Video and Telephone Telehealth Utilization and Online Patient-Portal Activation Among Rural-Dwelling Patients: Demographic Analysis and Policy Implications (Preprint)
Authors: Rowe Ferrara Meghan , Intinarelli-Shuler Gina , Chapman Susan A 
Published: October 2024

BACKGROUND

Telehealth may help redress rural healthcare shortages in the United States and improve related rural health disparities. However, following the expansion of telehealth related to the COVID-19 pandemic, telehealth utilization has been lower overall among rural populations compared to urban populations. Certain populations are also more likely to use audio-only telehealth, with implications for care quality.

OBJECTIVE

To describe demographic and telehealth utilization characteristics of a population of rural-dwelling adult patients and explore relationships of these characteristics with patients’ level of rurality and with modality of patients’ most recent telehealth encounter.

METHODS

Retrospective medical record review of adults who lived in rural California ZIP codes and utilized telehealth at an urban medical center from December 2021 to December 2022. Rural-Urban Commuting Area Codes were used to assign ZIP code rurality and to group patients by three levels of rurality. Telehealth visits defined as video-enabled and telephone encounters with any provider type. Demographic variables included age, race or ethnicity, preferred language, payer, and online patient portal activation status, as proxy for digital health literacy. Telehealth encounter variables were video or telephone modality, visit provider, and specialty area. Chi Square and Fisher’s Exact were conducted to test associations of demographic and encounter characteristics with patient level of rurality and telehealth encounter modality.

RESULTS

A total of 9,359 patients were included. Telehealth patients living in the most rural ZIP codes were older, and a higher proportion were White, compared to those in less rural ZIP codes. Although patients who were American Indian, Asian, Black, and Latino together comprised 25% of the sample, this was lower than their average population in rural counties in California. Video visit use was significantly lower among patients who were older, Latino race or ethnicity, primary Spanish speakers, and publicly insured. Spanish-speaking patients had the lowest use of video telehealth visits. Patient portal activation was lower among Latinx and Spanish-speaking patients compared to White and English-speaking patients, respectively, and among Medicare patients compared to other insurance types. Telehealth modality and patient portal activation were not significantly associated with level of rurality.

CONCLUSIONS

Findings substantiate concerns of rural telehealth access disparities, particularly among patients who are older, of minoritized race or ethnicity, and Spanish-speaking. Ongoing research is needed to understand how underserved rural populations are utilizing telehealth, as well as to understand variation in utilization between regions and healthcare settings.
To help remedy rural telehealth utilization disparities, policy should address patient-level telehealth barriers by supporting measures such as healthcare navigation resources, culturally tailored telehealth patient outreach, digital access assessment, and patient digital education.