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

Systematic Review Dec 26, 2022
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  • 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 location for specific clinical care uses such as psychiatry, emergency, and stroke care. Use was increasing even before the COVID-19 pandemic and this seems likely to continue, though research evaluating new and increased use has yet to be published.
  • Effectiveness of Provider-to-Provider Telehealth for Rural Populations:
    • Telehealth to support direct patient care may provide benefits for in patientcare, for neonates in rural hospitals, outpatient management of depression and diabetes, and emergency care of stroke/heart attack/chest pain and 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 Facilitators to Implementation of Provider-to-Provider Telehealth for Rural Populations: Inadequate provider time, technology, and other resources, as well as limited understanding of the rural context and lack of long-term commitments to telehealth are barriers to broader implementation of provider-to-provider telehealth in rural settings. Telehealth implementation was facilitated when there were sufficient resources, access to knowledge, engagement of leadership and the program addressed patient needs.
  • 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.

Objectives. To assess the use, effectiveness, and implementation of telehealth-supported provider-to-provider communication and collaboration for the provision of healthcare services to rural populations and to inform a scientific workshop convened by the National Institutes of Health Office of Disease Prevention on October 12–14, 2021.

Data sources. We conducted a comprehensive literature search of Ovid MEDLINE®, CINAHL®, Embase®, and Cochrane CENTRAL. We searched for articles published from January 1, 2015, to October 12, 2021, to identify data on use of rural provider-to-provider telehealth (Key Question 1) and the same databases for articles published January 1, 2010, to October 12, 2021, 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, stakeholder suggestions, and responses to a Federal Register notice.

Review methods. Our methods followed the Agency for Healthcare Research and Quality Methods Guide (available at https://effectivehealthcare.ahrq.gov/topics/cer-methods-guide/overview) 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) methodological weakness in studies of provider-to-provider telehealth for rural populations. 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 with similar outcomes. We categorized barriers and facilitators to implementation using the Consolidated Framework for Implementation Research (CFIR) and summarized methodological weaknesses of studies.

Results. We included 166 studies reported in 179 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 seven studies using national or regional surveys and claims data. They reported variability across States and regions, but increasing uptake over time.

Ninety-seven studies (20 trials and 77 observational studies) evaluated the effectiveness of provider-to-provider telehealth in rural settings, finding that there may be similar rates of transfers and lengths of stay with telehealth for inpatient consultations; similar mortality rates for remote intensive care unit care; similar clinical outcomes and transfer rates 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 healthcare 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 two studies reported improvement (SOE: low). Evidence for telehealth interventions for other clinical uses and outcomes was insufficient.

We identified 67 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; regional initiatives that pool resources among rural organizations that may not be able to support telehealth individually; and programs that can support care for infrequent as well as frequent clinical situations in rural practices.

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

Conclusions. While the evidence base is limited, what is available suggests that telehealth supporting provider-to-provider 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. Most barriers to implementation are 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 Coronavirus disease 2019 (COVID-19) pandemic is likely to produce more data and offer opportunities for more rigorous studies.

Totten AM, Womack DM, Griffin JC, et al. Telehealth-guided provider-to-provider communication to improve rural health: a systematic review. J Telemed Telecare. 2022 Dec 25. Epub ahead of print. PMID: 36567431.

Totten A, Womack DM, McDonagh MS, Davis-O’Reilly C, Griffin JC, Blazina I, Grusing S, Elder N. Improving Rural Health Through Telehealth-Guided Provider-to-Provider Communication. Comparative Effectiveness Review No. 254. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 75Q80120D00006.) AHRQ Publication No. 22(23)-EHC023. Rockville, MD: Agency for Healthcare Research and Quality; December 2022. DOI: https://doi.org/10.23970/AHRQEPCCER254. Posted final reports are located on the Effective Health Care Program search page.

Project Timeline

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

Jan 12, 2021
Topic Initiated
Jan 15, 2021
Dec 26, 2022
Systematic Review
Page last reviewed May 2023
Page originally created December 2022

Internet Citation: Systematic Review: Improving Rural Health Through Telehealth-Guided Provider-to-Provider Communication. Content last reviewed May 2023. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.

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