������Ƶ

More than 80% of American counties lack some form of healthcare infrastructure. These areas, known as “healthcare deserts,” have inadequate access to primary, emergency, mental health or dental care, and they lack public transportation and public health services, according to a 2021 report by GoodRx. About 30 million people nationwide do not have access to the services needed to maintain their health.

������Ƶ experts work to enhance accessibility to healthcare for rural and underserved communities across the globe through telehealth and mobile applications and by bringing more providers to rural areas. These researchers believe a greater focus on interdisciplinary approaches and innovative technology will reshape the rural healthcare landscape, fostering a future where distance no longer impedes access to quality care.

“Access is a major concern. Technology will help improve access, but it won’t completely solve the problem,” says Pamela Stewart Fahs, associate dean and professor of nursing at the Decker College of Nursing and Health Sciences.

Fahs, who holds the Dr. G. Clifford and Florence B. Decker Endowed Chair in Rural Nursing, edits the Online Journal of Rural Nursing and Health Care. For more than 30 years, her research has highlighted inefficiencies and inadequacies within the field.

“The closures of rural hospitals and the absence of maternity units in rural areas are significant. Transportation presents a challenge. While most research acknowledges a transportation problem, it often fails to pinpoint the specific transportation issues,” she says. “This aspect is not covered in many federal grants. I believe that transportation will continue to be a major issue in rural areas for the foreseeable future.”

Fahs’ work focuses on cardiovascular disease and stroke. These are two of the causes — along with cancer, chronic lower respiratory disease and unintentional injury — that people living in rural areas are at a greater risk of dying from, according to the Centers for Disease Control and Prevention.

Her research shows that faster access to care reduces debilitating outcomes for rural women who suffer strokes. One of her studies measured the effectiveness of a program designed to improve knowledge about strokes. A key takeaway: Both education and transportation are essential.

The rise of telehealth

For people living more than 30 miles from a healthcare provider and unable to reach one by foot or public transportation, the lack of access to preventative services is not just an inconvenience — it’s a matter of life or death. Telehealth, which has existed for decades but became prominent during the COVID-19 pandemic, can bring care to patients earlier in the disease process. Time-sensitive treatments require quick diagnoses.

“Telehealth research related to patient outcomes has grown exponentially. In many cases, it has been viewed by patients as equal to or even better than an in-person visit,” says Ann Fronczek, associate professor and director of Decker’s undergraduate and doctoral nursing programs. “In particular, telehealth offers a significant benefit to individuals with chronic illnesses like heart failure, COPD, diabetes, asthma and those who need neonatal or HIV care. It can also benefit primary and urgent care visits, as many issues can be addressed through a video visit and careful history taking.”

Fronczek works with Stephanie Tulk Jesso, an assistant professor of systems science and industrial engineering at Binghamton, to design mobile health clinics in collaboration with United Health Services, a local healthcare system. The idea is to integrate telehealth and bring more providers to rural areas.

“In nursing, there is always a bit of worry that too much technology can affect the caring relationships between a provider and a patient and, therefore, become a potential net harm,” Fronczek says. “Nurses and patients both need some choice as to how the technology will be used to support health.”

Leveraging mobile applications

Researchers in Binghamton’s School of Management hope to improve healthcare from an operations perspective. Though telehealth technology has grown significantly in the past decade, it is rarely used correctly or efficiently, says Saligrama Agnihothri, professor of operations and business analytics.

His research focuses on treating cardiovascular health — particularly patients with hypertension, which affects an estimated 121.5 million Americans ages 20 and older. The current model typically has patients seeing providers once every six months or so to have their blood pressure measured. The problem: Readings can vary significantly even within one day, especially for those with unmanaged chronic illness.

“Providers take one or two measurements and decide whether you have a problem and how to intervene,” Agnihothri says. “Office visit readings are a periodic measurement that is not generalizable to the patient’s steady state of health. It’s not a reliable measure to take the most accurate action.”

Agnihothri believes if healthcare providers had better knowledge of a patient’s behavior through regular readings, they could educate the person toward behavioral changes and better manage medication dosage and other therapies. With an app on their smartphone and a blood pressure cuff, patients easily can track their data, which can then be communicated to the provider’s decision-support system to assist with interventions — including education — as needed.

One of Agnihothri’s doctoral students is developing the app. “They’ve added exercise and diet; you can take pictures of what you eat, and the app automatically converts that into calories and protein,” he explains. “They recently incorporated a Wi-Fi-enabled stethoscope. You can record heart sounds, and that is a part of the data as well. It even has a chat tool where patients can ask questions.”

Agnihothri adds that the most pressing problem isn’t the technology; it’s the current medical payment model, which doesn’t incentivize providers to make changes that could improve care.

Understanding the differences in the payment models comprising the healthcare markets and how those motivate providers is another arm of Agnihothri’s work, and his findings show that adopting “capitation reimbursement” could improve care. Under this plan, an insurance company pays a provider a fixed amount per month, per patient, whether those patients visit the provider or not.

Agnihothri says it is in the provider’s best interest to focus on disease prevention under such a system. If nobody comes to the office, the provider earns the same amount.

One of Agnihothri’s recent papers shows that when payers encourage patients to upload their data from mobile apps, it benefits all parties involved. This information allows healthcare providers to prescribe more effective and timely interventions, leading to better patient outcomes and resulting in higher profit margins for insurance companies.

“Even if you upload your data once a week, the doctor knows what is happening during this period and can take action to intervene sooner rather than later,” he says. “It is almost like having a private doctor at home who continuously monitors you, and the cost is much less compared to the cost of actually seeing the provider.”

Bringing providers into the home

Rachel Klosko, clinical associate professor of pharmacy practice at Binghamton’s School of Pharmacy and Pharmaceutical Sciences, also serves as a clinical cardiology pharmacy specialist at Guthrie Robert Packer Hospital in Sayre, Pa. She and a team at the hospital are developing a paramedicine program that brings paramedics into patients’ homes for comprehensive examinations. The paramedics then connect with a pharmacist like Klosko to discuss the patient’s chronic disease management, including medications.

Klosko says that while access is still a concern — many patients live in areas so rural they have no cellphone or network service — she has caught many medication discrepancies that could endanger lives.

“When you ask patients about their medication in a hospital, they will just read from their list of medications,” Klosko says. “Sometimes what’s on their list is not always what they have at home and what they’re taking. We can coordinate care to help patients — educating and reviewing medications and side effects.”

Klosko believes healthcare will improve by prioritizing population health. She agrees with Agnihothri that addressing the underlying causes of poverty and illness is essential. This approach is evident in the heightened attention to the social determinants of health and their effects.

“Social determinants of health will encompass anything that can impact the patient’s healthcare and well-being — what their health literacy is like, what access to transportation they have, their access to water, what their education has been like,” Klosko says. “I think a lot of upcoming research in the rural health space is going to be targeted in how we can bridge some of these gaps to make care more accessible to all.”

Global access issues

Of course, many countries have healthcare deserts. Sometimes entire populations lack technological infrastructure and face the same chronic healthcare needs. Some countries in the Pacific Islands are among the world’s poorest and are particularly susceptible to infectious diseases and health issues related to climate change.

Koji Lum, a professor of anthropology and biological sciences at Binghamton, studies these populations, most notably the people of the archipelago of Vanuatu in the South Pacific. He has examined the malarial epidemiology of Melanesia, Southeast Asia and Africa. Using this experience, his recent studies have focused on how the disease’s progression has affected the health of the inhabitants of the Vanuatu island chain.

Chronic disease is prevalent in Vanuatu. Lum and his team, which includes student researchers, noted a correlation between malarial control and health. With the World Health Organization successfully controlling malaria in the archipelago, the islanders have been able to focus more on growth and development. Consequently, the age of menarche, the onset of the first menstrual period, has decreased, while obesity rates for women have significantly increased.

“As malaria is controlled, we’re watching what happens to people’s bodies. We found that the men are almost the same as they were 10 years ago, but the women have been getting bigger,” Lum says.

Compounding the problem is a lack of healthy foods thanks to the European tourist market on the islands.

“The only thing women can control is food — so they overeat. There’s also a lot of sexual violence … and bigger may mean safer,” Lum suggests. “But the high blood pressure is terrible, the obesity rates are terrible.”

Moving forward

The Association of American Medical Colleges projects a shortage of 54,100 to 139,000 healthcare practitioners in the United States by 2033. To make matters worse, the Health Resources and Service Administration shows that 60% to 80% of “medically underserved” areas are rural, and that the average age of existing physicians in these areas is already older — nearly a quarter are likely to retire by 2030. For nursing, there are only seven nurse practitioners per 10,000 people in rural areas.

Despite these statistics, the future of healthcare is constantly expanding. Turning toward the newest innovations is just one way the industry can meet the need for better access and patient care. Researchers say it’s essential to keep up with these technologies and their implementation as rural areas continue to see decreases in physical facilities and providers.

Looking ahead, Fronczek emphasizes the need to continue exploring technological options.

“Telehealth is not a replacement for in-person care,” she says. “I don’t want to put that bias out there. But it is another way of reaching very difficult access populations. We need to consider it as we’re entering a world of a two-channel health system, where we have the traditional in-person care, but we’re also going to have the telehealth avenue available to us. There’s a lot of value in reaching people that wouldn’t necessarily come to the office, because of the convenience of the technology.”