Bridging the rural-urban divide: An implementation plan for leveraging technology and artificial intelligence to improve health and economic outcomes in rural America

Rural residents have higher age-adjusted mortality and prevalence rates for cardiovascular disease, diabetes, cancer, unintentional injury, and stroke.^1-8 Those living in rural settings experience shorter lifespans^9-11 amplified by higher the premature mortality rates implicated in “deaths of despair.”¹² These longstanding rural-urban disparities in health outcomes, clinical care, health behaviors, and social determinants of health are increasing^{11, 13} as is the “rural mortality penalty,”^14-16 which has tripled in the past two decades.¹⁷

While “Health Care Access and Quality” was the primary health priority for rural America in Rural Healthy People 2010 and 2020, it dropped to the third most important priority in Rural Healthy People 2030. Over the past decade, both mental health and addiction have risen in relative importance for rural America, with “Economic Stability” debuting among the top 10 social determinant priorities.¹⁸

Utilization data indicate an increasing demand for telemedicine services in rural settings: the relatively low uptake of telepsychiatry services in rural settings prior to the COVID epidemic¹⁹ and persistent rural-urban disparities in preventable acute care use suggest an unmet demand for high-quality ambulatory care in rural areas²⁰ and portend increasing reliance on telemedicine to improve rural residents’ healthcare access and health management.

Finally, rural districts reported significantly fewer students who have access to an internet-enabled device that is adequate for online learning and access to reliable broadband; given that inadequate broadband infrastructure is a critical barrier both to telehealth services provision and remote learning in rural settings, efforts to expand broadband access should focus on rural settings to ensure health and education equity.²¹

In this context, access to healthcare among rural US residents is declining: rural hospitals are experiencing substantial financial distress,²² closing at a faster rate than urban hospitals²³ (accounting for 71% of total hospital closures between 2017 and 2021),²⁴ and restricting the types of care that they offer if they remain open.^{25, 26} These realities have direct adverse impact on local healthcare outcomes and indirect adverse impacts on the local economy: rural hospitals are important local employers and drivers of local economic health and their closures can reduce care access and create local economic chaos.^{23, 27, 28} That rural residents disproportionately rely on emergency services and experience greater mortality for symptom-based conditions, underscores the importance of ensuring access to treatment of life-threatening conditions in rural emergency departments, which are increasingly endangered by hospital closures.²⁹

In addition to rural hospitals’ persistent challenges of low patient volumes, poor payer and patient mixes, workforce shortages, economic and demographic shifts, the opioid epidemic, and inadequate medical surge capacity,²⁵ they are more vulnerable to cyberattacks,³⁰ with ransomware attacks causing unprecedented crises in rural and small hospitals.³¹ While security and training offer potential solutions, barriers to technological solutions include initial and ongoing costs, technical concerns with current systems, and inadequate local technical support.³² Rural hospitals’ lack of technological sophistication has clinical practice ramifications: those lacking electronic health records have lower odds of adopting telehealth.³³

In the post-COVID era, from a national public health perspective, it is important to ensure that rural hospitals maintain solvency to avoid delayed and deferred care:³⁴ in the last decade, rural public health systems have lost public health capacity, while urban systems have expanded that capacity.³⁵

The goal of healthcare is to achieve the quadruple aim: improving the patient experience, improving the provider experience, improving care quality and outcomes (in an equitable way), and reducing per-capita costs over time.³⁶

In rural settings, AI-informed telehealth models have been associated with positive outcomes for patients and healthcare professionals,³⁷ reduced overall healthcare utilization and improved cardiovascular disease risk factors,³⁸ and enhanced self-care and knowledge of heart failure.³⁹ Technological solutions could effectively expand the rural provider workforce by using computer vision analysis of skin, tympanic membranes, retinas, or CT scans⁴⁰ to identify cases without follow-up needs, reducing existing providers’ workload and allowing them to focus on patients with healthcare needs. Further, technology infrastructure transformation could improve patient-provider communications: while rural residents are as likely as their urban counterparts to own and use digital health technology to manage health conditions, they are less likely to communicate with their health providers using that technology, particularly when EHRs are unavailable.⁴¹

Fundamental technological transformation could reduce healthcare costs in rural settings by reducing ransomware exposure and automating back-office operations, including scheduling, correspondence, and billing. It could support the implementation of AI-informed models of health monitoring and healthcare delivery (both for direct patient care and telemedicine consultation), development of new roles for rural hospitals (like the provision of recovery care and care at home), and analytic capacity of electronic medical records. Such implementation could help rural hospitals become more financially viable while improving access to high quality, affordable, local healthcare.

Further, technological transformation may generate positive community externalities by stimulating rural economic growth in several ways. First, it could serve as a basis for technology training for other sectors important in rural America, helping to build a rural technology workforce. Second, it could facilitate technology use in the classroom, thereby improving the quality of local rural educational systems. Third, it could support applications designed to enhance rural America's cultural and entertainment experience, improving access to benefits sought by those who leave rural settings and helping address rural health workforce recruiting and retention challenges.⁴²

While new policies and incentives are needed to overcome the health information technology shortcomings in rural America,⁴³ we propose a three-phased technology implementation proposal designed to improve rural hospitals’ financial performance, support clinical and population health in rural settings, and help rural hospitals and communities thrive. In the short term, for national security purposes, rural hospitals should implement cloud-based software solutions that can reduce ransomware risk and help with back-office operations, scheduling, and patient communications. Supported by industry and government, this would improve data security, financial performance (by reducing overall on-premises information technology costs), and provider- and administrator-productivity. In the medium term, building on this ecosystem, rural hospitals could implement AI-informed diagnostic, patient-management, and population management tools that would further enhance financial performance (by avoiding unnecessary care and enhancing provider efficiency) while improving patient engagement, care access, and population health. In the long term, rural hospitals might engage in public-private-partnership-funded programs designed to explore how best to deploy technology to deliver care and improve population health across the rural-urban continuum. By pairing rural hospitals with financially sound academic medical centers in the same general region, a “hub and spoke” model could give rural hospitals access to resources beyond their current budgetary capacities like systems that allow for copatient management across settings and ambient intelligent solutions that facilitate high quality and safe care.

Rural residents and the rural hospitals that serve them are increasingly under advantaged compared to their urban counterparts. We propose a phased technological transformation process that can improve national security, improve productivity and financial sustainability, achieve the quadruple aim, improve the local economic environment, and provide local access to technology, skilling, educational, and cultural experiences in rural settings. Such an initiative could stabilize rural economic environments and potentially reverse longstanding rural-urban health disparities.

The authors have no conflicts of interest to report.