Health information and communications technologies, such as electronic medical records and telemedicine, have the potential to increase access to healthcare in rural areas. This potential was one of the main drivers of the Health Information Technology for Economic and Clinical Health (HITECH) Act that was passed 10 years ago. HITECH gave the Centers for Medicare and Medicaid Services (CMS) the power to use financial incentives to encourage “meaningful use” of technology. Much has been written about HIT in both the academic press and the media: HIT might improve patient care, affect physician productivity, jeopardize patient privacy, empower patients, might reduce costs or not, and evaluations of the HITECH Act are mixed. Conflicting narratives about HIT potential and outcomes aside, the National Cancer Institute’s Health Information National Trends Survey (HINTS) has been tracking health communication, including engagement with technology, for representative samples of adults in the US since 2003. With these data, we are starting to answer questions about access in rural areas.
A paper by Krakow and colleagues in a recent supplement on HIT and health disparities published in Medical Care does just that. Using the most recent wave of HINTS, Krakow and colleagues estimate whether there are differences in access and engagement with health IT between rural and urban residents. The authors did not find a significant difference in the percentage of residents who reported that their regular provider maintained electronic health records (about 76% overall). Without controlling for demographic characteristics and internet use, the authors found a significant difference in the percentage of rural (about 19%) versus urban (30%) residents who had accessed their medical records online within the past year.
Controlling for demographics and other factors, the authors found strong associations between having accessed medical records online (the outcome variable) and reported internet use, having a regular provider, and being encouraged to access the records online by their provider. They did not, however, find strong associations with rural residence (vs. urban), age, education, or race/ethnicity. These results track with a previous systematic review about patient use of electronic records, particularly the importance of having access to the internet and receiving advice from providers to use the online records.
The authors drew the conclusion from these results that perhaps it is structural rather than individual factors that contribute to lower rates of health IT use in rural areas. While the paper isn’t able to provide evidence that the differences in electronic health record access are responsible for some of the differences in health (a tall order!), the insight that mechanisms could be hampering the use of information technology and communication in rural areas is an important one.
We know that broadband access is markedly lower in rural areas than in exurban or urban areas and when it is available the speeds are often slower. There are federally sponsored programs, such as BroadbandUSA that provide support to communities with the aim of increasing connectivity. These programs aim to “close the digital divide” between rural and urban communities. Fortunately, it seems that collective efforts are having some positive effects. The Federal Communications Commission recently released a report [pdf] stating, among other things, that the gap in broadband access is closing. If information is the lifeblood of modern medicine as suggested by Blumenthal, and if HIT is its circulatory system, making sure that this information can flow smoothly back and forth between patients and providers is going to be critical to improving outcomes in our system.
Jess Williams