter in the United States was billing. Medicare’s coverage of telehealth services was structured as a rural access exception, not a general standard of care delivery. That single framing had consequences that compounded across every layer of the system. Government agencies and health systems had no institutional incentive to redesign workflows around remote care when reimbursement was unavailable to most of their patient populations. The technology worked. The infrastructure to support its adoption did not.
Telemedicine, strictly defined as clinical care at a distance, is distinct from telehealth, which encompasses a broader system of triage, patient communication, and care coordination. That distinction matters because it explains why improving the consultation technology alone was never sufficient. A video call is one point of contact. The tools surrounding it — scheduling, documentation, referral management, billing integrations — had to function around it for it to deliver consistent value.
Many early telehealth models assumed conditions that didn’t exist in practice: stable patient IDs, predictable appointment flows, reliable connectivity. Operating across rural Indonesia, remote India, and markets with limited infrastructure, RingMD encountered power cuts, staffing gaps, and clinical cultures with no prior experience of remote care delivery. Adapting to those real-world conditions was not optional; it was the cost of serving the markets where the need was greatest.
The institutional drag slowing adoption, however, extended far beyond the developing world. Outdated processes in credentialing, compliance, and reimbursement across US health systems created the same compound inefficiencies. They weren’t ideological. They were structural. And in regulated environments, structural obstacles outlast most of the technology introduced to work around them.
The Conditions That Actually Had to Change
Smartphones changed the consumer side of the equation in ways that billing reform had not. By the early 2010s, devices were proliferating in markets where basic clinical infrastructure was still absent. Patients were ready to use telehealth before the organizations responsible for delivering it had redesigned around what that required.
The pitch Fulcher’s team made in every market was the same: telehealth as an extension of clinical reach, not a challenge to clinical authority. That reframing required time and operational teams who understood each local regulatory environment.
The constraint was never the technology. It was whether adopting it cost institutions more than it saved them. For most of the 2010s, adding telehealth to a clinical operation meant absorbing significant new complexity before realizing any benefit. Clinicians had to learn new workflows. Administrators had to manage new compliance requirements. The organizations that moved first often bore that burden without sustainable reimbursement to justify it.
The commercial internet had made basic forms of telehealth possible for ordinary clinics, but billing and workflow issues kept adoption limited. Smartphones changed user expectations at scale, but changing consumer expectations did not automatically change institutional behavior. The two moved on different timelines, and the gap between them was where the sector stalled for nearly a decade.
What COVID Forced, and What It Left Unfinished
COVID-19 accelerated telehealth adoption by removing the option to treat it as optional. Medicare expanded its telehealth benefits substantially. Billing and compliance requirements that had constrained remote care were relaxed as health systems across the country shifted to remote delivery out of necessity. Initiatives that had been under evaluation for years were deployed in a matter of weeks.
“What COVID demonstrated,” Fulcher has said, “was that the institutional capacity to adopt telehealth had always been there. The question was never whether health systems could move. The pandemic answered that question for everyone at once.”
What it did not do was resolve the structural questions that had always defined telehealth’s fragility. After the public health emergency, many billing flexibilities were extended, but on a time-limited basis. Reimbursement remains uneven. Organizations making workforce investment decisions and infrastructure build-out plans on the basis of time-limited regulatory frameworks are building on uncertain ground. The integration questions — how remote care would connect with labs, referrals, and electronic records — were deferred rather than answered.
Justin Fulcher’s second vantage point on institutional resistance came through public service. In early 2025, he joined the Defense Department as a senior advisor, working on acquisition reform and technology modernization in Washington. His six months inside federal agencies, working with teams responsible for some of the most complex systems in government, gave him a direct view of a parallel challenge: the same gap between technical possibility and institutional process, workflows and approval chains built for conditions that had long since changed. The structure of the problem was identical to what he had encountered in healthcare.
Artificial intelligence is now running the same test across government and healthcare alike. Its value in government is in removing the administrative load that consumes institutional capacity without contributing to what the institution actually delivers. In government as in healthcare, the technology that earns lasting adoption is the technology that fits what the institution is already doing — not the technology that asks it to change first.
Justin Fulcher on What the Industry Still Has to Prove
Telehealth is now a necessary part of healthcare delivery. That point is established. What the industry has not yet fully proved is whether it can integrate well enough to be genuinely durable.
Justin Fulcher has described the sector’s current challenge in direct terms: “Telehealth proved it could reach patients. The test now is whether it integrates with everything else that patient care requires — labs, records, referrals, the full coordination infrastructure. Without that, it becomes another silo, and the healthcare system has enough of those.”
Reimbursement is the most immediate structural risk. The post-pandemic billing extensions have provided continuity across the nation, but permanence has not followed. The planning uncertainty this creates falls hardest on smaller providers and underserved markets. That’s precisely where telehealth’s access benefits are most significant. A funding and policy environment that rewards the well-resourced disproportionately will not produce equitable access as an outcome.
Fragmentation is the longer-term problem. Telehealth that operates as a parallel channel rather than within existing systems adds to coordination burden rather than reducing it. For patients navigating complex care needs, another entry point that doesn’t connect to their records or referral network is not a service improvement. The vision of telehealth as a load balancer for healthcare — routing the right problems to the most efficient safe channel and freeing capacity for the care that genuinely requires it — depends entirely on that integration being real.
Clinician shortages are the limit that technology doesn’t remove. Remote delivery extends reach. It does not expand the workforce. For communities relying on telehealth as their primary access point, the capacity constraint does not disappear because the delivery channel has improved; it simply becomes visible again once everything else is working.
“The future of telehealth will reward reliability, integration, and durability,” Justin Fulcher has said. “That’s what the sector still has left to prove — that it can focus on those things and not just on what’s impressive. What’s impressive got us here. What’s durable will determine whether ‘here’ is just the beginning or the high-water mark.”
For a technology founder who spent a decade building across markets where the systems required to carry new technology were often the hardest part of the problem, the remaining work is recognizable. Telehealth has moved past the point of proving itself. The decade ahead will determine whether the infrastructure built around it is equal to what the argument always promised.
This content is brought to you by the FingerLakes1.com Team. Support our mission by visiting www.patreon.com/fl1 or learn how you send us your local content here.