• NIH Seeks Input on Rural Telehealth Research Needs

    Family Physician Expert Who Helped Draft Report Weighs In

    January 27, 2022, 4:10 pm. Cindy Borgmeyer — Although the benefits of country living are plentiful — fresh air, minimal traffic, relative peace and quiet — there are downsides, of course. Access to some health care services may be limited in sparsely populated areas where low patient volumes make local availability of certain specialists and high-level hospital care less feasible. Further complicating matters is the fact that rural communities have disproportionately higher rates of serious health conditions and a greater proportion of older residents.

    telemedicine concept

    Meanwhile, more than 180 rural hospitals have either closed completely or ceased providing inpatient care since 2005, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. Attributed to factors ranging from rising numbers of mergers and affiliations to the proliferation of new models of care, the pace of these closures has ticked up considerably since the recession of 2008-2009, with 21 of them having occurred just since the pandemic began.

    The closures are especially concerning given that people living in rural areas experience consistently higher morbidity and mortality rates for a host of health disorders compared with their urban counterparts. According to a 2019 Morbidity and Mortality Weekly Report, for example, percentages of potentially excess deaths for the nation’s five leading causes of death (heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke) from 2010-2017 were all higher in nonmetropolitan than metropolitan areas. And in 2019, CDC statistics showed that rates for each of 10 leading causes of death in the United States were higher in rural than urban areas.

    The implications of this yearslong trend have not been lost on federal and state policymakers who, over time, have initiated policies and made significant financial investments intended to bolster rural health care infrastructure and facilitate greater access to care. Telehealth technology — whether to connect rural patients with their physicians or to facilitate collaboration between rural and urban health care professionals — has shown great promise in achieving this goal.

    Recognizing that wholesale investment in this technology is best informed by a clear understanding of how it affects all stakeholders, several federal agencies have partnered in an initiative to determine what is known about the effectiveness of rural clinician-to-clinician telehealth, or RT, and its impact on improving health outcomes.

    Story Highlights

    A recently published draft report produced as part of that effort is now available for public comment through Feb. 4.

    Assessing and Addressing Research Gaps

    Last year, NIH’s National Center for Advancing Translational Sciences, National Heart, Lung and Blood Institute, and Office of Disease Prevention; the Health Resources & Services Administration’s Federal Office of Rural Health Policy; and the CDC’s Office of the Associate Director for Policy and Strategy launched a joint effort to examine the use of RT communication in rural health settings.

    As part of NIH’s Pathways to Prevention Program, the initiative included a systematic review conducted by the Oregon Health and Science University Evidence-based Practice Center to assess the use, effectiveness and implementation of RT to provide health care services to rural populations.

    An October 2021 P2P workshop, “Improving Rural Health Through Telehealth-Guided Provider-to-Provider Communication,” featured summary presentations of the systematic review’s findings, as well as reports from experts invited to speak about various aspects of RT applications, including local and regional efforts and applications to specific populations, health conditions and medical specialties.

    NIH then convened an independent panel of experts to assess information from both the systematic review and the workshop, reflect on its significance and prepare a report outlining the results of those deliberations. That draft report identifies what is known and what knowledge gaps remain around four key questions and offers recommendations for moving RT applications forward. This information is intended to inform discussion and planning by clinicians, health care administrators, funders and policymakers.

    The four foundational questions that guided the systematic review, workshop and panel deliberations, as well as recommendations from the report related to those questions, are as follows:

    1. What is the uptake of different types of RT in rural areas?

    • Develop a consistent definition of RT types that can be applied across programs, clinicians and organizations. A central telehealth resource center could be established to convene key stakeholders (both public and private) to develop a consensus-based definition of RT.
    • Build insight into utilization by partnering with payers in future research, identifying barriers to accurately quantifying relevant billing data and establishing methodologies to quantify unbilled services.
    • After quantifying uptake across rural areas, expand research to examine (1) the effect of hospital and practice consolidation on uptake; (2) whether value-based payment or other business models encourage uptake; and (3) if disparities exist related to smaller hospitals or clinicians being left out of partnerships, integrated systems, shared-savings networks or other value-based models of care.
    • Examine the extent to which lack of reliable broadband affects uptake and assess less robust RT methods such as audio-only and FaceTime use.
    • Establish a national and/or regional database of models for RT uptake and necessary infrastructure.

    2. What is the effectiveness of RT among rural patients?

    • Conduct evaluation studies to assess what works best for which patients in specific settings. Standardize organizational factors and outcomes across multiple sites to gauge impact.
    • Assess the types of RT partnerships associated with improved patient and clinician outcomes.
    • Evaluate processes through which RT partnerships are established and sustained to guide widespread dissemination.
    • Evaluate whether RT impacts rural clinician recruitment/retention.

    3. What strategies are effective, and what barriers and facilitators to implementation and sustainability of RT in rural areas exist?

    • Engage clinicians in shaping and evaluating RT to better meet community and population needs.
    • Study the impact of leveraging infrastructure resources and implementing strategies to reduce known barriers to facilitate RT sustainability.
    • Ensure that studies capture and assess the impact of environmental factors that may facilitate RT sustainability.
    • Examine sociocultural factors that may facilitate uptake, improve outcomes and help foster sustainability.

    4. What are the methodological weaknesses of studies of RT for rural patients and what improvements in study design might increase the impact of future research?

    • Consider alternative study designs when rigorous designs such as randomized controlled trials are not feasible. Use statistical approaches to minimize selection bias and address confounding effects.
    • Use qualitative and mixed methods to understand difficult-to-quantify clinicians’ attitudes, perceptions, constraints and behaviors that affect RT implementation. Qualitative study limitations can be reduced by using well-designed sampling procedures and employing mixed methodologies to triangulate qualitative and quantitative results.
    • Adopt appropriate methods to characterize and model the institutional context and geographic/community context of RT implementation.

    “Today, there is an unprecedented opportunity to understand temporal and contextual effects on an array of issues ranging from barriers, adoption and impact of RT on patient outcomes to its impact on retention of rural providers,” the panel members noted in their report. Leveraging that opportunity, however, will require robust new research efforts.

    To that end, they continued, “a focused research agenda to fill gaps identified in this report should be a priority for policymakers, payers and others, with the intent of developing evidence-informed RT practice, policy and payment.”

    Insight From a Rural FP Expert

    Family physician Robert Moser, M.D., served as a member of the NIH panel that drafted the report. Now dean of the University of Kansas School of Medicine-Salina and clinical professor in the Department of Population Health at KU’s Kansas City campus, he practiced rural family medicine for more than two decades before entering academic medicine.

    Recognized as an expert on rural health policy and research, Moser served as secretary and state health officer for the Kansas Department of Health and Environment from January 2011 to December 2014.

    Tapped to be the sole primary care physician on the NIH panel, Moser told AAFP News he viewed his role as ensuring that research conducted to advance the use of RT communication in rural health settings was pragmatic and provided value to clinicians, patients and payers.

    “We need well-designed studies to evaluate the effectiveness and efficiency of clinician-to-clinician provider telehealth,” said Moser, “so payers accept this as a mode of consultation, equivalent to what would take place in person.”

    After all, he stressed, in each scenario, the individuals involved are delivering a service that can benefit the patient by improving care and outcomes while lowering costs for both the patient and the payer.

    We already do some of this by phone,” Moser noted. “A telemedicine consultation between health care professionals, with the patient or family looped in, is a model I think essential for providing care locally at the rural hospital and reducing transfers until necessary.”

    In fact, he added, such consultations could obviate the need for transfers in some cases.

    “A few years ago, right after leaving KDHE, a couple of large regional hospitals informed me they had noticed relatively high mortality rates within the first 48 hours for patients transferred from rural communities,” Moser explained. “These weren’t only trauma patients, as one might expect, but patients approaching the end of life from various conditions. I understood that some of the reasons these transfers occurred were due to patient or family requests. They may have felt that more advanced care settings could change the trajectory of the outcome.”

    In such instances, he continued, “A telemedicine consult between clinicians and involving the patient or family could help manage the patient locally, reassuring everyone that care at the local level is what the patient needs if the higher level of care couldn’t offer anything that would change the outcome.”

    Granted, Moser acknowledged, “It’s hard for busy specialists and local physicians to take time to connect by phone, let alone by another means, but I would like to see if a telemedicine consult prior to transfers makes a difference.”

    Of course, he went on, “We have to address some barriers to utilization of this model, like technology: What would be the minimum platform necessary to deliver effectively? And what level of reimbursement makes it worth the time to set up the consult with patient/family involvement? How do we make sure payment reflects the costs to deliver the care and includes an assessment of the savings to the payer or system and the patient?”

    Answering those questions, according to Moser, will take involving health care professionals in rural areas in research. “But I know how busy rural physicians are just keeping up with their workload, so we have to make it as seamless as possible by blending those efforts into the usual workflow,” he cautioned. “Rural clinicians understand that and other challenges at a level someone in a resource-rich environment won’t. So, recognizing the time and work disruption and lost revenue will be essential considerations.”

    And it’s not just the individual clinicians who should be involved in studying these rural telemedicine consults, Moser observed: “I would like to see rural health systems step up to volunteer to be part of some of these future research efforts.” After all, he added, these health systems have to be confident that the technology is reliable and will be available when they need it.

    Ultimately, all stakeholders’ contributions will be needed to achieve an integrated system of clinician-to-clinician telemedicine that can improve health in rural areas.

    “I think some of the academic and larger regional health systems could offer the complex platforms needed and services that would support care at home or in the patient’s community through telemedicine and telehealth services,” Moser concluded. “There can be bits and pieces through various products and means, but a centralized and comprehensive approach would allow us to provide care according to the need in each community rather than a cookie-cutter approach to all.”

    Comments on the draft report will be accepted through Feb. 4. Commenters are asked to reference the corresponding line number in the report for each comment. Comments should be submitted to NIHP2P@mail.nih.gov.