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Improving Rural Health Through Telehealth-Guided Provider-to-Provider Communication

Systematic Review Draft

Open for comment through Nov 9, 2021

This report is available in PDF only (Draft Report [PDF, 1.7 MB]; Appendixes [PDF, 2.3 MB]).

Main Points

  • Use of Provider-to-Provider Telehealth for rural populations: Limited research from regional and national surveys and claims data suggest that telehealth for provider-to-provider communication is used to different extents across specific clinical care uses such as psychiatry, emergency, and stroke care. Use was increasing even before the COVID-19 pandemic.
  • Effectivenss of Provider-to-Provider Telehealth for rural populations:
    • Telehealth to support direct patient care may provide benefits for inpatient care, for neonates in rural hospitals, for outpatient management of depression and diabetes, and emergency care for stroke/heart attack/chest pain as well as trauma.
      • Evidence on other uses, outcomes or populations was insufficient to support conclusions. No studies reported harms or unexpected negative outcomes for provider-to-provider telehealth.
    • Use of telehealth for provider education and mentoring, including programs like Extension for Community Healthcare Outcomes (ECHO) that use video for instruction and collaboration, may improve patient outcomes, change provider behavior, and increase provider knowledge and confidence in treating specific conditions.
  • Barriers and Faciliators to Implementaiton of Provider-to-Provider Telehealth for Rural Populations: Inadequate provider time, technology, and other resources, as well lack of understanding of the rural context and long-term commitments to telehealth are barriers to broader implementation of provider-to-provider telehealth in rural settings
  • Methodological Weakness of Studies: Effectiveness and implementation studies frequently employed less rigorous designs, had small sample sizes, and often did not minimize bias through design or analyses.

Structured Abstract

Objectives.To assess the use, effectiveness, and implementation of telehealth supported provider-to-provider communication and collaboration for the provision of health care services to rural populations.

Data sources. We conducted a comprehensive literature search of Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL for articles published January 1, 2015, to September 18, 2020, to identify data on use of rural provider-to-provider telehealth (key question 1). We searched the same sources for articles published January 1, 2010, to September 18, 2020,  for studies of effectiveness and implementation (key questions 2 and 3) and to identify methodological weaknesses in the research (key question 4). Additional sources were identified through reference lists, suggestions from stakeholders and responses to a Federal Register notice.

Review methods. The methods for this systematic review followed the AHRQ Methods Guide and the PRISMA reporting guidelines. We used predefined criteria and dual review of abstracts and full text articles to identify research results on 1) regional or national use; 2) effectiveness; 3) barriers and facilitators to implementation, and 4) methodologic weakness in studies of provider-to-provider telehealth in rural areas. We assessed the risk of bias of the effectiveness studies using criteria specific to the different study designs and evaluated strength of evidence (SOE) for studies of similar telehealth interventions and with similar outcomes. We categorized barriers and facilitators to implementation and methodological weaknesses of studies using the Consoldiated Framework for Implementation Research (CFIR).

Results. We included 138 studies reported in 143 publications. Studies on the degree of uptake of provider-to-provider telehealth were limited to specific clinical uses (pharmacy, psychiatry, emergency care, and stroke management) in six studies using national or regional surveys and claims data which found wide variability across states and regions, but increasing uptake over time.

Seventy-nine studies (19 trials and 60 observational studies) reported on clinical and non-clinical effectiveness outcomes of provider-to-provider telehealth in rural settings, indicating that there may be: similar rates of transfers and lengths of stay with telehealth for inpatient consultations; similar clinical outcomes for neonates; improvements in medication adherence and treatment response in outpatient care for depression; improvements in some clinical monitoring measures for diabetes with endocrinology or pharmacy outpatient consultations; similar mortality or time to treatment when used to support emergency assessment and management of stroke, heart attack or chest pain at rural hospitals; and similar rates of appropriate versus inappropriate transfers of critical care and trauma patients with specialist telehealth consultations for rural emergency departments (SOE: low). Studies of telehealth for education and mentoring of rural health care providers may result in intended changes in provider behavior and increases in provider knowledge, confidence and self-efficacy (SOE: low). Patient outcomes were not frequently reported for telehealth provider education, but they may be improved based on two included studies (SOE: low). Evidence for telehealth interventions for other clinical uses and outcome combinations was insufficient.

We identified 53 program evaluations and qualitative studies that identified barriers and facilitators to rural provider-to-provider telehealth. Success was linked to well-functioning technology; sufficient resources, including time, staff, leadership and equipment; and adequate payment or reimbursement. Some considerations may be unique to implementation of provider-to-provider telehealth in rural areas. These include: the need for consultants to better understand the rural context; the need for regional initiatives that pool resources among rural organizations that may not be able to support telehealth individually; and the need for programs that can support care for both infrequent as well as frequent clinical situations in rural practices.

An assessment of methodologic weaknesses found that studies were limited by less rigorous study designs, small sample sizes, and lack of analyses to address risks for bias. A key weakness is that studies do not assess the risk that temporal changes may impact the results in studies that compare outcomes before and after telehealth implementation.

Conclusions. While the evidence base is limited, what is available suggests that telehealth supporting provider-to-provider to communications and collaboration may be beneficial. Telehealth studies report better patient outcomes in some clinical scenarios (e.g., outpatient care for depression or diabetes, education/mentoring) where telehealth interventions increase access to expertise and high quality care. In other applications (e.g., inpatient care, emergency care) telehealth results in patient outcomes that are similar to usual care, which may be interpreted as a benefit when the purpose of telehealth is to make equivalent services available locally to rural residents. Barriers to implementation are known and common to practice change efforts. Methodological weaknesses stem from weaker study designs, such as before-after studies, and small numbers of participants. The rapid increase in the use of telehealth in response to the COVID-19 pandemic is likely to produce more data and offer opportunities for more rigorous studies.