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Narrowing the rural-urban health divide

Bringing virtual health to rural communities

Alex Schulte
Melissa Majerol
Dr. Jessica Nadler

There is growing evidence that virtual health can be a cost-effective and powerful tool to improve rural health care. Here's how health care providers can get started and how government agencies can help.

Executive summary

ACCESS to health care ranks among the top challenges facing rural communities today due to provider shortages, long travel distances and the acceleration of hospital closures in recent years. While not a panacea, virtual health can address many of these issues and in turn, help narrow the rural-urban health divide—the stark disparity between access to care and the overall health of citizens in rural areas compared to their urban counterparts.

In this report, we lay out some of the key steps rural health care organisations—including critical access hospitals, federally qualified health centres, rural health clinics and tertiary care facilities—should consider when delivering virtual health in rural settings and what government can do to support and enable rural communities in this capacity. Our analysis is based on interviews with more than a dozen rural health care experts and reviews of secondary literature.

Below are six key steps leaders of health care organisations should consider as they build their virtual health programmes:

  • Conduct a needs assessment. Before starting a virtual health programme, leaders should conduct a needs assessment of the organisation and the population it serves to identify the most appropriate virtual health solutions, current technological capabilities, future technological needs and how to bridge the gap.
  • Develop a strategy, governance structure and partnerships. Having a coordinated strategy and a centralised governance structure within the health care organisation are critical to the success of any virtual health programme. In addition, organisations should build partnerships and networks with other entities.
  • Invest in data and technology infrastructure. Hardware and software investments are core to any virtual health programme, but health care organisations should also pay attention to interoperability and investments that should be made in cognitive technologies and analytics.
  • Engage with and train your workforce. Making virtual health a mainstream aspect of rural care will require significant buy-in from—and investment in—the health care workforce. To help win over key stakeholders, leaders can emphasise the benefits to patients and clinicians and teach the workforce to use the new technology.
  • Create new workflows, care models and risk mitigation protocols. Virtual health should be integrated into a seamless and coordinated delivery process across different providers, services and settings.
  • Engage with and educate patients. Just like clinicians, patients should be educated on the benefits of virtual health and how to use the new technology.

While health care organisations will need to take the lead, they won’t be able to do it alone. In order to see the potential of virtual health realised, public and private organisations should work together to align incentives, leverage scarce resources, share best practices and create economies of scale. The role of government is critical as well. By helping to build connectivity, simplifying the process of applying for funding and driving the adoption of value-based care, government agencies can enable and support rural communities as they use virtual health to help bridge the rural-urban health divide.

Virtual health

The opportunity for rural communities

Martina was born in a hospital in rural Nebraska. Shortly after her birth, her doctors detected a pneumothorax, or collapsed lung. Neonatal events like these sometimes require an intervention; other times they heal on their own—a call that a neonatal specialist needs to make. But this rural hospital wasn’t equipped to handle rare conditions such as the one Martina was experiencing and no such specialist was on hand.

The standard protocol would have been to put Martina in a helicopter and transport her to the nearest tertiary care facility, more than 150 miles away, so that a specialist could assess whether an intervention was, in fact, needed. Luckily, the local hospital had just joined a virtual hospital service: Martina’s parents were given the option to have a remote neonatal intensive care unit (NICU) physician monitor the newborn via two-way video conference.

They chose this option. As a result, Martina was able to fully recover with very little treatment and has grown into an active and healthy toddler. Her parents were able to stay in their community with their three other children, rather than being separated from their newborn and having to travel long distances each time they went to see her in the NICU. And thousands of dollars were saved in helicopter transfer costs.1

This story is emblematic of some of the challenges facing rural communities and how virtual health could improve health care access for rural residents. Virtual health services can also offer important benefits to the health care system more broadly: the opportunity for rural clinicians to learn from specialists, and for rural hospitals to retain vital income and enhance the quality of their services. Moreover, a growing number of studies have shown that virtual health can improve health outcomes, reduce costs, reduce unnecessary utilisation (such as nonurgent visits to the emergency room), improve adherence to medication and other protocols and improve patient satisfaction. (See the appendix for a summary of studies documenting the impact of virtual health.)

What is virtual health?

Virtual health refers to the delivery of health services in a way that is independent of time or location using enabling technology, such as video conferences, mobile apps, in-home sensors, text-based messaging and analogue telephones. Virtual health visits can take place between a patient and his/her clinician, or between clinicians. But virtual health goes beyond video conferences (synchronous visits) to include remote patient monitoring, email/telephone communication and store-and-forward technology (asynchronous visits, in which data such as MRI scans or photos of a rash are captured and sent to medical professionals via a secure and encrypted internet connexion). With applications designed to drive connected, co-ordinated care, virtual health can complement, or substitute for, in-person care as appropriate (figure 1). These applications present a critical opportunity for rural areas to receive improved access to care.

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How can virtual health help rural communities?

Among the many issues impacting rural America, access to health care and related health disparities rank among the top (figure 2). A recent spike in hospital closures has exacerbated these issues, as more health care professionals in rural areas already experiencing provider shortages have left to find jobs elsewhere. This has resulted in many rural residents needing to travel even longer distances to receive care and has increased access barriers to both speciality and primary care because hospital emergency departments are a major source of primary care in rural communities.2 Among the hardest hit have been elderly and low-income populations; both are more likely to delay or forego needed care because of transportation challenges. What’s worse, the trend in rural hospital closures is expected to continue.3

Virtual health has been identified as one part of a suite of new health care models that could help address rural health needs and narrow the rural-urban health divide. Virtual health has been around in some form for decades. However, due to advances in digital technologies,4 an increasingly supportive policy landscape5 and a growing evidence base showing its effectiveness (see appendix), implementing it now makes more sense than ever. Nevertheless, successful implementation of virtual health into mainstream health care systems has been slow.

There are several forms of virtual health that can be used in lieu of and in addition to, in-person visits to alleviate various rural health challenges, including provider shortages and time, distance and transportation barriers. These include virtual visits, shop-and-forward technology and email/ telephone communication (see sidebar, “What is virtual health?”). Virtual visits can be used to address speciality provider shortages by connecting groups of community providers with specialists at centres of excellence in real-time sessions. This allows specialists to share their medical knowledge and expertise with on-site clinicians, helping them diagnose and determine a course of treatment for a patient.

Finally, health care organisations can use remote patient monitoring (RPM) to track the vital signs of people who require chronic, postdischarge, or senior care, allowing them to keep track of patient data between visits and intervene with medication adjustments or other treatment recommendations before a patient requires urgent medical attention. Using virtual health as a preventive care tool can help reduce the number of unmonitored chronic conditions that become urgent episodes. Given that rural areas have a higher prevalence of chronic disease,6 RPM can be especially effective at preventing adverse events and maintaining continuity of care in these settings.

Virtual health can also help rural residents maintain privacy and confidentiality, while overcoming the stigma associated with certain health conditions. In small, tight-knit communities, individuals with a behavioural health condition may know the local behavioural health specialist personally—if their community is lucky enough to have such a specialist. Some may be reluctant to seek help for their condition because of privacy and confidentiality concerns and due to the stigma still often associated with these conditions. The ability to receive treatment from a professional outside the community may encourage an individual with these needs to seek care.7

Rural patients who have tried virtual health generally report high satisfaction. According to a recent survey of life in rural America, one-quarter (24 per cent) of rural adults have used telehealth to obtain prescriptions and manage chronic conditions and among them, the vast majority report satisfaction (90 per cent).20 The most common reason rural Americans give for using telehealth is convenience (69 per cent), followed by inability to see a regular doctor in person (30 per cent) and difficulty travelling to a doctor/hospital (26 per cent).21

Methodology

To get insights into what rural health care organisations should be doing to expand virtual health, the Deloitte Center for Government Insights interviewed more than a dozen rural health care experts with experience in virtual health. Interviewees included leadership from hospital systems, federally qualified health centres (FQHCs), health technology companies, broadband providers, academic institutions, advocacy groups, policy institutes and philanthropic organisations. We used the findings from our interviews as well as secondary sources to offer practical recommendations to health care organisations and government agencies as they plan and implement virtual health programmes in rural areas.

Note: We largely set aside reimbursement and clinician licensure policies in this paper and during our interviews because these issues have been covered extensively in other literature on virtual health and because the policy landscape around these issues is rapidly evolving and varies greatly by state and insurance type.

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Planning and implementing a virtual health programme

Key steps for health care organisations

Conduct a needs assessment

Before starting a virtual health programme, health care organisations should conduct a needs assessment to identify organisational and population needs. This can help leaders determine whether virtual health solutions can help address the specific needs of their population and if so, which solutions are most appropriate. Health care organisations should draw on existing evidence to assess the impact of potential virtual health solutions, looking at current technological capabilities and future technological needs, and how to bridge that gap (both within the organisation and among the population being served).

For example, access to high-speed internet is a problem for roughly one in five rural adults (21 per cent).22 This may limit the ability of rural residents to access virtual health and the ability of rural providers to deliver it. Still, several people we spoke with told us that many forms of virtual health require only a smartphone with cellular service (which, in some cases, is also difficult to access), an intermittent internet connexion, or a landline telephone, depending on the virtual health solution. “Remote patient monitoring can be as simple as setting up an interactive voice response system and having a patient or caregiver enter or report their daily blood pressure or heart rate using an analogue phone—it can be done in online or offline mode,” said Bill Paschall, vice president of business development at Vivify Health, a company that offers remote patient monitoring solutions to health care organisations throughout the country. Health care organisations should take the technological capabilities of their populations into account when designing their virtual health programmes, recognising that low-cost solutions are also available.

As they get started, health care organisation leaders should also reach out to federally-funded national and regional telehealth resource centres (TRCs). The Office of Advancement of Telehealth established 12 regional and two national TRCs to expand the availability of health care to underserved populations through virtual health. Each TRC is staffed with experts in policy, technology evaluation, operational implementation, technical assistance and knowledge of funding sources. In addition, because they are federally funded, their services are generally provided free of charge.23

Develop a strategy, governance structure and partnerships

A coordinated strategy and centralised governance are critical to the success of any virtual health programme. The decision to implement a virtual health programme should come from executive leadership and be part of the organisation’s strategic vision. Organisations should earmark time and resources for the initiative and develop centralised governance structures inside the organisation, with a clear delineation of decision rights and responsibilities, operational champions and an integrated roadmap. This can enable leadership and clinical staff to be engaged and aligned on the vision for virtual health and how to get there as an organisation.24

“Ensure there is a solid strategic plan for what needs to be implemented. You need clinician buy-in, leadership buy-in and a stated vision of virtual health for the organisation.”

—Tim Polley, interim vice president, enterprise strategy and development, Carle Foundation Hospital

At the same time, organisations should build networks with other health care providers. According to experts we spoke with, this is especially critical in rural communities due to provider shortages, long distances to sites of care, varying access to the internet, low patient volume and slim operating margins. As mentioned, rural health care providers, such as critical access hospitals (CAHs) and Federally Qualified Health Centre (FQHCs) may need to establish networks, often with tertiary care centres that are geographically distant, to deliver speciality care services to their local populations.

Beyond sharing clinical resources, however, partners can also share technological capabilities and data infrastructure. For example, the Finger Lakes Telehealth Network provides open access to its telehealth infrastructure and support resources to partnering organisations in exchange for a small subscription fee. This arrangement allows for a collaborative sharing of services as well as cost savings to providers.25 These networks often help members develop the required broadband infrastructure, usually for a discounted rate and can provide access to data analysts and other experts that may be needed to deliver certain virtual health services (see section below on data and technology infrastructure).

“We’re talking about small communities with smaller budgets. For us, buying equipment is a big deal. Rolling out a new programme is a big deal … We have no choice but to collaborate. With networks and partnerships, we have shared risk and responsibility.”

—Mary Zelazny, chief executive officer, Finger Lakes Community Health

Public-private partnerships can be an effective way to establish local sites of care to address issues related to internet access or privacy concerns. Many individuals, including those who have slow or inconsistent internet access and those who lack access to a private space inside their home, may need to go to a site outside their home for virtual sessions. Accessing Telehealth through Local Area Stations (ATLAS), a veterans affairs (VA) initiative designed to enhance access to VA health care through virtual health, has teamed up with Walmart to deliver video sessions to veterans. Established in autumn 2019, the pilot sites were created to offer a convenient, comfortable and private space with strong internet connectivity in communities where veterans often have long travel times to VA facilities and/or poor connectivity at home.26 Other locations that can serve similar functions include libraries and schools (see sidebar, “North Carolina is building Health-e-Schools”).27 Developing innovative partnerships can help rural communities make the most of limited resources.

Invest in data and technology infrastructure

Hardware and software investments are core to any virtual health programme, but health care organisations should also pay attention to interoperability and investments that should be made in cognitive technologies and analytics. Hardware and software investments can vary, depending on the type of virtual health solution. A basic virtual visit could be enabled by a simple digital camera and an audio/video software platform.28 Other solutions may require more sophisticated technology. For example, a specialised examination tool with an integrated high-resolution camera may be necessary for one medical professional to capture and transmit the image of the inside of a patient’s ear to another professional.29

North Carolina is building Health-e-Schools

In four counties in western North Carolina, elementary, middle and high school students can receive virtual primary care at school through a programme called “Health-e-Schools.” With the help of a school nurse, high-definition video conferencing and specially equipped stethoscopes and cameras, students can receive a range of physician-supervised services, including sports physicals, behavioural health services and consultations for respiratory issues.

The programme was created in 2011 by the Center for Rural Health Innovation (CRHI), with support from BlueCross and BlueShield North Carolina Foundation and grants from Health Resources and Services Administration (HRSA) and United States Department of Agriculture (USDA), among others.30 CRHI is a nonprofit whose mission is to apply innovative technologies to improve access to health care in rural communities.31 It created Health-e-Schools after recognising that traditional sites of care are often geographically distant from where students live and go to school. A parent might have to take several hours off from work to bring their child to a health care facility, while the student would miss several hours of school—both of which could present strong barriers to accessing health care. School-based health centres have been shown to improve attendance and reduce barriers to learning, and Health-e-Schools has increased classroom attendance for students and decreased time spent away from work for parents and caregivers.32

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While the need to make hardware and software investments may be obvious, less so is the need to build interoperability, security and analytics into every aspect of the virtual health programme. Doing so should not be an afterthought, but rather, baked into the vision of a seamless, patient-centred virtual health programme. Interoperability allows data from the virtual visit to be sent to the patient’s primary care clinician or medical team and integrated into their electronic health record (EHR). Meanwhile, organisations need to ensure that systems are protected and that data is not intentionally or unintentionally compromised, altered, or made public.

“I should know if my patient used Teledoc and the outcome of that visit. Virtual health should contribute to seamless care, not drive further fragmentation.”

—Dr. Steve North, founder and medical director, Centre for Rural Health Innovation

Virtual health solutions such as remote patient monitoring (RPM) may require investments in cognitive and analytic capabilities. RPM involves the use of smart devices to provide real-time data to health care teams on vital health measurements such as blood pressure and heart rate. Algorithms are used to process data streams and notify a patient’s health care team if a problem arises that requires analysis or intervention. Health care organisations should invest not only in the software, but also in the workforce needed to continuously run and update such algorithms and analyse the data. Rural health care providers may face significant challenges finding such talent locally and may not be able to afford to pay competitively for such a position. In such cases, leveraging partnerships, as discussed above, is key.

Engage with and train your workforce

Making virtual health a mainstream aspect of rural care will require significant buy-in from—and investment in—the health care workforce. Rural clinicians may have a keen sense of the health care challenges facing their communities, but may not necessarily trust that virtual health can help solve these issues. Sharing the evidence base on virtual health effectiveness with respect to outcomes, quality and patient experience, in addition to real-life stories on how it has made patients’ lives easier, are important first steps to gaining clinician buy-in. However, it’s also important to emphasise how clinicians themselves can benefit. Virtual visits between specialists and primary care clinicians allow specialists in rural areas to care for a broader range of acutely ill or complex patients than they would otherwise have access to, keeping their skills sharp and continuing their practical education.33 Connexions made through virtual health also allow rural providers to become part of a broader community of clinicians, helping to decrease feelings of professional isolation.34 Once engaged, some clinicians may emerge as champions, rallying peers to get onboard with virtual health, too.

But engagement is only half the story. The workforce should also be trained to use these new technologies. According to a 2018 physician survey from the Deloitte Center for Health Solutions, more than half (51 per cent) of physicians say that training on a new technology is necessary to support its adoption. But training isn’t simply about getting clinicians comfortable with the new technology and modified workflow. It’s also about teaching them how to modify their bedside manner—or “webside” manner—to build rapport with patients in virtual interactions, provide them with knowledge of the legal and clinical limitations of virtual health, teach them competencies in virtual examination using the patient or on-site family members,35 and make sure they know what to do if an emergency arises. This training may happen formally, either in continuing education classes or it can be engrained into medical school curricula. It can also happen more informally, as technologically sophisticated clinicians or identified “super users” provide hands-on training and mentoring to their hesitant colleagues.

Create new workflows, care models and risk mitigation protocols

Virtual health should be integrated into a seamless and coordinated delivery process across different providers, services and settings. Once health care organisations gain workforce buy-in, they need to sustain that buy-in by ensuring that delivering virtual health doesn’t create additional work or inefficiencies.36 The goal is to explicitly integrate virtual health into mainstream care delivery so that it becomes as routine as in-person visits.

At Carle Health System, registered dieticians in the nutrition service department have dedicated virtual days or half-days where they go to the “virtual health room” in the clinic and see patients virtually.37 Blocking off time on their calendars helps other providers, administrative staff and patients know when the dietitians are available for virtual visits. Additionally, having a dedicated room ensures that the necessary equipment will be available, and privacy and security concerns are addressed. When planning to adjust staffing and operational workflows, consider conducting interviews and simulations with clinicians, administrative staff and patients so that all perspectives and experiences are incorporated into the new workflow. This can help create a more human-centred design and experience.

Risk mitigation and clinical escalation paths should also be integrated into virtual health workflows. An unexpected emergency can take place during any virtual visit, but the risks may be higher in rural areas where distances to the nearest emergency room or site of care may be greater. Health care organisations should develop protocols for connecting patients experiencing emergencies with clinical support, regardless of whether the patient is in their own home, a retail clinic, or a virtual health centre. Additionally, if the electricity goes out or there are other technological difficulties during a virtual visit, there should be protocols in place to continue or reschedule the visit as necessary that are known to clinicians and communicated to patients.

Engage with and educate patients

Just like clinicians, patients should be educated on the benefits of virtual health and how to use it. Eighty-five per cent of rural Americans use the internet. They do so to get health information, manage their finances and carry out business-related activities. But only one-quarter (24 per cent) of rural adults have ever had a virtual visit.38 This could be because virtual health visits are not available to them, they don’t trust the quality of care they might receive, worry that they won’t know how to initiate or interact in a virtual visit, or don’t know that the service is available. Just like clinicians, patients should be told about the availability of virtual health services, educated about the benefits and effectiveness of virtual health and shown how to use some of the technology, such as patient-operated digital stethoscopes.39 Clinicians themselves can play a key role in informing their patients that they offer virtual health services, showing them how it works and telling them what kind of equipment they might need.40 Whenever possible, health care organisations should ensure that patients see the same clinician during virtual and in-person visits. This consistency can help maintain a personalised clinician-patient relationship, which is a top priority for many patients.41

“We need to educate and empower patients, and keep in mind that people have different levels of comfort with virtual health. Meet the patient where they are in terms of understanding and comfort.”

—Jennifer Farrell, senior director, global market development, Medtronic Care Management Services

How government can help

Health care organisations should drive the adoption of virtual health solutions; however, there are a variety of actions federal, state and local governments can take to accelerate the adoption of virtual health in rural areas. Below, we discuss the role government agencies can play in helping rural communities implement virtual health programmes.

Building connectivity

The federal government has developed several programmes to help bring broadband to rural communities. Among them are the Federal Communications Commission’s (FCC) Rural Health Care Programme, which provides funding to eligible health care providers for telecommunications and broadband services,42 and the USDA’s ReConnect Loan and Grant Programme, a pilot programme authorised by the Consolidated Budget Act of 2018 to facilitate broadband deployment in rural areas that lack sufficient access.43

But local governments and communities should also explore creative infrastructure deployment strategies that go beyond broadband networks offered by private companies. These can include wireless (4G and soon, 5G), low earth orbit,44 and municipal internet, in which a municipal electrical provider lays down fibre-optic cables next to existing electrical wires. The cost of municipal internet is often well below that of large internet providers. And while more than 150 communities in 29 states have publicly owned municipal networks offering at least 1-gigabit services, 19 states have laws in place discouraging or preventing local communities from making such investments.45 Finally, state and local governments should establish formal mechanisms to coordinate broadband efforts across the state and share best practices for rural infrastructure development. Such efforts can also help unlock new economic value and enable rural communities to reach their full potential in a digitally connected world.

Simplifying the process for applying for funding

Nonprofit organisations and health care providers in rural areas typically rely on government and state funders as well as foundations to help launch or sustain virtual health projects. However, getting a grant is resource-intensive and often complicated. Funders hold competitive cycles for grant programmes in which rural organisations must sometimes compete against well-funded, well-prepared organisations with dedicated and experienced grant writing teams. Organisations in rural areas are less likely to have staff members strictly dedicated to grant writing and even when rural communities seek to tap some of those resources, it is not always obvious which programmes they may be eligible for.46 Conducting research on dozens of programmes to zero in on the most likely prospect often takes more labour than a small, resource-strapped rural organisation can commit.

Government agencies should simplify their rural health funding programmes to make it easier for communities to establish these essential services. One option is for agencies to create a government funding portal for health care organisations to use to access information about programmes and apply for funding. After entering their relevant data into the portal, a health care organisation would be presented with a streamlined list of grants and funding opportunities for which it is eligible and links to the organisation’s regional telehealth resource centre for additional assistance.

Driving value-based care

Issues related to whether and how virtual health is currently reimbursed by various payers were explicitly set aside for this paper; however, they inevitably came up during many of our interviews. Several rural health experts we interviewed expressed scepticism about the widespread adoption of virtual health until the shift from fee-for-service to value-based care (VBC) was more broadly adopted in rural areas. They mentioned that many hospitals are currently incentivized to keep their hospital beds full rather than provide preventive care through virtual visits, RPM and other forms of virtual health.

Currently, accountable care organisations and other value-based payment (VBP) models are less prevalent in rural areas,47 as they often lack sufficient patient volumes and the core capabilities needed to succeed. Recognising these challenges, the National Rural Health Association, along with other partners, has developed draught legislation to establish a critical access hospital VBP programme, which would give critical access hospitals an on-ramp into VBP models and help them to assume more financial risk over time.48 By supporting and enabling value-based care delivery in rural settings, government agencies can create the right financial incentives and the business case for rural providers to integrate virtual health into a mainstream delivery model.

“We’re seeing the incentives change, which has encouraged providers to move away from the fee-for-service mentality and instead look upstream and prioritise preventive services. You can herd cats, you just need to move the food.”

—Brock Slabach, senior vice president of member services at the National Rural Health Association

Conclusion

Rural health care challenges are nothing new, but the recent acceleration of rural hospital closures threatens to increase rural and urban health disparities, even beyond what they’ve been historically. Virtual health is one tool among many that can help address these challenges.

With leadership from rural health care organisations, support from government agencies and collaboration with other public and private entities, virtual health can help bridge the rural-urban health divide and allow rural residents and providers to reap the benefits of technology-assisted health care delivery.

Appendix

Research findings

About Deloitte Consulting's Virtual Health practice

Deloitte Consulting's Virtual Health practice helps clients assess the transformative opportunities that can be possible through the use of virtual health, determines which capabilities would best serve their customer or patient populations and aligns potential solutions to their strategic imperatives. Our work helps health care organisations build a scalable virtual health programme that fits their needs, deploys strategic capabilities and aligns capabilities to care delivery pathways. Our practice brings insights from leaders across the industry with experience in strategy, operations, human capital, technology and a foundation in clinical and operational experience.

Learn more

The authors would like to thank Shaun Rangappa, Dr. Bruce Green, Dr. Ken Abrams, Dr. Bill Fera, Sarah Thomas, Bill Eggers, John O’Leary, Jake Wildfire, Jason Miller, Will Carroll, Tina Mendelson, Pedro Arboleda, Nancy Chen, Casey Graves, Ryder Riess, Margaret Anderson, Katie Knudtson, Meera Kanhouwa, Dorrie Guest, Summer White, Urvi Shah, and Mamta Elias for their guidance and support with this project.

Cover image by: Sonya Vasilieff

  1. This is based on a true account of events faced by one family. We have changed names and other specific details to protect individuals' privacy.

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  2. Jane Wishner et al., “A look at rural hospital closures and implications for access to care: Three case studies,” Kaiser Family Foundation , 7 July 2016.

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  3. Ibid.

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  4. Rural Health Information Hub, “Rural data explorer," accessed October 17, 2019; HRSA Area Health Resources Files, 2014 and 2015. No statistical tests were run to compare rural and nonrural measures.

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  5. Ibid.

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  6. Kim Parker et al., “Views of problems facing urban, suburban and rural communities,” Pew Research Centre, 22 May 2018. Pew Research’s analysis includes urban, suburban, and rural communities. Our table includes data on urban and rural communities only. Differences between urban and rural are statistically significant.

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  7. Onyi Lam, Brian Broderick, and Skye Toor, “How far Americans live from the closest hospital differs by community type,” Pew Research Centre, December 12, 2018. Pew Research’s analysis includes urban, suburban, and rural communities. Our table includes data on urban and rural communities only. Differences between urban and rural are statistically significant; Longest average minutes refers to those whose travel time to the nearest hospital is above the 75th percentile for their community type.

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  8. There are several different ways to measure rurality, and rural-urban comparisons using different definitions may yield different conclusions. In this table, data from the Rural Health Information Hub and from the North Carolina Health Research Programme categorise counties as metropolitan and nonmetropolitan using the Office of Management and Budget metropolitan and micropolitan statistical area definitions. According to this definition, nonmetro counties include noncore (small rural) and micropolitan (large rural) counties. The Pew Research Centre asked survey respondents to describe the area in which they live as rural, suburban, or urban and relied on these responses for classification purposes.

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  9. The University of North Carolina at Chapel Hill, “Sheps Centre for Health Services Research,” accessed 17 October 2019. All differences in weighted population averages are statistically significant at the level of 5 per cent.

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  10. Rural Health Information Hub, “Rural data explorer.” US Census ACS, 2011 and 2017 five-year estimates. No statistical tests were run to compare rural and nonrural measures.

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  11. UNC, “Sheps Centre for Health Services Research.” All differences in weighted population averages are statistically significant at the level of 5 per cent.

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  12. Rural Health Information Hub, “Rural data explorer.” CDC Diabetes County Data Indicators, 2006–2016. No statistical tests were run to compare rural and nonrural measures.

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  13. Ibid.

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  14. Rural Health Snapshot, North Carolina Health Research Programme. All differences in weighted population averages are statistically significant at the level of 5 per cent.

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  15. Sarah Purdy et al., “Ambulatory care sensitive conditions: Terminology and disease coding need to be more specific to aid policy makers and clinicians,” Public Health 123, no. 2 (2009): pp. 169–73.

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  16. Pew Research Centre, “Mobile fact sheet,” 12 June 2019; Melissa Majerol and William Carroll, Medicaid and digital health: Findings from the Deloitte 2018 survey of US health care consumers, Deloitte Insights, 7 September 2018.

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  17. CMS.gov, “CMS finalises policies to bring innovative telehealth benefit to Medicare Advantage,” press release, 5 April 2019; American Telemedicine Association, “Telehealth policy and reimbursement vary widely from state to state, ATA Report finds,” 19 July 2019.

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  18. Alexis Skoufalos et al., “Rural ageing in America: Proceedings of the 2017 Connectivity Summit,” Population Health Management 20, no. S2 (2017): pp.

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  19. Rural Health Information Hub, “Telehealth models for increasing access to behavioural and mental health treatment,” accessed 17 October 2019.

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  20. NPR, Robert Wood Johnson Foundation, and Harvard T.H. Chan School of Public Health, Life in rural America Part II, May 2019.

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  21. Ibid.

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  22. Ibid.

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  23. National Consortium of Telehealth Resource Centres (NCTRC), “About our consortium,” accessed 17 October 2019.

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  24. Rajendra Singh et al., “Sustainable rural telehealth innovation: A public health case study,” Health Services Research 45, no. 4 (2010): pp. 985–1004.

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  25. Rural Health Information Hub, “Finger Lakes Community Health Telehealth Network,” 4 December 2017.

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  26. U.S. Department of Veterans Affairs, “ATLAS: Offering veterans VA care closer to home,” accessed 18 October 2019.

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  27. Joshua Ball, “Nation’s first Virtual Living Room Telehealth Centre brings unique care to Appalachian veterans,” Kentucky Today , 3 February 2018; Kay Miller Temple, “

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  28. Zoom, “Zoom for healthcare,” accessed 18 October 2019.

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  29. eVisit, “Welcome to the eVisit resources,” accessed 18 October 2019.

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  30. Rural Health Information Hub, “Health-e-Schools,” 9 October 2019.

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  31. Centre for Rural Health Innovation, “The Centre for Rural Health Innovation,” accessed 4 November 2019.

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  32. Centre for Rural Health Innovation, “What is Health-e-Schools,” accessed 18 October 2019.

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  33. Bonnie Darves, “Telemedicine: Changing the landscape of rural physician practise,” NEJM Career Centre, 17 May 2013.

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  34. National Advisory Committee On Rural Health and Human Services, “Telehealth in rural America,” March 2015.

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  35. Michael Nochomovitz and Rahul Sharma, “Is it time for a new medical speciality? The medical virtualist,” The Journal of the American Medical Association 319, no. 5 (2018): pp. 437–438.

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  36. Ken Abrams, Steve Burrill, and Natasha Elsner, What can health systems do to encourage physicians to embrace virtual care?: Deloitte 2018 survey of US physicians, Deloitte Insights, July 18, 2018.

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  37. Virtual visits are used in several departments at Carle, but one of the most widely used departments is Nutrition Services. Carle, “Patients can access virtual doctor's visits for themselves, their kids,” September 21, 2015.

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