Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

Abstract

Introduction: Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare.

Methods: We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes.

Results: Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples.

Discussion: Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

Keywords: Extension for Community Healthcare Outcomes (ECHO); Rural health; remote consultations; systematic review; telehealth; telemedicine; video education.

Figure 1.

Literature flow diagram. Key Question 1: What is the uptake of different types of provider-to-provider telehealth in rural areas? Key Question 2: What is the effectiveness of provider-to-provider telehealth for rural patients? How does provider-to-provider telehealth affect outcomes for patients and populations? How does provider-to-provider telehealth affect outcomes for healthcare providers? How does provider-to-provider telehealth affect outcomes for private and public payers? Key Question 3: What strategies are effective and what are the barriers and facilitators to implementation and sustainability of provider-to-provider telehealth in rural areas? Key Question 4: What are the methodological weaknesses of the included studies of provider-to-provider telehealth for rural patients and what improvements in study design (e.g. focus on relevant comparisons and outcomes) might increase the impact of future research

Figure 2.

Facilitators and barriers to implementation*.