Telehealth's impact on rural hospitals: A literature review

The adoption of telehealth technologies has become a transformative tool in addressing the unique health care challenges faced by rural hospitals. Rural health care systems, especially those in critical access hospitals (CAHs) and smaller emergency departments, are burdened with shortages in specialists, limited infrastructure, long distances between patients and health care providers, and financial constraints. Telehealth offers a promising solution, providing patients in these underserved regions access to specialized care without the need for long-distance travel. This piece examines the value of telehealth for rural health care, the financial challenges associated with its adoption, the impact of telehealth on rural emergency departments, and recommendations for hospital administrators to engage with telehealth effectively to address rural health care disparities.

Telehealth as a solution to rural health disparities

Rural areas in the United States are home to approximately 15 percent of the population, but they often experience poorer health outcomes compared to urban centers. These disparities are primarily due to limited access to specialty services, workforce shortages, and high transportation costs for patients traveling long distances to receive care. For many rural residents, the nearest hospital or specialist can be miles away, and in some cases, hours of travel are required for treatment.

Telehealth addresses many of these challenges by providing a platform for remote consultations with specialists. This enables patients to receive medical advice and care without the need for transportation to urban centers, significantly reducing delays in diagnosis and treatment. For example, rural hospitals use telehealth technologies for telecardiology, telestroke, teleneurology, and telebehavioral health, ensuring that patients with critical conditions like stroke receive care within the "golden hour," a crucial window for intervention that would otherwise be lost during transfers to distant facilities (Fairchild, 2019; Tsou et al., 2021).

Telehealth also alleviates the burden of specialist shortages in rural communities. The ability to consult with specialists virtually allows rural hospitals to provide a broader range of services without requiring patients to travel to larger hospitals. This is especially critical in areas like neurology and psychiatry, where access to providers is especially limited. Programs such as teleneurology have demonstrated their ability to reduce patient transfers while improving stroke care outcomes and overall patient satisfaction (McCormick, 2021).

Impact of telehealth on emergency departments

Emergency departments in rural hospitals face some of the most severe challenges related to health care access. Limited resources, low patient volume, and shortages of emergency medicine specialists contribute to longer wait times and unnecessary patient transfers to more advanced hospitals. Telehealth has proven particularly valuable in these settings by enabling remote consultations with specialists and improving clinical decision-making in real-time.

A study on 15 CAHs using telehealth for emergency care found that the availability of telemedicine consultations led to more accurate decision-making, reduced unnecessary patient transfers, and improved the likelihood that patients would be admitted locally rather than transferred (Natafgi et al., 2020; Rural telehealth ED, 2020). This is particularly important for time-sensitive cases such as stroke and trauma, where early intervention can make a significant difference in outcomes. The use of telepsychiatry, for example, has reduced wait times and ensured that patients presenting with behavioral health crises receive timely care, thereby preventing longer stays in the ED and improving patient flow (Tsou et al., 2021; Fairchild, 2019).

Moreover, telehealth in rural EDs can improve the overall efficiency of care delivery. By utilizing telemedicine, rural hospitals can avoid unnecessary transfers and associated costs, which not only benefits patients by keeping them in their local communities but also enhances hospital revenue by increasing the number of patients treated locally (Zachrison, Richard, & Mehrotra, 2021).

Financial impact and barriers to adoption

Despite the clear clinical benefits of telehealth, the financial viability of these programs remains a significant challenge for rural hospitals. The upfront cost of implementing telehealth infrastructure — including telemedicine equipment, high-speed internet access, and training — can be a barrier for small rural hospitals with limited budgets. The cost of setting up telemedicine technology in a rural hospital can range from $17,000 to $50,000, with ongoing subscription fees that can exceed $60,000 annually (Zachrison et al., 2021).

Moreover, rural hospitals often struggle to justify these expenses due to their low patient volumes. The financial return on investment from telehealth may be slower for hospitals that see fewer cases requiring telemedicine consultations. In many rural areas, the number of patients needing specialty consultations in fields like neurology or cardiology is not large enough to generate sufficient revenue to cover the upfront costs of telemedicine services (Zachrison et al., 2021).

Another financial barrier is the current reimbursement model. In most cases, reimbursement for telehealth consultations goes to the remote specialist rather than the local hospital, which makes it difficult for rural hospitals to recover their costs (Zachrison et al., 2021). While reimbursement for telemedicine services has improved, especially for Medicare and Medicaid beneficiaries, it remains insufficient to cover the costs of implementation and maintenance, making sustainability a significant concern for rural health care providers (Chen, Amaize, & Barath, 2020; Fairchild, 2019).

Teleneurology as a case study

The use of teleneurology, especially for stroke care, has highlighted the potential of telemedicine to bridge the gap in rural areas. For example, at INTEGRIS Bass Baptist Health Center in Oklahoma, teleneurology has significantly reduced the need for patient transfers while providing high-quality stroke care (McCormick, 2021). This approach not only improves patient outcomes but also saves the hospital money by reducing reliance on locum tenens physicians and avoiding costly patient transfers. In rural hospitals where neurologists are in short supply, teleneurology allows timely, expert care without the need for a specialist to be physically present (McCormick, 2021; Zachrison et al., 2021).

Barriers to telehealth adoption in rural areas

Telehealth adoption in rural hospitals is hindered by several barriers, including limited access to high-speed internet, lack of specialized training, and financial constraints (Telemedicine and Telehealth, 2020; The Journal of Rural Health, 2019). Rural hospitals often lack the infrastructure to support telemedicine effectively, which can deter implementation. Additionally, despite the growth of telehealth, rural hospitals are still less likely to adopt advanced telehealth capabilities such as eICU or stroke care compared to urban counterparts (The Journal of Rural Health, 2019). This discrepancy contributes to significant health disparities, as rural populations face challenges in accessing timely, specialized care.

Policy solutions and financial support

To overcome financial barriers and encourage greater adoption of telehealth, several policy solutions must be considered. First, reimbursement models need to be adjusted to allow rural hospitals to be compensated for telemedicine consultations, not just distant specialists. This would help rural hospitals offset the costs associated with providing telehealth services (Zachrison et al., 2021). Additionally, expanding reimbursement to include a wider range of telehealth services — such as teleneurology, telestroke, and telebehavioral health — could help improve the financial sustainability of rural hospitals.

Second, rural hospitals need access to subsidies or grants to support the initial investment in telehealth infrastructure. Programs like the Frontier Community Health Integration Project have shown that providing technical assistance and financial incentives can help rural hospitals adopt and sustain telehealth services (Haque et al., 2023). Federal and state programs should expand on this model, offering financial support for infrastructure development and training to ensure rural hospitals can integrate telehealth into their operations effectively.

Third, collaborative models should be promoted to allow multiple small rural hospitals to share resources, thus reducing the financial burden on individual hospitals. For example, regional telehealth networks could pool demand from several hospitals to create a more sustainable model similar to the cooperative purchasing models used in other sectors (Zachrison et al., 2021). Academic medical centers could also play a role in supporting telehealth networks by providing technical assistance, credentialing, and consultation services for rural hospitals (Haque et al., 2023).

Lastly, to address infrastructural challenges, expanding access to high-speed internet in rural areas is essential. Without reliable internet access, the full potential of telehealth cannot be realized. Policymakers should prioritize broadband expansion as part of the broader effort to enhance health care delivery in rural communities (Chen et al., 2020).

Conclusion

Telehealth is a powerful tool for addressing the health care disparities faced by rural hospitals, particularly in enhancing access to specialty care and improving patient outcomes in emergency situations. However, for telehealth to be more widely adopted in rural areas, there is a need to address financial and infrastructural barriers, adjust reimbursement models, and provide ongoing support for health care providers. By implementing targeted policies, fostering collaboration between hospitals, and expanding access to high-speed internet, telehealth can help bridge the gap in health care access for rural populations and ensure patients in these communities receive the timely, high-quality care they deserve.

NRHA adapted the above piece from Equum Medical, a trusted NRHA partner, for publication within the Association’s Rural Health Voices blog.

About the author: Karsten Russell-Wood, MBA, MPH, resides in rural Maryland and is passionate about improving health care access in underserved communities. As the chief marketing & experience officer at Equum Medical, he works to connect innovative virtual care solutions with rural health care needs. With a background in health care marketing and a commitment to community development, Karsten advocates for telehealth as a means to ensure equality in care, regardless of geography.

References

Fairchild, R., Brogoitti, K., & Scurlock, C. (2019). Telehealth decreases rural emergency department wait times for behavioral health patients in a critical access hospital setting. Journal of Rural Health.

Haque, S., DeStefano, S., Banger, A., Rutledge, R., & Romaire, M. (2023). Telehealth impact in frontier critical access hospitals: Mixed methods evaluation. Journal of Medical Internet Research. https://doi.org/10.2196/49591

Zachrison, K. S., Richard, J. V., & Mehrotra, A. (2021). Paying for telemedicine in smaller rural hospitals. JAMA Health Forum. https://doi.org/10.1001/jamahealthforum.2021.1570

Tsou, C., Robinson, S., Boyd, J., Jamieson, A., Blakeman, R., Yeung, J., McDonnell, J., Waters, S., & Bosich, K. (2021). Effectiveness of telehealth in rural and remote emergency departments: Systematic review. Journal of Medical Internet Research. https://doi.org/10.2196/30632

Natafgi, N., Mohr, N. M., Wittrock, A., Bell, A., & Ward, M. M. (2020). The association between telemedicine and emergency department disposition: A stepped wedge design of an ED-based telemedicine program in critical access hospitals. Journal of Rural Health. https://doi.org/10.1111/jrh.12370

Chen, J., Amaize, A., & Barath, D. (2020). Evaluating telehealth adoption and related barriers among hospitals located in rural and urban areas. The Journal of Rural Health. https://doi.org/10.1111/jrh.12534

McCormick, T. (2021). Teleneurology: Why it works for rural hospitals. Telemedicine and Telehealth. https://doi.org/10.30953/tmt.v1.72