Why Virtual Care Fails Without Governance and Accountability

Last week, Michael Dalton did not talk about telehealth adoption in aspirational terms. He laid out an operating model. The difference matters. In an industry saturated with short-cycle digital initiatives, Dalton’s argument was clear: virtual care is a redesign. And if health systems want to lead rather than lag, they must stop framing virtual care as a delivery channel and start governing it as infrastructure.

The governance issue is the crux. Dalton’s emphasis on durable, equity-driven models of accountability is a challenge to how health systems define success. Most virtual initiatives today still prioritize throughput and platform utilization. But scalable models demand clarity on clinical relevance, operational sustainability, and integration across every care setting. Those levers are not optimized in IT departments. They are shaped by leadership, policy, and the hard work of cross-functional coordination.

Dalton is not alone in sounding this call. The National Academy of Medicine has pushed for digital health equity as a governance issue, not a feature request. Likewise, MedPAC continues to recommend linking telehealth coverage to measurable outcomes, rather than open-ended volume incentives. This framing reshapes how investments in virtual infrastructure are justified, and how failure is defined.

Too many health systems still treat virtual care like a pilot. They wrap legacy workflows in front-end interfaces, fail to retrain or reassign clinical staff, and measure ROI on scheduling throughput or app logins. These signals are insufficient. Virtual-first care models must be judged by their ability to reduce fragmentation, activate patients, and extend system capacity without deepening inequity or compliance risk.

This is particularly urgent as systems approach digital care as a population health lever. A virtual-first infrastructure is not episodic by design. It is longitudinal. It starts with the patient’s lived environment and prioritizes navigation, not transactions. When care begins in the home or in the community, not in the waiting room, every subsequent engagement becomes more contextually intelligent. That is the scalability promise of virtual care. But it cannot be realized if compliance, integration, and fiscal alignment are treated as afterthoughts.

As Dalton made clear, this is a strategic problem. The failure to establish clear governance models that define what success looks like, clinically, financially, and equitably, is what keeps virtual-first initiatives in perpetual pilot mode. When governance is fragmented, care is fragmented. And when the incentives driving infrastructure investments are not aligned to long-term accountability, systems spend more and achieve less.

This is not simply a health system problem. Policy friction remains high. CMS telehealth flexibilities are set to expire in 2025 without further congressional action. Licensure reform remains limited, locking clinicians into state-specific silos that stifle care continuity. Broadband access, as tracked in the FCC’s 2024 Broadband Deployment Report, still lags in rural and low-income communities. Without federal action to treat digital infrastructure as a public good, health systems will remain constrained no matter how sophisticated their platforms.

Yet these constraints are design parameters. The systems best positioned to lead are those treating virtual-first care as an ecosystem of accountability, not a catalog of tools. This requires governance frameworks that start with patient journeys, not departmental structures. It means evaluating performance through the lens of continuity, access equity, and outcomes over time. And it means building models that are transparent, iterative, and adaptive enough to evolve with policy shifts, not stall because of them.

One emerging model worth watching is the alignment between system-based virtual care platforms and EHR-integrated workflows. As Dalton noted, Ovatient’s integration with Epic allows for seamless documentation, continuity of care, and cross-setting coordination. These models reduce cognitive load for clinicians and eliminate duplicative infrastructure. But they also reinforce a more important point: integration must be built in, not layered on.

Leadership teams should ask harder questions. Where are our governance decisions being made for virtual care? Who owns the patient experience across settings? Are compliance and equity considerations built into design or retrofitted after launch? What are the success criteria, and do they reflect the lived realities of our most vulnerable patients?

The future of virtual care will be shaped by governance. And governance, when it works, is not a bureaucratic obstacle. It is the foundation for innovation that lasts.

Dalton’s clarity should be a call to action. For provider executives, digital strategists, and policymakers alike, the message is simple: sustainable virtual-first care requires strategic alignment, not digital enthusiasm. If we want digital health to finally deliver on its promise, we need to stop launching products and start building systems.