1. The big one: Most insurances wont pay for it. Lets face it, behind the marketing BS, a major driving factor is making a lot of money. Doctors get paid a lot of money, Big wigs at a large healthcare institution get paid a lot too. Money is a big driving factor. A few insurances are willing to pay for it. But not enough for wide distribution.
2. Health Care Technology is behind the time. There are a lot of reasons for this, Usually due to most of it being very expensive, having to buy a new multi-million dollar MRI just to allow for better transmission of data, or the millions spent on a new EHR system. After the investment they want to keep it for a while to pay off the investment. The bad part is they keep them for far too long and technology bypasses them. This aged infrastructure make telepresence hard because we need it integrated as part of the health record, otherwise it could come down to a point where the doctor said he saw the patient and the patient said no he didn't.
3. The ones who need it the most don't have the resources to use it. If you are in very rural locations, chances are you may not have the internet speed to take advantage of it. Or you are too poor to access transportation, that means you will be on the slowest internet connection (if you have one at all) with a slow hand me down computer.
4. IT Skills. For both Doctors and the Patients. Many of the older doctors are reluctant to learn technology, their Ego gets in the way of them learning something new, as they may look stupid in front of those normal people who didn't study for 8+ years in a particular field. Still even today most Doctors will make paper charts and hand them off to someone else to put in those damn expensive EHR that the government told them to use. As well for patients, many of the people needing health care are the older folks who are not so technology aware, where you suffer from watching them trying to move the mouse, and confused that scrolling down makes the text go up. Also how many times do you see someone struggling to start a web-ex session. Imagine how hard it would be for two people who don't use it regularly?
5. Image quality. It is getting better, however there are some odd things about telepresence... People look at the eyes of the people on the screen... So they look like they are looking down, giving a false non-verbal communication. Resolution at slower speed, or cheaper web-cams may not be good enough to see particular issues, a Rash may be a red blur or may not be picked up at all. Details such as sweating for flushness of face or swelling may not be picked up.
6. Security. Most health care systems have this approach to security. Go with a vendor who will take the blame if there is a problem. This means they will pick a big company with an army of lawyers who will find a way to differ the problem. This isn't security or choosing the best secure system. Just saving your butt. This is newer technology and trying to find a vendor who is willing to take the blame if some how that Dr. visit was captured and transferred to a scrupulous source due to a virus or some sort of malware on the home users PC.
7. Patient location may not be HIPAA safe or just safe for the patient to have a consult. Having that abusive other just outside the door or the child listening in and taking what is said out of context.
There are a lot of issues to be resolved