Section 1 of 7
The Heart Spark Method
The Heart Spark Method: A National Blueprint for Virtual Care Programs Sherry-Ann Brown MD PhD*1,2
1 My Heart Spark P.C., Miami, FL 2 Heart Innovation and Equity Research (HIER) Institute, Miami, FL
Running Title: National Virtual Care Blueprint
*Correspondence:
Dr. Sherry-Ann Brown, Heart Innovation and Equity Research (HIER) Institute, Miami, FL, USA.
connect@myheartopulence.com. Twitter/X: @drbrowncares.
Section 2 of 7
ABSTRACT
Background: Chronic noncommunicable diseases dominate global morbidity and mortality, and cardiovascular disease (CVD) remains the leading cause of death and a major driver of years of life lost, necessitating scalable, longitudinal, and equitable care models that extend beyond facility walls; in the United States, contemporary statistics document persistent cardiometabolic risk and a shifting burden toward heart failure and arrhythmias that strain episodic paradigms and demand team-based continuity across settings, while telemedicine stabilized at elevated post-pandemic levels with 43% of adults using telemedicine in 2022.
Objective: To synthesize high-impact clinical and policy evidence and articulate a reproducible national blueprint virtual care—the Heart Spark Method—that embeds cardiology as an exemplar specialty within multidisciplinary chronic care modules, aligned to licensure, accreditation, payment, technology, governance, and equity requirements in the United States.
Methods: A structured narrative and integrative synthesis was conducted of selected randomized controlled trials, meta-analyses, systematic reviews, large cohort/claims studies, national surveillance reports, national statistics, and federal rules spanning the years of 2018-2026. Approximately 60 sources verified by active DOIs/URLs were curated and mapped to five operational domains using a design science translation approach. We structured the manuscript as a narrative review to enable rigorous design-science translation across heterogeneous evidence—including randomized trials, meta-analyses, real-world data, national surveillance, and federal policy—allowing integrated mapping of findings to operational care domains that are not amenable to conventional systematic synthesis.
Results: When thoughtfully implemented, telehealth achieves outcomes broadly comparable to in-person care across conditions; hybrid cardiac rehabilitation is non-inferior to center-based programs; structured telemonitoring in heart failure reduces mortality and rehospitalizations; and self-monitored blood pressure programs improves systolic control, while Medicare and Drug Enforcement Administration policy windows through late 2025 shape near-term scalability and equity.
Conclusions: The Heart Spark Method specifies licensure and accreditation scaffolds, payer integration strategies, cardiology-anchored chronic care modules, an interoperable technology backbone, and governance with equity dashboards, offering a practical and policy-compliant path to national virtual chronic care.
KEYWORDS: Telehealth; Cardiovascular Disease; Chronic Care; Remote Patient Monitoring; Accreditation; Multistate Licensure; Payment Policy; Equity; Virtual Care Blueprint; Remote Care
Section 3 of 7
INTRODUCTION
Cardiovascular disease remains the leading cause of death worldwide and a principal source of years of life lost, requiring scalable secondary-prevention and longitudinal-management models that function beyond facility-bound care (1, 2); a conclusion reaffirmed by the 2021 Global Burden of Disease update, which highlights cardiovascular disease as the major source of years of life lost and reinforces the urgency of scalable chronic care delivery models that transcend geographic barriers (3); in the United States, persistent cardiometabolic risks and a rising burden of heart failure underscore the need for team-based continuity across modalities and sites (4, 5) (Table 1). National survey data confirm telemedicine’s durable role—43% of adults used telemedicine in 2022—signaling permanence and the necessity of rigorous operating models for quality, safety, and equitable reach (6-8). Medicare fee-for-service data show that telehealth comprised 7.8% of evaluation and management encounters in 2022, with audio-only disproportionately serving medically complex and socioeconomically disadvantaged beneficiaries, linking modality allowances directly to equity (9). Contemporary syntheses conclude that telehealth outcomes are broadly comparable to in-person care when infrastructure and workflows are strong, particularly when enabling the infrastructure connectivity, devices, workflows, as well as a follow-up is deliberately designed, a conclusion reinforced by perioperative evidence of reduced readmissions and parity in diabetes experience and by likely equivalence for web-based chronic monitoring (10-13). Policy frames the operating envelope: federal policy maintains the patient’s home as an originating site for non-behavioral telehealth through September 30, 2025, while tele-prescribing flexibilities extend to December 31, 2025 alongside a proposed Special Registration pathway—timelines that carry implications for equity-protective design (14-17). Payment-parity analyses associate parity mandates with increased utilization in employer markets and sustained use in community health centers, indicating that benefit design and rate policy are equity levers rather than administrative details (18-20). The cardiovascular evidence base—hybrid cardiac rehabilitation non-inferiority, randomized reductions in heart-failure mortality and hospitalizations with structured telemonitoring, and systolic blood pressure improvements with self-monitoring, demonstrating endpoints and payer relevant outcomes that position cardiology as an empirically validated anchor for modulated national chronic care design—renders cardiology an ideal launch specialty for a modular national blueprint that generalizes across chronic conditions (21-25) (Table 2).
Table 1. Chronic Disease Burden & Rationale—Global CVD YLLs; U.S. burden (1, 4).
CVD: cardiovascular disease; YLLs: years of life lost; GBD: Global Burden of Disease; HF: heart failure; RPM: remote patient monitoring; BP: blood pressure.
Table 2. Cardiovascular Virtual Care Evidence—Hybrid CR, home-based CR, HF telemonitoring (trial + meta-analysis), SMBP, digital CR standards (21-24, 52-54).
CR: Cardiac rehabilitation; RCT: randomized controlled trial; HF: heart failure; SMBP: self-measured blood pressure; AF: atrial fibrillation; ESC: European society of Cardiology; AHA: American Heart Association; ACC: American College of Cardiology.
METHODS This integrative, purposive synthesis translates high-quality clinical and policy evidence into a reproducible blueprint rather than a dual-reviewer systematic review, prioritizing implementation relevance and federal policy contemporaneity for 2025 (13). We targeted 2018–2025 because 2018 marked publication of seminal trials in telecardiology and digital hypertension management—TIM-HF2 for heart-failure telemonitoring and TASMINH4 for self-monitored blood pressure with/without telemonitoring—and because 2025 includes a definitive meta-analysis for heart failure and live federal rule endpoints defining the near-term operating window (14, 17, 22-24, 26). Candidate sources were identified via purposive searches of PubMed and Scopus and cross-validated against official repositories—Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services (HHS), U.S. Drug Enforcement Administration (DEA), and the Federal Register—emphasizing randomized trials, meta-analyses, systematic reviews, large cohort/claims analyses, national statistics, and primary federal rules (6). A curated corpus of 62 sources—each with an active DOI or official URL—was abstracted for design, population, outcomes, and policy levers and then mapped to five operational domains: Licensure & Accreditation, Payer Integration, Chronic care Modules, Technology Backbone, and Governance & Workforce, using a design science translation lens to produce the Heart Spark Method (10). Because policy is dynamic and decisive, federal endpoints were verified against the HHS policy hub, the CY-2025 CMS Physician Fee Schedule fact sheet, and DEA’s extension and proposed Special Registration rules, which collectively define Medicare originating-site allowances, audio-only pathways, and controlled-substance tele-prescribing authority for virtual chronic care programs in 2025 (14-17, 27).
Accreditation and compliance (in-text integration): Licensure determines who may practice while accreditation and security frameworks determine how quality, privacy, safety, escalation, interoperability, and equity are validated at scale, so we reviewed NCQA Virtual Care Accreditation and URAC Telehealth Accreditation as externally recognized benchmarks and summarized HIPAA, AICPA SOC 2, and HITRUST i1 as widely used vendor/security frameworks without associating them to any named clinical entity (28-33).
Operationalization from practice experience (integrated from your capture): The foundation of an independent national virtual cardiology practice consists of (a) a program-foundation stack—advisor/consultant, insurance agent, banker, legal counsel, accountant/bookkeeper/CFO, and marketing–sales–advertising—aligned to risk, compliance, liquidity, revenue cycle, and growth; (b) remote personnel—clinical and administrative teams configured for synchronous visits, asynchronous messaging, e-consults, RPM review, and CCM; (c) a platform triad—EHR + patient portal + telehealth interface—with service-level expectations for asynchronous triage and escalation; (d) a national patient footprint; and (e) access partners—employers, payors/health plans, health systems, self-insured programs—often reached fastest by collaborating with entities that already maintain these contracts (practice capture, integrated here) (Figure 1). Tables/Figures referenced by Methods: Table 1 (Accreditation & Compliance Standards) is summarized here and expanded in Results; Figure 1 (PRISMA-like flow, conceptual) clarifies transparency of curated inclusion in this integrative design.
Figure 1. PRISMA-like Flow (conceptual) identification → screening → assessment → included; curated 62-record corpus (10).
PRISMA-like Flow: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Design Science Translation Approach
This work was conducted using a design science translation approach, an applied research methodology focused on the systematic creation, demonstration, and evaluation of artifacts that address complex, real-world problems while generating transferable knowledge. Design science is particularly suited to health system innovation where clinical evidence, policy constraints, sociotechnical workflows, and equity considerations must be integrated into operationally viable solutions rather than isolated interventions. The central problem addressed was the absence of a reproducible, policy-compliant, and equity-forward national operating model for longitudinal virtual chronic disease care in the United States. Rather than evaluating a single technology or clinical intervention, this study sought to translate a heterogeneous evidence base—including randomized trials, meta-analyses, national utilization data, accreditation standards, and federal policy—into a coherent and implementable blueprint capable of functioning across jurisdictions, payers, and care settings.
Following design science principles, we defined explicit design objectives and constraints prior to artifact construction. These included national licensure feasibility, alignment with live Medicare and Drug Enforcement Administration regulations, compatibility with accreditation and security frameworks, integration of multiple telehealth modalities, and the capacity to monitor equity and outcomes at scale. Cardiology was selected as the exemplar specialty due to its high disease burden, mature telehealth evidence base, and well-defined clinical endpoints, enabling rigorous translation from evidence to
design.
The primary artifact produced through this process is the Heart Spark Method, a national virtual care blueprint structured across five interdependent operational domains: licensure and accreditation, payer integration, chronic care modules, technology backbone, and governance and workforce. Each domain was populated through an integrative synthesis of high-quality clinical evidence and contemporaneous federal policy, with explicit mapping of evidence to operational requirements. Supporting artifacts included modular cardiology care pathways, governance structures, technology architectures, and visual frameworks illustrating workflow orchestration and modality integration.
Artifact demonstration was achieved through contextual operationalization grounded in national virtual practice experience, including multistate licensure strategies, payer contracting pathways, workforce configurations, and modality-specific workflows for synchronous visits, asynchronous communication, interprofessional e-consults, remote patient monitoring, and chronic care management. Evaluation drew on multiple complementary lenses: clinical effectiveness evidence from randomized trials and meta-analyses, policy feasibility assessed against active federal rules, accreditation standards as external validation mechanisms, and equity implications examined through national utilization patterns and modality access differences.
Consistent with design science translation, the blueprint is intentionally modular and adaptive, recognizing the time-limited nature of current federal telehealth flexibilities and the necessity for iterative refinement as regulatory, payment, and technological conditions evolve. The knowledge contribution of this work extends beyond cardiology, offering transferable design principles for national virtual chronic disease programs across specialties while preserving sensitivity to local implementation contexts.
Section 4 of 7
RESULTS
Domain 1 — Licensure & Accreditation
Interstate Medical Licensure Compact
Commission
Multistate licensure remains a gating constraint for national access, which can be addressed via the Interstate Medical Licensure Compact Commission (IMLCC). The IMLCC represents a pivotal regulatory innovation designed to reconcile the realities of modern medical practice with the enduring structure of state-based licensure. Established to streamline the process by which physicians obtain licenses in multiple jurisdictions, the IMLCC functions as a physician-facilitating mechanism rather than a federal override, preserving state authority while reducing administrative friction. For clinicians, particularly those in highly specialized fields such as cardiology and cardio-oncology, the Compact addresses a fundamental mismatch between where expertise resides and where patients need care. Its significance lies not only in
efficiency but in its downstream clinical impact: accelerated access to subspecialty consultation, expanded continuity for mobile or underserved patient populations, and enhanced system-level resilience during public health emergencies. As cardiovascular care becomes increasingly data-driven, team-based, and virtual, the IMLCC serves as critical infrastructure, enabling physicians to extend evidence-based practice across borders with speed and accountability. In this way, the Commission quietly underpins a transformation in care delivery, aligning licensure policy with the scientific imperative to deliver the right expertise to the right patient, irrespective of geography.
In Figure 2, there is clear representation of the cumulative footprint of the contemporary physician reach across state lines, capturing where clinical authority, regulatory permission, and operational readiness intersect in real practice. It exists because modern cardiovascular medicine has outgrown the assumptions of a purely local workforce, as subspecialty scarcity, rising patient complexity, and uneven geographic distribution of expertise increasingly dictate outcomes. For practicing physicians, this visualization is not an abstract policy artifact but a practical indicator of where care can be delivered without delay, where consultative expertise can be extended, and where patients gain access to advanced cardiovascular and oncologic knowledge that would otherwise remain distant. Its significance lies in how it translates regulatory structure into clinical capacity, revealing the scaffolding that enables virtual care, regional centers of excellence, and rapid second opinions to function at scale. The implications are substantial: as licensure density expands, physicians gain leverage to practice at the top of their training, health systems acquire resilience against workforce volatility, and patients experience continuity that aligns more closely with disease biology than with geography. In this sense, the map signals a shift in medicine from location-bound service to networked clinical stewardship, redefining how expertise is mobilized in an era of increasingly complex cardiovascular care.
Figure 2. Geographic Distribution of Interstate Medical Licensure Compact Participation Across U.S. Jurisdictions: The figure illustrates the regulatory geography that enables or constrains cross-jurisdictional virtual care delivery and provides context for national-scale implementation of virtual cardiovascular care programs.
Over successive decades, this map has evolved from a sparse, jurisdiction-by-jurisdiction mosaic into a progressively integrated national landscape, reflecting the slow but deliberate convergence of policy, technology, and professional mobility in United States medicine. Early iterations were characterized by fragmentation, with isolated regions advancing independently, constrained by local regulatory inertia and uneven access to specialized expertise. Over time, incremental harmonization emerged, driven by workforce shortages, the maturation of telehealth, and the growing recognition that cardiovascular and oncologic disease burdens do not respect state boundaries. Each expansion represented not merely administrative progress, but a measurable shift in the capacity to deliver timely, high-quality, evidence-based care to diverse populations. Looking forward, this map is poised to transition from a static representation of licensure or coverage into a dynamic, data-responsive network, continuously reshaped by artificial intelligence–enabled credentialing, interoperable digital health infrastructure, and outcomes-driven policy alignment. In this future state, geographic borders will exert diminishing influence on care delivery, while national and internationally informed standards will accelerate the diffusion of innovation, enabling precision cardiovascular and oncologic care to be deployed at scale, with equity, speed, and scientific rigor commensurate with the demands of modern medicine. The IMLCC expedites coverage across more than forty jurisdictions but leaves heterogeneity in adoption and fees that must be anticipated in workforce and financial planning (34); legal scholarship signals scrutiny of restrictive cross-state limits and pragmatic proposals for exceptions that permit follow-up after out-of-state procedures while broader reforms evolve (35, 36). Accreditation translates clinical governance into payer-recognized assurance; NCQA and URAC programs codify safety, escalation, outcomes reporting, interoperability, and equity, while HIPAA, AICPA SOC 2, and HITRUST i1 are widely used security/compliance frameworks by technology vendors—summarized here strictly as industry standards (28-32) (Table 3). Table 3 shows a jurisdiction-level synthesis of IMLCC participation and related policy, workforce, and equity considerations for physician multi-state medical licensure across U.S. states, the District of Columbia, and U.S. territories. Jurisdiction is defined as each state, district, or territory included in the analysis, and each is classified by IMLCC Status to indicate formal participation in the Compact. The table further specifies State of Principal License (SPL) eligibility, identifying whether physicians may designate a given jurisdiction as their primary licensing anchor under Compact rules, and evaluates telemedicine alignment, reflecting the degree to which state-level telehealth policies facilitate interstate virtual care consistent with the Compact’s intent. To contextualize healthcare access needs, the table includes a workforce shortage indicator based on the presence of federally designated Health Professional Shortage Areas, alongside academic medical center density, which captures the relative concentration of accredited teaching hospitals and academic health systems that support clinical training, research, and specialty care delivery. Finally, these legal, policy, workforce, and structural dimensions are integrated into an equity impact potential measure, which qualitatively estimates the likelihood that IMLCC participation—or non-participation—could meaningfully influence access to care for underserved, rural, or historically marginalized populations. Together, this framework is intended to support interpretation of the table not only as a descriptive summary of licensure status, but as a multidimensional assessment of how interstate licensure policy may function as a lever for workforce mobility, telemedicine-enabled care, and equity-oriented health system improvement.
IMLCC Pathway in Spark50+ Model
In the evolving landscape of interstate medical practice and telemedicine, the IMLCC pathway is leveraged by the Spark50+ model developed within the Heart Spark Method. Spark50+ represents an operationalized validated approach for nationwide comprehensive medical licensure coverage across the United States. This approach leverages both expedited Compact mechanisms and strategic licensure planning to navigate the realities of existing regulatory frameworks. The IMLCC expedites the multistate licensing process in participating jurisdictions and allows eligible physicians to route licensure applications more efficiently through their state of principal license. The IMLCC currently encompasses approximately 39 states plus the District of Columbia and Guam and provides an expedited pathway for multi-state medical licensure. However, even with leveraging the IMLCC, a clinician is still required to complete individual licensure under each state’s medical boards albeit in an expedited and facilitated convenient manner. No national license yet exists, and separate state licenses are required for practice in each state where patients are located (37, 38) . Nevertheless, despite the individualized state-by-state regulatory framework, the Spark50+ model effectively leverages the IMLCC. By combining this Compact-based acceleration with standardized collaboration agreements, escalation policies, payer credentialing workflows, and practice management infrastructure, the Spark50+ model expands contracting opportunities with multiple telehealth platforms and virtual care ecosystems. This approach enhances geographic reach to underserved patients, and aligns coverage more rapidly with payer product maps. Additionally, despite ongoing heterogeneity in licensure costs, processing timelines, interstate policy nuances (37, 39), and regulatory requirements that clinicians must navigate in workforce and financial planning, the Spark50+ model illustrates the feasibility and the practical and operational complexity of achieving near-nationwide practice authority under current law. In this way, structured licensure expansion—integrated into virtual care workflows— can substantially enhance access to specialty care and continuity across borders, even as broader reforms toward license portability and telemedicine-specific registrations continue to evolve at the policy level. Notably, Compact licensure is not limited to physicians. Physician assistants and nurse practitioners, collectively advanced practice providers, also have Compact pathways. Physician Assistant Licensure Compact
The Physician Assistant Licensure Compact represents a structurally transformative policy mechanism for advancing nationwide and internationally scalable virtual telehealth while directly addressing persistent inequities in access to specialty and longitudinal care. By enabling physician assistants to practice across participating state lines through a single multistate privilege, the Compact reduces administrative friction, mitigates geographic maldistribution of the workforce, and aligns licensure infrastructure with the realities of digitally mediated care delivery. This framework is particularly consequential for cardiovascular and oncology-adjacent subspecialty care, where timely access often determines morbidity trajectories and long-term outcomes. Through its facilitation of cross-jurisdictional telehealth practice, the Compact supports rapid deployment of physician assistant expertise into rural, underserved, and medically marginalized communities, while maintaining rigorous professional standards and state-based oversight. In doing so, the Physician Assistant Licensure Compact functions not merely as a regulatory convenience but as a foundational enabler of health equity, workforce resilience, and continuity of care within an increasingly virtual national health system.
Nurse Practitioner Licensure Compact
The Nurse Practitioner Licensure Compact similarly serves as a cornerstone policy instrument for realizing equitable, nationwide, and internationally extensible telehealth access, particularly in preventive, primary, and chronic disease management domains that disproportionately affect vulnerable populations. By allowing nurse practitioners to practice across member states under a unified multistate licensure privilege, the Compact dismantles longstanding jurisdictional barriers that have constrained care delivery to high-needed regions. This has profound implications for cardiovascular prevention, survivorship care, and community-based risk modification, where sustained engagement and early intervention are essential. The Compact enhances system-level agility, enabling rapid scaling of virtual care models during public health crises and routine deployment of nurse practitioner-led services in areas with critical clinician shortages. As such, the Nurse Practitioner Licensure Compact advances not only telehealth expansion but also the ethical imperative of access equity, ensuring that high-quality, evidence-based care is no longer bounded by geography but guided by patient need and population health priorities.
Adoption Across 3 Compacts
To ensure implementation, we have developed a schema for assessing the operational readiness of each state, regarding the physician, physician assistant, or nurse practitioner licensure compact (Table 3). The schema is described as Tier 0–Tier 3 and integrates legislative adoption, compact membership, and operational usability. Tier 0 denotes jurisdictions without enacted compact legislation and no legal authority to participate; Tier 1 denotes enacted compact statutes without a functional licensure pathway; Tier 2 denotes jurisdictions actively implementing administrative systems with partial or transitional usability; and Tier 3 denotes fully operational jurisdictions in which compact privileges or expedited licenses are issued routinely in practice. This tiered approach distinguishes statutory authorization from real-world deployability and standardizes interpretation across physician, physician assistant, and nurse practitioner compacts, allowing regulatory readiness for interstate cross-border care to be assessed consistently and transparently. Table 3. Interstate Medical Licensure Compact Commission (IMLCC) Participation Status by U.S. State and Territory
IMLCC: Interstate Medical Licensure Compact Commission; SPL: state of principal license; CPOM: corporate practice of medicine.
Of three the Compacts, the IMLCC demonstrates the most advanced pathway, with the majority of states either fully participating or actively implementing expedited physician licensure. In contrast, the Physician Assistant Licensure Compact remains in an earlier adoption phase, with participation concentrated in states that have historically supported telehealth expansion, rural access initiatives, and advanced practice workforce optimization. The Nurse Practitioner Licensure Compact, while conceptually aligned with national access goals, remains structurally under-implemented for advanced practice roles, despite the widespread deployment of nurse practitioners as frontline providers in cardiovascular prevention, chronic disease management, and survivorship care. This temporal divergence in the diffusion of each Compact across the United States creates a licensure stratification effect, wherein physicians are increasingly enabled to deliver cross-state virtual specialty care, while advanced practice clinicians remain constrained by state-specific licensure silos. The resulting asymmetry limits team-based telehealth scalability and undermines comprehensive care models.
Within policy and health equity implications, states that combine participation in the physician Compact (IMLCC), early adoption of the Physician Assistant Licensure Compact, and full nurse practitioner practice authority (with or without the Nurse Practitioner Licensure Compact) consistently demonstrate the highest potential for equitable virtual cardiovascular care delivery. These states are best positioned to deploy interdisciplinary telehealth teams capable of addressing both acute and longitudinal cardiovascular risk, particularly in rural, frontier, and medically underserved communities. Conversely, states with restricted advanced practice authority and absent Compact participation (for physicians or advanced practice providers) experience compounded access limitations, disproportionately affecting populations already burdened by structural inequities, delayed diagnosis, and fragmented care pathways.
Taken together, state-level variation in licensure Compact participation for physicians, physician assistants, and nurse practitioners reveals a shift in the national architecture of virtual cardiovascular care. While the Interstate Medical Licensure Compact has substantially advanced physician mobility and cross-state telehealth capacity, parallel Compact adoption for advanced practice clinicians remains uneven and incomplete. This regulatory fragmentation constrains the scalability of team-based telehealth models that are essential for equitable cardiovascular prevention, chronic disease management, and survivorship care. States that align physician Compact participation with expanded advanced practice authority and emerging Physician Assistant Licensure Compact frameworks demonstrate the greatest potential to reduce geographic disparities, address workforce shortages, and deliver continuous, high-quality care across jurisdictional boundaries. Harmonizing licensure pathways across clinician roles is therefore not merely an administrative objective, but a foundational policy lever for advancing nationwide and internationally scalable telehealth and achieving durable health equity in cardiovascular outcomes. Table 4 indicates, at the state level, the degree to which the United States licensure infrastructure has begun to resemble the realities of modern virtual care: a system in which the patient location governs jurisdiction and licensure becomes either a conduit or a barrier. The physician pathway, through the Interstate Medical Licensure Compact Commission, shows the most mature multistate acceleration framework, with states categorized by full participation, partial participation, implementation, pending legislative introduction, or non-membership. In contrast, the Physician Assistant Licensure Compact is structurally newer, with member states identified but a contemporaneous rulemaking and operationalization phase still underway, reflecting an implementation arc that is active but not yet fully translated into ubiquitous Compact privilege at scale. The Nurse Practitioner Licensure Compact offers an elegant blueprint for advanced practice mobility, but the national activation threshold remains unmet, despite enacted legislation in four states, underscoring a persistent mismatch between telehealth demand and licensing modernization. When these Compact statuses are interpreted alongside nurse practitioner practice authority stratification, the policy portrait becomes clear: states that align physician Compact participation with Physician Assistant Licensure Compact membership and full nurse practitioner authority are positioned to deliver the most equitable, interprofessional, and durable telehealth access across geography, while states with non-participation and restricted advanced practice authority remain structurally constrained, reinforcing preventable gaps in continuity, prevention, and specialty access that directly shape cardiovascular outcomes and health equity trajectories.
Table 4. Integrated State-Level Licensure Portability, Telehealth Enablement, and Health Equity Alignment for Scalable Cardiovascular Delivery in the United States
NP: Nurse Practitioner; IMLCC: Interstate Medical Licensure Commission Compact; PA: Physician Assistant; DC: District of Columbia.
Policy Enablement & Equity Implications
The policy-enabling domains shown in Tables 4 and 5 are derived through a structured, multilayered classification framework designed to translate heterogeneous licensure statutes into analytically comparable indicators of virtual care scalability and equity relevance. IMLCC, Physician Assistant Licensure Compact, and Nurse Practitioner Licensure Compact maturity tiers are determined by statutory status and operational readiness, distinguishing states that have enacted enabling legislation only from those that have completed commission rulemaking, data-sharing agreements, fee structures, and active multistate privilege issuance (Supplemental Tables 1-6). Full maturity reflects not only legislative adoption but functional clinician mobility across state lines under Compact authority. Partial and implementation tiers capture states with enacted statutes that have not yet reached operational execution, while non-participation reflects the absence of Compact-enabling law. These categorizations are grounded in publicly available Compact commission documentation, state statutes, and implementation timelines, and are intentionally conservative, prioritizing real-world deployability over aspirational legislative intent. Table 5. Interpretive Framework for Licensure Alignment and Policy-Enablement Columns
Interstate Medical Licensure Compact Commission: IMLCC; IMLCC Maturity Tier (Physicians): IMLCC-MT (MD); Physician Assistant Licensure Compact: PA Compact; PA Compact Maturity Tier: PA-MT; Nurse Practitioner Compact: NP Compact; NP Compact Maturity Tier: NP-MT; NP Practice Authority: NP-PA; Primary Telehealth Use Case Enabled: PTUC; Rural Workforce Impact Potential: RWIP; Cardiovascular Workforce Access Alignment: CWA-A; Health Equity Leverage Index: HELI; Digital Readiness Context: DRC; Composite Licensure Alignment Score (0–5): CLAS (0–5).
The policy-enablement impact domains—primary telehealth use case enabled, rural workforce impact potential, cardiovascular workforce access alignment, and the health equity leverage index—are synthesized through an integrative assessment of licensure flexibility, scope-of-practice authority, clinician workforce distribution, and known telehealth utilization patterns. Primary telehealth use case reflects the degree to which licensure structure supports episodic consultation versus longitudinal, team-based chronic disease management, a distinction of particular relevance to cardiovascular care. Rural workforce impact potential estimates the capacity for cross-state clinician deployment into shortage areas when licensure barriers are minimized. Cardiovascular workforce access alignment reflects concordance between Compact participation and states with documented cardiology workforce gaps, high cardiovascular disease burden, or reliance on advanced practice clinicians for specialty extension. The health equity leverage index integrates these elements into a qualitative composite, emphasizing whether licensure architecture functions as a catalyst or constraint on equitable virtual access. Collectively, these measures do not claim causal inference but provide a reproducible, policy-relevant lens through which licensure modernization can be evaluated as a structural determinant of nationwide and internationally scalable telehealth access and cardiovascular health equity. In the Interstate Medical Licensure Compact (IMLCC), the distinction between implementation and full participation is operational rather than symbolic—it reflects whether a state’s statutory commitment has translated into actual, usable multistate licensure for physicians. Implementation refers to states that have enacted Compact legislation and joined the Compact Commission but have not yet completed all operational prerequisites required to issue expedited licenses. These prerequisites typically include finalizing regulatory rules, integrating state licensing systems with the Compact’s data-sharing and verification infrastructure, setting fee schedules, appointing and training Compact administrators, and executing intergovernmental agreements. During this phase, physicians cannot yet obtain or rely on Compact-issued licenses in that state, even though the legal authority exists. Full participation, by contrast, indicates that a state has completed both legislative enactment and operational activation. In fully participating states, physicians may immediately apply for expedited licensure through the IMLCC pathway, and licenses issued under the Compact are recognized and functional for clinical practice, including telehealth. These states have active commission representation, operational workflows, and ongoing compliance with Compact governance requirements. In short, implementation states are legally committed but not yet operational, whereas fully participating states are both legally and functionally integrated into the national physician licensure mobility framework. For telehealth and workforce modeling, this distinction is critical: only full participation produces real-world access gains, while implementation represents future capacity rather than current clinical deployability. The regulatory and licensure framework that supports interstate clinical practice is a dynamic, continuously evolving system. Policies, rules, and shared data systems are regularly reviewed and updated through committee discussions, draft proposals, and technical revisions. These adjustments often occur incrementally, yet they can substantially change how clinicians obtain interstate privileges, how states exchange information, and how compliance is maintained.
For clinicians and health systems, interstate practice therefore operates within a moving environment. Eligibility standards, reporting expectations, and data processes may change over time as priorities shift and new jurisdictions participate. Assumptions based on prior rules may no longer apply as revisions take effect.
In practical terms, this system requires ongoing attention. Interstate licensure functions like shared infrastructure under constant refinement. Awareness of these changes is essential for maintaining compliant, efficient, and forward-looking clinical practice across state lines.
USA Territory U.S. territories occupy differentiated positions within the national licensure ecosystem that require explicit and nuanced treatment rather than categorical exclusion. Guam stands apart as the sole territorial jurisdiction participating in the Interstate Medical Licensure Compact for physicians, achieving functional Tier 3 maturity that enables expedited physician licensure and cross-jurisdictional virtual specialty care. This physician-level mobility partially mitigates geographic isolation and supports access to subspecialty services, including cardiovascular care. However, no U.S. territory participates in the Physician Assistant Licensure Compact, and the APRN Compact remains non-operational nationwide, resulting in the absence of Compact-enabled pathways for physician assistants and nurse practitioners across all territories. Consequently, multidisciplinary and team-based virtual care models remain structurally constrained despite physician Compact participation in Guam. Other territories, including Puerto Rico, the U.S. Virgin Islands, the Northern Mariana Islands, and American Samoa, retain robust local licensure authority and telehealth activity but remain outside Compact frameworks altogether, limiting reciprocal clinician deployment. These territorial classifications reflect upstream licensure architecture rather than local health system capacity or clinical quality and illustrate how partial Compact inclusion can alleviate—but not fully resolve—persistent inequities in access to longitudinal, team-based virtual care for geographically isolated populations.
Domain 2 — Payer Integration
Medicare’s allowance for the patient’s home as an originating site for non-behavioral telehealth through September 30, 2025 is the central federal enabler for at-home chronic care and should be reflected explicitly in contracting, quality dashboards, and equity protections (14, 17, 40). The CY-2025 Physician Fee Schedule retains these flexibilities but underscores their provisional nature, requiring outcomes-forward contracting and measurement defensible under evolving rules (27, 41). DEA’s extension of tele-prescribing flexibilities through December 31, 2025 and its proposed Special Registration program define continuity requirements for cardiovascular pharmacotherapy, escalation rules, and monitoring workflows integrated with RPM and asynchronous titration (15, 16); payment-parity mandates are associated with increased utilization in employer plans and sustained adoption in community health centers, indicating parity is a structural equity lever that should appear in national templates alongside modality parity and outcomes-linked reimbursement (18, 19) (Tables 6 and 7). Table 6. Telehealth Modalities (One Ecosystem)—Synchronous, asynchronous, interprofessional e-consults, RPM, CCM, imaging (57).
RPM: remote patient monitoring; CCM: chronic care management; PCM: principal care management; PCP: primary care provider; CT: computed tomography; MRI: magnetic resonance imaging.
Table 7. Policy Enablers & Constraints (late 2025)—Medicare and DEA windows; Federal policy timelines affecting virtual care, including Medicare telehealth extensions, DEA prescribing flexibilities, and ongoing state-level parity dynamics
DEA: Drug Enforcement Administration; IMLCC: Interstate Medical Licensure Compact Commission; CPOM: corporate practice of medicine; RPM: remote patient monitoring.
Regulation and Reimbursement: September 30, 2025, to January 31, 2026
Between September 30, 2025, and January 31, 2026, the regulatory and reimbursement environment for national virtual medical practices continued its measured transition from pandemic-era emergency flexibilities toward a stabilized, policy-anchored telehealth framework. Federal regulators maintained continuity in Medicare telehealth coverage, preserving payment parity for a broad range of evaluation and management services, behavioral health, chronic care management, and interprofessional consults delivered virtually, while incrementally reinforcing documentation, medical necessity, and quality reporting expectations. Geographic and originating site restrictions remained largely relaxed during this interval, supporting home-based care and cross-state service delivery, while licensure Compacts and state-level reciprocity mechanisms expanded in parallel, reducing friction for multi-state physician networks. Reimbursement policy increasingly emphasized value alignment, with virtual services more explicitly integrated into accountable care, bundled payment, and population health models, rather than treated as isolated fee-for-service encounters. At the same time, compliance scrutiny intensified around fraud and abuse safeguards, prescribing practices, data privacy, and corporate practice of medicine alignment, signaling a clear regulatory expectation that virtual care platforms operate with the same governance rigor, audit readiness, and clinical accountability as traditional brick-and-mortar systems.
Anticipated Direction After January 31, 2026
After January 31, 2026, regulation and reimbursement for national virtual medical practices have moved decisively toward a permanent, post-transitional architecture that rewards integration, outcomes, and scalability rather than volume alone. Policymakers have formalized telehealth coverage within core Medicare and commercial benefit designs, with narrower but clearer definitions of covered virtual services, more durable interstate licensure pathways, and explicit differentiation between episodic telehealth, longitudinal virtual care, and interprofessional consultative models. Reimbursement has further converged with value-based frameworks, prioritizing risk-stratified populations, chronic disease management, and hybrid care pathways that blend virtual and in-person services. Simultaneously, regulatory enforcement will likely continue to intensify around ownership structures, management service organization relationships, data governance, artificial intelligence use, and cross-border practice, favoring organizations that demonstrate sophisticated compliance infrastructure and transparent clinical governance. In this next phase, national virtual medical practices that are designed as regulated healthcare institutions rather than technology add-ons will be best positioned to sustain reimbursement, earn payer trust, and serve as foundational partners in modern healthcare delivery.
Expanded Post–January 2026 Regulatory and Reimbursement Expectations
In this post-January 2026 world, national virtual medical practices should now continue to expect concrete and operationally consequential changes. Medicare and many commercial payers are likely to continue to narrow telehealth coverage lists into defined service categories, explicitly distinguishing synchronous video visits, asynchronous care, remote patient (physiologic) monitoring, remote therapeutic monitoring, digital mental and behavioral health services, and interprofessional consultative services, each with separate documentation, attribution, and billing requirements. Payment parity with in-person care is expected to persist for a smaller subset of clinically justified services, while other virtual services will increasingly be reimbursed at differential rates tied to complexity, longitudinal engagement, or demonstrated outcomes. Cross-state practice will rely less on temporary waivers and more on permanent licensure Compacts, special telehealth registrations, or multi-state licensing strategies, making credentialing infrastructure and state-specific compliance tracking a core operational necessity. Prescribing oversight, particularly for controlled substances and high-risk medications, is expected to tighten further through clearer federal and state guardrails, enhanced audit triggers, and mandatory integration with prescription drug monitoring programs. In parallel, payers and regulators are expected to demand stronger proof of clinical governance, including defined medical leadership structures, quality assurance programs, peer review processes, and explicit separation and documentation of management service organization and professional entity functions. Virtual practices will also face clearer expectations around data stewardship, including cybersecurity controls, interoperability with electronic health records, responsible use of artificial intelligence tools, and auditability of clinical decision support. Collectively, these changes mean that after January 2026, successful national virtual medical practices will operate less like flexible telehealth platforms and more like fully regulated, multi-state healthcare systems with embedded compliance, reimbursement strategy, and outcomes accountability at their core (Table 8). Table 8. Telehealth Adoption & Quality—Adoption, Medicare share, parity signals (6, 9-11).
RPM: remote patient monitoring; GDMT: guideline-directed medical therapy; HFrEF: heart failure with reduced ejection fraction; NPS: Net Promoter Score; ED: emergency department.
Access partner routes (integrated from practice capture): Rapid scale is frequently achieved by collaborating with organizations that already hold employer, plan, and health-system contracts; that “partner-with-those-who-have-access” sequencing, coupled with sub-arrangements for e-consults, asynchronous messaging, RPM review, and CCM, accelerates reach while preserving quality and equity (practice capture, integrated) (Figure 3).
Operational coverage scaffolds: National programs should maintain current knowledge of the CMS Telehealth Services List, Review Criteria, Changes/Deletions, Useful Links, RPM Coverage, MLN telehealth/RPM Booklet, and HHS Medicare Payment Policies to anchor billing, documentation, and audit readiness (14, 17, 41-51).
Figure 3. Policy Timeline 2025—Medicare to 9/30/2025; DEA to 12/31/2025; Special Registration marker Jan 2025 (16, 17). Domain 3 — Chronic Care Modules (Cardiology Exemplar)
Cardiology is optimal for first-wave modularization because burden is high and the evidence base is mature: hybrid cardiac rehabilitation is non-inferior to center-based care and U.S. cohorts link home-based CR to fewer hospitalizations (21, 52); heart failure telemonitoring in TIM-HF2 reduced days lost and all-cause mortality, and pooled analyses confirm reductions in rehospitalizations, justifying national HF bundles with RPM, titration protocols, asynchronous touchpoints, and escalation rules (22, 23); hypertension RCTs (TASMINH4, HOME-BP) demonstrate that self-monitoring with tele-titration improves systolic control over usual care, enabling standardized SMBP pathways with algorithmic protocols and short tele-visits (24, 53); implementation standards for digital CR detail patient selection, remote supervision, safety monitoring, and equity safeguards aligned to accreditation (54) .
Platform triad and clinical operations (from practice capture): An EHR + patient portal + telehealth triad—paired with response-time expectations for asynchronous messaging, structured RPM review intervals, and clear escalation criteria—constitutes the minimal backbone for cardiology modules and streamlines titration, surveillance, and documentation (practice capture, integrated) (Figure 4). Figure 4. Cardiology Swimlanes—Inputs → Protocols → Outcomes (HF, HTN, CR, Post-ACS/PCI/Valve, Cardio-oncology): These interventions map to measurable outcomes, including reduced hospitalizations, improved systolic blood pressure control, reduced heart failure–related mortality, and improved functional capacity.
BP: Blood pressure; ECG: Electrocardiogram; Post-ACS: Post-Acute Coronary Syndrome; Post-PCI: Post-Percutaneous Coronary Interventions.
Imaging integration: Cloud-based PACS allows remote interpretation of echocardiography, cardiac CT, and cardiac MRI, and reduces diagnostic delays for rural and critical-access hospitals, dovetailing with cardio-oncology survivorship and structural heart follow-up (55, 56).
Modalities as one ecosystem: Synchronous video visits anchor medication initiation, counseling, and complex follow-up; asynchronous telehealth (secure messaging, store-and-forward ECG/BP uploads) improves adherence and reduces titration delays; interprofessional e-consults (CPT 99446–99452) shorten time to specialty input and reduce unnecessary referrals; RPM supplies early warnings; and CCM reimburses monthly coordination across multimorbidity (57) (Figure 5). Figure 5. Integrated Modalities—synchronous, asynchronous, e-consults, RPM, CCM, imaging orbiting the blueprint hub: The central hub represents the Heart Spark Method, which provides policy-aligned governance, clinical oversight, and equity instrumentation. Surrounding modalities include synchronous video visits, asynchronous secure messaging, interprofessional electronic consultations, remote patient monitoring, chronic care management, and imaging and diagnostics. PACS: Picture Archiving and Communication System
Six practice-building postulates (from practice capture): Virtual Practice (design for joy, fulfillment, sustainability); Program Foundation (advisor, insurance, banking, legal, CFO/accounting, marketing/sales); Remote Personnel (clinical/administrative teams for synchronous/asynchronous/e-consult/RPM/CCM); Telehealth Platform (EHR-portal-telehealth triad); National Patients (multi-state modules and outreach); Access Partners (employers, payors/health plans, health systems, self-insured) with a “partner-with-those-who-already-have-access” scaling tactic (practice capture, integrated).
Grounding precepts for sustained leadership (from practice capture): Patients, Pivot, Prioritization, Plan, Paydown, Puzzle, Picture, Pursuit, Present, Prize, Purity, Person—human-factors principles that stabilize adoption fidelity, preserve clinical joy, and sustain culture over time (practice capture, integrated).
Domain 4 — Technology Backbone
Program value depends less on modality than on infrastructure: interoperable telehealth-EHR workflows, PACS connectivity, e-prescribing, RPM ingestion, analytics dashboards for quality/equity, and governance for AI-assisted interpretation, where validated, all against sustained national demand and Medicare utilization (6, 9); comparative evidence shows lower readmissions in perioperative telehealth, parity in diabetes experience, and likely equivalence for web-based chronic monitoring, indicating well-designed pathways can achieve reliable safety and outcomes at scale (11-13) (Figure 6) (Figure 7).
Figure 6. Heart Spark Blueprint—hub (Heart Spark Method) with five spokes (licensure & accreditation, payer integration, chronic care modules, technology backbone, governance & workforce): The model emphasizes policy alignment, outcomes-driven design, and equity instrumentation, positioning cardiology as an empirically grounded anchor specialty that can be generalized across multidisciplinary chronic disease programs.
Figure 7. Burden & Equity Panels—global CVD YLLs; U.S. HF prevalence/telehealth mix; unadjusted vs adjusted equity (1, 4, 6, 58).
Domain 5 — Governance & Workforce
Governance defines physician leadership, prescriptive authority, supervision, escalation, documentation, and outcomes accountability, while equity must be instrumented through dashboards that stratify utilization and outcomes by race/ethnicity, geography, and modality, because unadjusted Medicare analyses show higher telehealth use among Black and Hispanic beneficiaries while adjusted patterns vary, and national data confirm older and digitally disadvantaged adults rely more on audio-only pathways that should be protected and measured as equity enablers (6, 58) (Figure 8).
Locations of Care (explicit in main text)
A site-agnostic design enables consistent workflows across office-based clinics, hospital inpatient services, home-based encounters, skilled nursing facilities (SNFs), critical access hospitals (CAHs), emergency departments (EDs), and assisted living facilities (ALFs), with standardized synchronous/asynchronous/e-consult/RPM/CCM/imaging patterns that preserve safety and quality as patients and clinicians move across settings (57) (Figure 8).
Figure 8. Locations of Care—office, hospital, home, SNF, CAH, ED, ALF: Virtual modalities enable continuity between sites, supporting integrated home and clinic visits, interprofessional consultation, diagnostics, titration, and procedural care as needed. Equity dashboards and outcomes reporting span all locations, reinforcing consistent quality and access regardless of care setting.
Section 5 of 7
Discussion
National virtual care can be responsibly implemented when five interdependent domains—licensure and accreditation, payer integration, chronic care modules, technology backbone, and governance with equity—are specified and aligned to the strongest clinical trials, meta-analyses, national datasets, and live federal rules, with cardiology serving as a credible launch specialty given measurable endpoints and mature implementation standards (10). Comparative effectiveness data confirm that telehealth achieves outcomes broadly comparable to in-person care when programs are deliberately designed, a conclusion triangulated by reduced readmissions in perioperative settings, parity in diabetes experience, and likely equivalence in web-based chronic monitoring, thereby placing responsibility on infrastructure, workflows, and follow-up rather than the mere choice of modality (10-13). Existing telehealth models often focus narrowly on single conditions, isolated technologies, or short-term policy allowances. In contrast, this framework integrates multiple cardiovascular domains, care modalities, and governance structures within a national perspective. Policy architecture is a determinant of reach and equity: Medicare’s originating-site flexibilities to September 30, 2025, and DEA’s tele-prescribing flexibilities to December 31, 2025, with a proposed Special Registration pathway, constitute a time-boxed opportunity to institutionalize audio-capable, equity-protective, outcomes-instrumented virtual care within payer contracts (14-17). The policy timeline underscores the time-sensitive nature of national virtual care expansion. The identification of these windows emphasizes the importance of acting decisively within current regulatory allowances while preparing for longer-term policy stabilization. Payment-parity analyses show consistent associations with increased utilization across employer markets and sustained use in community health centers; parity should be treated as a core design requirement alongside accreditation and licensure strategies in national contracts (18, 19). Equity requires intentionality because modality access patterns differ by race/ethnicity, geography, and digital capital; dashboards, device programs, broadband supports, language services, and explicit audio-capable protocols—measured and reported—are necessary to ensure telehealth closes rather than widens disparity gaps (6, 58). When embedded within a coherent governance and accreditation structure, these modalities support clinical quality, operational efficiency, and patient-centered care. This translational approach recognizes that sustainable virtual care adoption depends not only on evidence but also on clarity, timing, and clinical relevance. Cardiology is the ideal exemplar because hybrid cardiac rehabilitation is non-inferior to center-based CR and home-based participation reduces hospitalizations; structured heart-failure telemonitoring reduces days lost and mortality with pooled evidence for fewer rehospitalizations; and SMBP programs improve systolic control over usual care, all under portable standards for remote supervision, safety, and equity; furthermore, imaging, asynchronous messaging, interprofessional e-consults, RPM, and CCM together create a closed loop for diagnosis, titration, surveillance, and coordination across sites of care (21-24, 52-54, 59). Strengths include breadth across 62 high-impact sources, explicit alignment to 2025 federal endpoints, accreditation-anchored governance, and modularization that maps clinical results to payer value; limitations include the integrative (non-systematic) design, heterogeneity across included studies, and time-limited federal allowances that require ongoing vigilance and adaptation (14). Future work should link EHRs to telehealth utilization and outcomes to establish survival and disparity effects beyond intermediate endpoints, scale hybrid CR/RPM/CCM implementations under implementation-science frameworks, evaluate licensure-exception pilots and the DEA Special Registration for multistate sustainability, and rigorously assess asynchronous messaging and interprofessional e-consults as throughput and access multipliers in chronic care networks (6, 16, 21) (Table 9) (Figure 9). Table 9. Accreditation & Compliance Standards for Virtual Care—NCQA Virtual Care, URAC Telehealth, HIPAA, AICPA SOC 2, HITRUST i1 (30-33, 60).
NCQA: National Committee for Quality Assurance; URAC: formerly Utilization Review Accreditation Commission; HIPAA: Health Insurance Portability and Accountability Act; AICPA: American Institute of Certified Public Accountants; SOC 2: Service Organization Control 2; HITRUST: Health Information Trust Alliance; CSF: Common Security Framework; NIST: National Institute of Standards and Technology; DEA: Drug Enforcement Administration; PDMP: Prescription Drug Monitoring Program; CMS: Centers for Medicare & Medicaid Services; RPM: remote patient monitoring; CCM chronic care management; BAA: business associate agreement; SOP: standard operating procedure.
Figure 9. Clinician One-Page Infographic—distilled burden, adoption, policy windows, cardiology anchors.
Section 6 of 7
ACKNOWLEDGEMENTS
We are grateful to Michael A. Garcia for assistance with this manuscript, as well as Gabriela Andrade and Zachary McGuire, all currently or formerly at Florida International University, for their valuable assistance and input during the preparation of this manuscript. Artificial intelligence tools were used in the development of this manuscript. AI, specifically ChatGPT (OpenAI, GPT-4, 2024), was used to edit this manuscript. These drafts were reviewed and edited by the author for clarity, accuracy, and integration with the manuscript’s overall argument.
Section 7 of 7
CONFLICT OF INTEREST The authors declare no conflict of interest.: References:
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Supplementary Table 1. Legislative Verification (All Clinician Groups)
Supplementary Table 2. Administrative Implementation Verification
Supplementary Table 3. Functional Operability Verification
Tier assignment rule: Tier 3 requires all criteria in Sections A–C to be satisfied. Tier 2 requires Section A and at least one criterion in Section B or C. Tier 1 requires Section A only. Tier 0 fails Section A.
Supplementary Table 4. Scope-of-Practice Determination (Nurse Practitioners Only)
Supplementary Table 5. Policy-Enablement Classification Inputs
Supplementary Table 6. Composite Licensure Alignment Score Derivation