Expansion of Telehealth Across the Rural–Urban Continuum

• Author: Ann D. Bagchi
• Published date: 01 December 2019
• Date: 01 December 2019
• DOI: http://doi.org/10.1177/0160323X20929053
• Subject Matter: Articles

Article
State and Local Government Review
2019, Vol. 51(4) 250-258
Expansion of Telehealth
ª The Author(s) 2020
Article reuse guidelines:
Across the Rural–Urban
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DOI: 10.1177/0160323X20929053
Continuum
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Ann D. Bagchi1
Keywords
telehealth, underserved, structural inequity, digital divide
Rural America faces a health-care crisis due, in
Defining Telehealth
part, to mergers in large hospital systems and
The Health Resources and Services Adminis-
divestments that threaten the closure of nearly
tration (HRSA) is the federal agency that
700 rural hospitals (National Rural Hospital
houses the Office of the National Coordinator
Association 2020). Since 2013, the number of
for Health Information Technology that over-
annual rural hospital closures has been in the
sees telehealth-related policies. Officially, the
double digits with 2019 seeing nineteen clo-
agency defines telehealth as “the use of elec-
sures, the highest number to date (HealthLea-
tronic information and telecommunications
ders 2020). More generally, residents of rural
technologies to support and promote long-
areas face significant health disparities due to
distance clinical health care, patient and profes-
the lack of access to specialists/subspecialists,
sional health-related education, public health,
low patient volumes that drive up health-care
and health administration” (HealthIT.gov
costs, geographic isolation that increases travel
2017). HRSA recognizes the following four
times to obtain services, and the demographics
general categories of telehealth modalities:
of rural residents (i.e., higher percentages of
synchronous, asynchronous, remote monitor-
elderly and low-income residents) that increase
ing, and mobile health (mHealth; HealthIT.gov
health-care risks and incidence of chronic con-
2017). Live videoconferencing (i.e., synchro-
ditions (Taylor 2019). Indeed, recent evidence
nous service) involves real-time videoconfer-
documents higher rates of “deaths of despair”
encing between a patient and a health-care
(i.e., deaths associated with suicide, poison-
provider located at a remote site. Asynchronous
ings, drug overdoses, and cirrhosis) within rural
technologies involve successive data exchanges
areas, which highlight the vulnerabilities rural
between two users. Also known as “store and
residents face (Case and Deaton 2015). Expan-
forward” technologies, these modalities
sion of telehealth services in rural areas offers
promise for addressing the factors contributing
to health vulnerability. This article provides an
1 School of Nursing, Rutgers, The State University of New
overview of telehealth implementation in rural
Jersey—Newark, NJ, USA
areas of the United States, discusses barriers to
wide-scale uptake, presents a review of recent
Corresponding Author:
Ann D. Bagchi, School of Nursing, Rutgers, The State
policy changes initiated by the SARS-CoV-2
University of New Jersey—Newark, 366 Ackerson Hall,
(i.e., COVID-19) pandemic, and offers recom-
Newark, NJ 01702, USA.
mendations for future policy initiatives.
Email: abagchi@sn.rutgers.edu

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Bagchi
251
generally involve information exchange
US$3.5 million in cost savings and the avoid-
between primary and specialty providers (e.g.,
ance of more than 700 unnecessary patient
radiographic images sent from a radiologist’s
transfers (Avera eCARE 2020b).
office to a primary care office). Remote moni-
toring systems include wearable technology
(e.g., heart rate or wireless blood pressure moni-
Skills Training in Affective and
tors) that can transmit data directly from a
patient to the health-care provider. Finally,
Interpersonal Regulation (STAIR)
mHealth technologies include applications and
The STAIR program is an evidence-based
other health-related functions accessible on
therapy originally designed to treat people
mobile devices (i.e., smartphones, tablets).
with post-traumatic stress disorder who were
victims of childhood abuse (Cloitre et al.
Models of Telehealth Services in
2010). The program was adapted to provide
telemental health services to women veterans
Rural Communities
living in rural areas who have a history of
The Rural Health Information Hub (RHIhub
military-associated sexual and other traumas
2020), funded by the Federal Office of Rural
(Weiss et al. 2018). Participants receive
Health Policy, serves as the national clearing-
evidenced-based treatment for post-traumatic
house for rural health issues. The site provides
stress disorder through individual or group tel-
comprehensive tools for the development of
econferencing available in local outpatient
telehealth solutions in rural areas and describes
clinics or their own homes. The ten-week pro-
models for telehealth delivery to manage
gram focuses on managing depression symp-
chronic health conditions, access specialty
toms, enhancing mood regulation, and
services, and support patient and provider
increasing social functioning. Research
education (RHIhub 2019b). The following
demonstrated enhanced program participation
examples, described in greater detail on RHI-
through the use of teleconferencing (Weiss
hub, highlight a number of successful programs
et al. 2018).
addressing a variety of health-care needs.
Avera eCARE© Emergency
Bridges to Care Transitions-Remote Home
Avera eCARE (2020a), a private company,
Monitoring and Chronic Disease Self-
has supported telehealth solutions across a
Management
range of specialty practice settings (e.g.,
school health, pharmacy, correctional health)
Designed by researchers at Emory University,
in rural areas since 1993. Launched in 2009,
the Bridges to Care program seeks to address
Avera eCARE (2020b) Emergency provides
behavioral health issues in patients with poorly
rural hospitals and local practitioners access
managed chronic health conditions (RHIhub
to board-certified emergency department
2019a). Patients enroll in this program follow-
(ED) physicians to consult on complex ED
ing preventable hospitalizations or ED visits for
cases, provide ED orders, and assess and
chronic health conditions. The program offers
facilitate transfers for higher levels of care.
in-home monitoring equipment to track vital
Participating health-care systems access
signs and prompt additional assessments in the
high-definition audiovisual support, with ED
context of abnormal readings. With particular
providers credentialed and licensed as part of
focus on the management of comorbid beha-
the local health-care delivery team. According
vioral health conditions, the program is associ-
to the company’s Web site, the service pro-
ated with lower rates of hospital readmission
vided more than 7,700 telehealth encounters
and ED visits and high patient satisfaction
to rural areas in 2019, which resulted in
scores (RHIhub 2019a).

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252
State and Local Government Review 51(4)
Project Extension for Community
example, in March 2020, the month when
Healthcare Outcomes (ECHO®)
social distancing directives went into effect,
48 percent of physicians reported use of tele-
Established in 2003 at the University of New
health services up from 18 percent in 2018
Mexico, Project ECHO® uses telehealth to train
(Merritt Hawkins 2020). Similarly, one of the
rural primary care providers in specialty care as
large private health plans operating in Massa-
a way to increase access to these services in
chusetts reported a 3,600 percent increase in
local communities (University of New Mexico
reimbursements for telehealth visits from
2020). Clinicians participate in grand rounds
February to March 2020 (America’s Health
presentations and case studies in weekly
Insurance Plans [AHIP] 2020). The following
teleECHO™ clinics. Although the program
sections highlight some of the more common
started with training in hepatitis C manage-
solutions across the aforementioned categories
ment, it has expanded to provide training on
of barriers; a full accounting is beyond the scope
more than hundred health conditions and
of this article.
operates in thirty-one countries around the
world.
Technical Barriers
Addressing Barriers to
Solutions to the lack of access to broadband
connectivity in rural and underserved urban
Widespread Implementation
areas and the digital divide are topics addressed
Technology’s ability to reach consumers in
in greater length in the papers by Feld and Gal-
geographically isolated areas, particularly rural
...