USE THE EXAMPLE CAPSTONE AND POWERPOINT TO CREATE THE SIGNATURE PAGE AND TABLE OF CONTENTS PORTION OF YOUR CAPSTONE. COMPLETED CHAPTERS OF CAPSTONE ATTACHED.

,

A SYSTEMATIC REVIEW OF THE EFFECTIVENESS OF TELEHEALTH/TELEMEDICINE

IN IMPROVING ACCESS TO CARE AND PATIENT SATISFACTION

Student Name

Capstone Project

In partial fulfillment of the degree Master of Public Health

National University

End of Course Date

I accept this capstone project on behalf of the Community Health Department, School of Health and Human Services, National University. Below the faculty who taught the capstone course, and the MPH Program Director will sign.

__________________________________________ ___________

Faculty/Professor of Capstone Date

Brandon Eggleston PhD

__________________________________________ ___________

MPH Program Director Date

Tyler Smith PhD

iii

Abstract

Objective: This systematic literature review aims to provide a comprehensive synthesis of the impact of Telehealth and Telemedicine in improving access to care and increasing patient satisfaction in various healthcare services before, during, and maybe after the COVID-19 pandemic.

Design: Systematic literature review.

Methods: This systematic review was conducted from January to February 2022 using comprehensive and general searches throughout the National University Smart Search, EBSCO Host, ProQuest, and Google Scholar databases. The publication date range was from 2008 to 2022. After collecting articles from databases, further selection was performed by reading the abstract and results. The chosen articles were further studied by reading the entire text to analyze the research questions.

Results: The articles studied in this systematic review strongly supports that telehealth and telemedicine play an essential role in increasing access to care and improving satisfaction rate. During the COVID-19 pandemic, telehealth and telemedicine were deployed unprecedentedly, providing continuous care for patients of various services.

Conclusion: Telehealth/Telemedicine has a remarkable impact in widening access to care and a high satisfaction rate. It is poised to provide public health, relieve pressure on to healthcare workforce, and help to reduce financial stress to many.

ii

iii

Keywords: Telehealth, Telemedicine, Barriers, Access to Care, Patient Satisfaction

Acknowledgment

Personally written content.

Dedication

Personally written text

iv

List of Tables

Table 1. List of Reviewed Articles 51

v

Table of Contents

Acknowledgments iii

List of Tables v

CHAPTER 1. INTRODUCTION 1

Background of the Problem 2

Statement of the Problem 2

Research Question 2

Significance of the Study 3

CHAPTER 2. LITERATURE REVIEW 5

Patients' Satisfaction and Preference for Telehealth Visits 5

Virtual Visits and Patient-Centered Care 6

Patient and Caregivers' Satisfaction with Telehealth 6

Home Telehealth, Patient Satisfaction, Functions and Challenges 7

Military Health System Access to Care: Performance and Perceptions 8

Telehealth and Patient Satisfaction:

A Systematic Review and Narrative Analysis 9

Acceptability and Cost-Effectiveness of

Military Telehealth Mental Health Screening 10

Telemedical Support for Military Medicine 11

Telehealth: Reducing 30-Day Hospital Readmissions

Among Health Failure Patients 12

Virtual Clinic in General Surgery Patients 12

Virtual Visits for Follow-Up Stroke Care 13

Virtual Visits for Acute, Nonurgent Care 13

Virtual vs. Traditional Consults 14

Practice-Based vs. Telemedicine Based: Care for Depression 14

Managing Hypertension in Urban Underserved Subjects Using Telemedicine 15

Telehealth in the Developing World 16

Telemedicine During COVID 19 Pandemic- Western China 16

Virtual Rheumatology Appointments During COVID-19 Pandemic 17

Perception of Telehealth 18

Telehealth in Health Centers 19

Barriers to Participation and Adoption of Telehealth and Telecare 20

Telehealth in Overcoming Barriers in Licensure and Improve Access to Care 21

Crossing the Telemedicine Chasm: U.S. Barriers to

Adoption of Telemedicine Reduced? 21

Cost of Telemedicine in Diabetes Education 22

Telehealth in Veterans Affairs Mental Health Care 23

CHAPTER 3. METHODOLOGY 24

Introduction 24

Research Question 24

Instrumentation 24

Ethical Considerations 25

CHAPTER 4. DATA COLLECTION, ANALYSIS AND RESULTS 26

Introduction 26

Data Collection Procedures 26

Data Analysis and Results 27

Pre-COVID-19 Pandemic 27

During COVID-19 Pandemic 29

CHAPTER 5. CONCLUSIONS AND RECOMMENDATIONS 32

Introduction 32

Limitations 35

Conclusions 35

Recommendations for Further Study 36

REFERENCES 37

APPENDIX A: ARTICLE SELECTION PROCESS 50

APPENDIX B. SYSTEMATIC LITERATURE REVIEW 51

vi

vi

CHAPTER 1. INTRODUCTION

The face of healthcare is fast changing, brought by new technological developments not just with hospital equipment, medical techniques, and pharmacology, but with the advances in communication modes as well. Telehealth services have never been more essential than now (CDC, 2020). Healthcare professionals and health systems need to treat their patients from a distance and securely collaborate with colleagues in real-time (McMahon & Duncan, n.d.). The number of telemedicine consultations reached a 700 percent increase in 2015, and 77 percent of consumers say they would be more likely to choose a doctor who offers telehealth than those who are not using the technology (McMahon & Duncan, n.d.). 

In the military, the Defense Health Agency (DHA), which governs the healthcare system, recently sought to expedite the process of aggressive utilization of telehealth due to the urgency to continue providing care and maintaining access to care during the pandemic (MHS, 2020b). The agency put out three significant changes to impact the need for access while preventing direct-contact patient care; (1) audio-only telephone visits with providers, (2) incentivizing network providers telehealth, and (3) waiving of cost-share for telehealth users (MHS, 2020b).

During the recent pandemic, the Center for Disease Control and Prevention suggests changes to health care delivery are needed to reduce staff exposure to infected persons, preserve personal protective equipment (PPE), and minimize the impact of patient influx on facilities. Furthermore, telehealth services can provide these necessary care and precautions to prevent the spread of SARS-CoV-2, the virus that causes COVID-19. Telehealth services can be used for COVID-19 screening, low-risk urgent care, primary care, specialists access, patient coaching and support, physical and occupational therapy sessions, monitoring patients with chronic medical problems, case management, and follow-up care (CDC, 2020).

1

3

Background of the Problem

Access to care is only one factor in measuring patient satisfaction in any health system (MHS, 2020a). Patients may perceive poor access to care due to many factors, including parking or distance from the entrance of the facility to the clinics and long lead time between a schedule is made and the actual appointment (Mayo Clinic, 2020). Access is also an issue that remote areas have been facing for many years, brought by distance and lack of medical providers to manage the care of the local population. In the military, healthcare providers are civilian government employees, civilian contracts, and military personnel, and typically, military health care professionals change duty stations every two or three years (Abiero et al., 2020). Hence, access to care and patient satisfaction become pressing issues in times like these. The options are to transfer the patients to the civilians and contract providers or refer patients to a network provider (Kellerman, 2017).

Statement of the Problem

The world's eventful situation changed how people seek medical care. During the COVID-19 pandemic, the need to utilize telehealth in a much larger and robust capacity was initiated. It will be worth studying the effectiveness of telehealth/telemedicine as an answer to access to care shortages and to promote positive experiences to patients during the COVID-19 pandemic and maybe in the future.

Research Question

This project will answer the following research questions: How effective is Telehealth/Telemedicine in addressing access to care problems and increasing patient satisfaction before, during, and maybe after the pandemic? What are the possible barriers and other benefits it brings to health care systems?

Significance of the Study

Healthcare professionals use telemedicine/telehealth to evaluate, diagnose, and treat patients without a face-to-face visit in the clinic. It is a two-way communication system between a physician and patient that is frequently used for follow-up visits, medication management, consultation, management of chronic conditions, and a wide array of other clinical services (Mayo Clinic, 2020). Kruse et al. (2017) and Polinski et al. (2016) both showed in their studies that the telehealth system could optimize access to care and increase patient satisfaction. During a pandemic such as COVID-19, where the safety of each individual is at stake, virtual appointments are crucial to address the routine medical needs of the people (CDC, 2020).

Telehealth is a tool that uses technology to provide health care and other health-related services remotely. Though it does not increase the size of the provider workforce nor a service itself, telehealth is a mechanism for delivering health care services that can help increase efficiency and extend the reach of existing providers (Mayo Clinic, 2020). This includes communication and education between providers and between patients and providers (Mayo Clinic, 2020). At the same time, telemedicine is the practice of medicine using technology to deliver care at a distance where a physician in one location uses a telecommunications infrastructure to provide care to a patient at a distant site (Mayo Clinic, 2020).

In the US military, since 1992, telehealth and telemedicine have emerged as valuable components of the Military Health System (MHS) in both garrison and deployed settings (Schulder Rheuban & Krupinski, 2018). The MHS has a worldwide mission of supporting active duty service members, retirees, and their beneficiaries in peacetime health care needs, including the continental United States, and deployed active duty service members and retirees outside the continental United States (Schulder Rheuban & Krupinski, 2018). Embedded in the 2017 National Defense Authorization Act (NDAA), it stated the universal use of telehealth in various military settings (Kellerman, 2017). The military health system uses as a platform of support to health care providers working in small forward operating bases and on ships at sea (Kellerman, 2017). Despite the successful deployment of telehealth overseas and in the civilian sectors, the military health system was slow to adopt it at home due to stringent information security requirements and budgetary constraints (Kellerman, 2017). However, 2017 NDAA directs the military health system to rapidly expand telehealth in its clinical operations (Kellerman, 2017).

CHAPTER 2. LITERATURE REVIEW

Patients' Satisfaction and Preference for Telehealth Visits

According to Polinski et al. (2016), a quarter of patients in the United States do not have a primary care provider or do not have complete access to one. Their work and personal responsibilities affect their capabilities to find convenient and accessible care. Telehealth services facilitate patients' access to care, but whether patients are satisfied with telehealth is unclear (Polinski et al., 2016).

Polinski et al. (2016) conducted a study comparing face-to-face visits and telehealth visits in eleven clinics in Texas and California to measure patient satisfaction. With 1,734 telehealth patients surveyed, 32% expressed a preference for receiving care via telehealth. An additional 57% rated a telehealth visit as just as good as a traditional visit, while only 1% of patients rated the telehealth visit as worse than a traditional visit (Polinski et al., 2016). Additionally, over half of patients expressed shorter to no wait time as their primary motivation for using telehealth, 95% of all patients were very satisfied, 98% rated the assisting nurse as highly capable, and 94 % were very satisfied with the treatment plan and educational materials they received (Polinski et al., 2016).

This study strongly supports that many patients would prefer using telehealth. According to Polinski et al. (2016), patients who were very satisfied with telehealth appointments, quality of care, and convenience had more than 2.3 times the odds of liking telehealth. These results provide insights into patients' motivations for using telehealth and factors associated with their preference for telehealth visits (Polinski et al., 2016).

Virtual Visits and Patient-Centered Care

While the use of virtual visits is growing rapidly, several health systems are integrating virtual visits into primary care to complement existing modes of care, in part reflecting a growing focus on patient-centered care (McGrail et al., 2017). McGrail et al. (2017) conducted a study to describe the patients' and providers' virtual visits and explain why patients use virtual care. In the study, during 2013-2014, there were 7,286 virtual visit encounters observed, involving 5,441 patients and 144 physicians. It was found that the 399 virtual visits indicated that patients liked virtual visits; with 372 (93.2%) responded that their virtual visit was of high quality; and 364 (91.2%) reported their virtual visit was "very" or "somewhat" helpful to resolve their health issue. 

The number of virtual visits continues to increase to complement and provide a new way for patients and providers with existing relationships to interact (McGrail et al., 2017). Other important reasons for the use of telehealth are easing access and providing patients with needed care at a convenient point in time, but not necessarily displacing subsequent service use (McGrail et al., 2017). McGrail et al. (2017) mentioned that a patient-centered system is organized to respond to patient needs without these unintended side effects. Virtual visits may be one way the system can be refocused. Additionally, it is essential to consider how technologies are integrated into the system to support the existing relationships or simply another way to see a provider as needed (McGrail et al., 2017). This study supports that telehealth is an excellent way to satisfy the medical needs of patients.

Patient and Caregivers' Satisfaction with Telehealth

Telehealth is an alternative method of delivering health care to people required to travel long distances for routine health care (Orlando et al., 2019). Population in rural and remote areas are generally satisfied with telehealth as a mode of service delivery because of improved access to care and convenience. Orlando et al. (2019) conducted a systematic examination of whether patients and their caregivers living in rural and remote areas are satisfied with telehealth videoconferencing as a mode of service delivery in managing their health.

According to Orlando et al. (2019), patient satisfaction is essential for telehealth to be a viable mode of service delivery. One criterion observed in the study was system experience, which was the most commonly measured dimension of satisfaction appearing in 29 studies (81%). It was also found that there were high satisfaction levels concerning service accessibility in telehealth. Furthermore, there is consistent evidence that telehealth has an overall positive impact on patient and caregivers' satisfaction highlighting that distance may no longer be a barrier, especially in rural and remote areas (Orlando et al., 2019). According to the researchers, consumer focus should not be compromised with the advances in information and communication technologies; but rather improve the functional delivery of telehealth. Since this study was focused mainly on a specific population, rural and remote areas, it is found that telehealth, such as video conferencing, is an essential mode of healthcare delivery. However, while telehealth is not a replacement for face-to-face appointments, an alternative method of healthcare delivery that, when integrated into an established service, could form part of patients’ choice when clinically safe and appropriate. Aligning a health care service with patients' expectations and needs can lead to overall patient satisfaction (Orlando et al., 2019).

Home Telehealth, Patient Satisfaction, Functions and Challenges

To support the needs of the aging U.S. population, Congress and the U.S. Department of Veterans Affairs (V.A.) prioritized the noninstitutionalized care services with The Veterans Millennium Health Care and Benefits Act of 1999 (Young et al., 2011). The program is known as the care coordination/home telehealth (CCHT), established in 2003. Home telehealth programs can enhance older adults' access to care, but gathering accurate information regarding the program's effectiveness is challenging because patients can be reluctant to provide criticisms (Young et al., 2011).

There are three common elements of CCHT, the care coordinator (CC), the telehealth technology, and the patient (Young et al., 2011). The home telehealth technology, which involves messaging devices, monitoring and measuring devices, videophones, or personal computers, is used depending on the needs and capabilities of the patient. At the same time, the CC is usually a registered nurse. The study demonstrated that home telehealth holds value not only for providers but also for patients. The patients are more involved with their care because they learn more about their condition and are better monitored. With the expansion of home telehealth programs, enrollment increases, the scope of health issues being addressed, and tracking the program functionality becomes increasingly important and challenging. Despite the challenge, it was found that 98% of the surveyed individuals indicated that they were extremely satisfied with CCHT. Although the study involves more than one mode of telehealth, it provides the fact that telehealth has a positive effect on healthcare management. Lastly, addressing equipment failures and patient frustrations with connection accessibility, the successful expansion of telehealth is more likely (Young et al., 2011).

Military Health System Access to Care: Performance and Perceptions

Like in other healthcare systems, access to care in the military is an essential component in providing high-quality healthcare. According to Abiero et al. (2020), in the Military Health System (MHS), access to care (ATC) is essential not only for ensuring the health and well-being of MHS beneficiaries but also for ensuring the medical readiness of active-duty personnel. They conducted a study to examine the relationship between ATC administrative data and patient survey results. The Joint Outpatient Experience Survey (JOES) and administrative data were collected from the Military Health System Data Repository from May 2016 through March 2017 for 135 parent Military Treatment Facilities (MTF) (Abiero et al., 2020).

The JOES can help diagnose potential access issues, which involve call center scheduling and provider availability (Abiero et al., 2020). In the study, researchers have found that as the wait time for appointments increases, patients' ratings of the time between scheduling and appointment dates decline, and patients' assessments of being able to see a provider decline as well. Additionally, the study suggested exploring the gaps in looking into best practices at facilities with high patient experience with access and looking at other survey measures related to access, such as telephone resources and web-based communication programs. Finally, patients may perceive poor access to care due to many factors, including parking or distance from the entrance of the facility to the clinics and long lead time between the date an appointment was made and the actual appointment (Abiero et al., 2020). Although not directly mentioned anything about telehealth, it strongly suggested seeking best practices to address the access to care issues.

Telehealth and Patient Satisfaction: A Systematic Review and Narrative Analysis

Telehealth is a viable platform to deliver quality patient care that meets high patient satisfaction. Kruse et al. (2018) performed a systematic review and narrative analysis to explore the association of telehealth and patient satisfaction regarding effectiveness and efficiency. The study found that 20% of the articles showed improved outcomes, 10% as preferred modality, 9% as ease of use, 8% as low cost, 8% as improved communication, and 7% as decreased travel time, which accounted for 61% of occurrences. The authors stated that telehealth is feasible for providers who want to expand their practices to remote areas without relocating or expanding their practice footprint. Additionally, telehealth was identified to have the potential to extend the boundaries of providers' practices by overcoming the barrier of proximity.

Acceptability and Cost-Effectiveness of Military Telehealth Mental Health Screening

Jones et al. (2012) pointed out that telehealth has been identified as addressing the military shortage of mental health providers. Hence, no research supports the viability of mental telehealth care for the population on mental health screening as a standard component of post-deployment medical screening. Jones et al. (2012) conducted a study that summarizes soldier perceptions of three separate screening events in which telehealth was used and the cost-effectiveness of telehealth versus in-person implementations of the same screening such as; (1) soldiers who have not been through telehealth screening report a strong preference for in-person screening; (2) soldiers who have been through telehealth screening still report a preference for in-person screening, but they express more ambivalence about the screening method; and (3) using telehealth-only mental health screening for large numbers of soldiers within a compressed time frame is more expensive than in-person screening.

Although findings suggest that in-person interviews are more efficient than telehealth interviews because of the increased difficulty of long-distance coordination with telehealth, there is a meager refusal rate of 7% for those subjected to VTC visits. At the time of this study, while at an early stage of consideration of telehealth as an option, there is a sign of improved understanding of the costs and acceptability; the military and government leaders are off to a good start to provide an alternative post-deployment care to our service members (Jones et al., 2012).

Telemedical Support for Military Medicine

To sustain the mission of deployed units of the U.S. military, especially in the Iraq and Afghanistan areas of operations (A.O.), the healthcare system needs new ways to ensure proper and timely care to casualties within the "Golden Hour" to life-saving surgical care. Nettesheim et al. (2018) identified telemedicine as one solution that can aid in this environment because it can reduce the medical footprint in a theater of operation by bringing the remote expert's knowledge and experience to the point of need. It can augment the capabilities of caregivers in austere operational settings using available communication technologies to optimize the care of casualties who are delayed in evacuation to higher levels of care (Nettesheim et al., 2018).

Nettesheim et al. (2018) conducted a systematic historical review of literature about military telemedicine. The researchers pointed out that Military telemedicine is currently focused on providing specialty care to general medical caregivers such as physicians, physician assistants, independent duty corpsmen, and special operations medics, when distance, time, and operational requirements make doctrinal evacuation guidelines or routine medical evaluation is impractical (Nettesheim et al., 2018). Telemedicine, notably VTC used to support direct patient care or procedural mentoring, which requires significant bandwidth and minimal latency and jitter. According to Nettesheim et al. (2018), with the continuous development of new technologies arise in the field of telemedicine, they can never replace the necessity of training and nurturing the experience of deployed clinicians and remote consultants. Ensuring telemedicine is used by appropriately trained personnel is paramount to its success and optimizing casualty care in the future. This study proves that there are other areas where telemedicine or telehealth can be helpful and valuable.

Telehealth: Reducing 30-Day Hospital Readmissions Among Health Failure Patients

This study looked at telehealth as one strategy to reduce 30-day hospital readmission for heart failure patients. Telehealth programs were used to provide a wireless computer-based reporting system (tablet) that collects patient vital signs (i.e., weight, heart rate, blood pressure, and blood oxygenation) via wireless peripherals, and are preloaded with subjective questions related to heart failure and symptoms and instructional videos. It was found that there was a 73% reduction in 30-day readmission within three years. It was concluded that telehealth is a promising approach to caring for a chronically ill population while improving the patient's ability for self-care in the comforts of their homes (O'Connor et al., 2016).

Virtual Clinic in General Surgery Patients

The increasing demand for various healthcare specialists creates considerable demand for hospital services. Available technologies such as telehealth offer an alternative means by which healthcare providers can increase the efficiency of healthcare delivery. Rutherford et al. (2020) conducted a pilot study of the feasibility, benefits, and drawbacks of virtual clinics (V.C.) in general surgery service at the tertiary level.

Virtual clinics are at the forefront of technological innovation, which can be used for consultation between patients and their providers or between two or more healthcare providers (Rutherford et al., 2020). Although advances in technology have come a long way, the authors found some pitfalls in the telehealth process, such as limited capacity, differing internet access, and concerns among patients and the medical community. Rutherford et al. (2020) concluded that V.C.s could deliver on its expectations of reducing patient waiting times, improving patient satisfaction, and better patient care. It was pointed out that V.C.s require a meticulous integration into the existing system to convince patients of its advantages.

Virtual Visits for Follow-Up Stroke Care

People living with health difficulties such as stroke that resulted in the loss of independence are subject to timely, in-person access to health care. Appireddy et al. (2019) conducted a study to assess the feasibility and logistics of implementing eVisits (telehealth) in a stroke prevention clinic for seniors.

Virtual visits, also known as eVisits, are composed of secure 2-way digital communication between health providers and their patients (Appireddy et al., 2019). The results of this pilot program indicated that the eVisit was well received by patients and can provide cost savings to both patients and the healthcare system. It was found that such transformative change needs the involvement of health care professionals, health services researchers or economists, hospital leadership, clinician associations, and health system governance bodies at the regional and provincial levels to inform evidence-based practice guidelines and sustainable models of care (Appireddy et al., 2019).

Virtual Visits for Acute, Nonurgent Care

Virtual healthcare, such as real-time video consultation with a physician via the internet, will continue using mobile devices and patient demand for immediate, convenient access to care. Gordon et al. (2017) conducted a study to analyze the care provided and the cost of virtual visits over three-week episodes compared to in-person visits to retail health clinics (RHC), urgent care centers (UCC), emergency departments (E.D.), or primary care physicians (PCP) for acute, non-urgent conditions. The analysis found that care received via virtual visits for non-urgent conditions was comparable to that obtained in in-person health care settings. Additionally, both modes of visits had similar follow-up rates that suggest an adequate clinical resolution, outpatient evaluation, and management (Gordon et al., 2017).

Virtual vs. Traditional Consults

This study identified that electronic consultations might have better, faster, cheaper processes for diagnosing, treating, and monitoring health conditions (Palen et al., 2012). Virtual consultation between physicians may provide a method of streamlining care, potentially saving patients’ the time and expense of added visits. Palen et al. (2012) conducted a study that aimed to compare physician usage and patient satisfaction with virtual consultations (V.C.s) with formal talks (T.C.s) facilitated within an electronic health record (EHR).

Palen et al. (2012) surveyed 205 physicians who submitted a V.C. or T.C. The authors demonstrated that using virtual consults via secure messaging within an EHR did not adversely affect patients' perceived satisfaction with their care. It was observed that less than 7% of all the consults were virtual during the study time when a provider opted to use a virtual consult to ask a question regarding patient care; 40% of the time, face-to-face consultation with the specialist was not needed. It was concluded that V.C.s were received faster by referring physicians than T.C.s, but the value and application of information from both types of consultations were similar. Furthermore, V.C.s decreased the need for face-to-face specialty encounters without diminishing the patient's perception of care.

Practice-Based vs. Telemedicine Based: Care for Depression

Fortney et al. (2013) defined practice-based collaborative care as a complex evidence-based practice that is difficult to implement in smaller primary care practices lacking onsite mental health staff. Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care settings. This study aimed to compare the outcomes of the two techniques in the care of patients suffering from depression (Fortney et al., 2013).

Federally qualified health centers from 2007 to 2009 serving the medically underserved populations screened for depression, 364 of which were positive. They were enrolled and followed for 18 months. It was identified 83.2% met diagnostic criteria for major depressive disorder, and nearly half or 48.4% were already receiving depression treatment at enrollment, indicating treatment resistance. The studied population composed 64.5 % were unemployed, and 68.1% lived in a rural area (Fortney et al., 2013). The study found that the high degree of treatment resistance likely contributed to the low response rates among those randomized to the practice-based (PBCC) group, while patients randomized to TBCC had significantly and substantially more excellent treatment response rates, remission rates, reductions in depression severity and increases in mental health status and quality of life. Additionally, better outcomes were achieved in the TBCC group without increasing the number of P.C. visits, attributed to higher fidelity to the care manager (Fortney et al., 2013).

Managing Hypertension in Urban Underserved Subjects Using Telemedicine

It was mentioned that screening and managing 60 to 80 million patients with hypertension is an impossible task for the current health care system. Bove et al. (2013) conducted a randomized, controlled trial to test the hypothesis that self-monitoring of B.P. and internet and telephone-based communication system will allow more patients to reach goal B.P. compared with usual care. This study focused on reducing hypertension cases in the underserved urban population using the internet and telephone telemedicine system. The study was conducted in an urban population comprised mainly of African Americans with a high incidence of hypertension and diabetes, mainly in Philadelphia, Pennsylvania (Bove et al., 2013).

After over four years, the study was concluded with recruited 241 subjects, of which 206 completed the six-month study; 241 patients were randomized into 121 controls and 120 telemedicine subjects (Bove et al., 2013). It was found that the proportion of subjects who reached goal B.P. was the same as in the control and telemedicine groups. There were more significant reductions in systolic and diastolic B.P. in the telemedicine group than in controls, but the differences were insignificant.

Telehealth in the Developing World

Telehealth is gaining high popularity among healthcare systems in developed and developing countries (Scott & Mars, 2015). The utilization of telehealth varies between developed and developing worlds; the latter struggles with infectious diseases and non-communicable diseases and very few resources. Telehealth is geared towards improving health and healthcare in the developing world, driven by altruistic and profit motives

Scott and Mars (2015) authored a systematic analysis of the state of telehealth in the world at that time. It was found that the use of telehealth offers a partial solution through direct clinical services, training, and task shifting to lower levels of health workers. However, the shortage of trained health workers and professionals remains the major problem as the production rate of healthcare workers fails to keep up with the fast growth of the human population (Scott & Mars, 2015).

Telemedicine During COVID 19 Pandemic- Western China

The world is unique as disasters and pandemics pose grave challenges to healthcare delivery (Hong et al., 2020). As the COVID-19 pandemic continues exhausting the resources for most countries globally, telemedicine may be an effective way to allocate medical resources rationally. Hong et al. (2020) conducted a narrative illustration of how Western China deployed a telemedicine network at this pandemic. They stated that telemedicine demonstrated to be feasible, acceptable, and practical, which allowed significant improvements in healthcare outcomes.

Telemedicine was successfully used in information and telecommunications technology to transfer medical data for diagnosis, therapy, and education. It was described that telemedicine could support long-distance clinical care, education, health administration, and its use has increased dramatically in the past decade. A variation of the program showcased telehealth's usefulness, such as tele-education, 5G technology deployment with the multidisciplinary medical team, 5G technology with remote computed tomography scanning, telephone consultations, and an internet-based drug prescription system. While Western China is not as economically prosperous as its Eastern counterpart, it capitalized on the remote capabilities of staff and technology and played an essential role in the pandemic (Hong et al., 2020).

Virtual Rheumatology Appointments During COVID-19 Pandemic

Howren et al. (2020) studied the perspective of individuals living with rheumatic diseases towards virtual rheumatology appointments during the COVID-19 pandemic. The study was conducted through an online survey (www.unifiedcovid.com) to 429 people of at least 18 y/o, mainly from the North American population diagnosed with rheumatoid arthritis. The survey questions included demographics, type of rheumatic disease(s) and treatments, and experiences with virtual rheumatology appointments.

Howren et al. (2020) stated that the COVID-19 pandemic had generated notable changes to the delivery of rheumatology care. The study showed that nearly half of the participants attended a virtual rheumatology appointment (Howren et al., 2020). The study showed that 73.8% of survey participants were not bothered by a lack of choice regarding appointment format, while 71.2% were satisfied with their virtual appointment. It was also found that disease severity and satisfaction to virtual appointments were significantly associated; with higher satisfaction among participants under control, 19.3% vs. 4.5%, and with severe disease, 11.9% vs. 4.5%, and lower satisfaction among participants with mild, 27.5% vs. 43.5%, and moderate illness, 41.3% vs. 47.7% (Howren et al., 2020). They recommended to include prioritizing in-person appointments when discussing difficult news, considering a patient's disease severity, and providing the option for telephone or video conference, where possible, for virtual follow-up appointments to ensure that patient preferences are considered while supporting the reasonable allocation of resources (Howren et al., 2020).

Perception of Telehealth

In this study, telemedicine is considered an effective factor to aid in the recruitment and retention of physicians in underserved areas and improve access to healthcare (Ly et al., 2017). However, Ly et al. (2017) identified that telemedicine's use depends on individual and contextual factors. They initiated this research to study these factors using a mixed-methods design in Senegal based on a micro, meso, and macro framework.

According to the study, health professionals can have a negative inclination regarding telemedicine and are doubtful of its effectiveness, fearing their patients' safety and privacy, preferring traditional methods of care, or doubting the ability of telemedicine to ensure their wages. The study involved those working in district health centers that were 39 years on average, while the average age of their colleagues who worked in public hospitals was 41 years. In a similar situation, physicians working in Dakar were more numerous than those outside (Ly et al., 2017).

This study provided comprehensive insights on the individual and contextual factors that influence the use of telemedicine in resource-constrained settings by identifying and assessing the micro (physicians' intention), meso (technical, organizational and ethical), and macro (financial, political, legal, and socioeconomic) factors that determine the use of that technology in Senegal (Ly et al., 2017). A few of the issues found by the researchers was the lack of equipment maintenance in the health system, which could harm the sustainable development of telemedicine. Additionally, the researchers stated that these individual and contextual factors could assist players in the health sector in supporting the development of telemedicine in Senegal. Hence, also improving the recruitment and retention of physicians in remote areas.

Telehealth in Health Centers

The potential to improve access to care, especially in rural or urban areas with scarce healthcare resources, is a relative benefit of telehealth (Lin et al., 2018). However, telehealth has not been adopted or fully implemented in many health centers despite the potential benefits (Lin et al., 2018). Lin et al. (2018) examined the factors associated with and barriers to telehealth use by federally funded health centers analyzed using the data in 2016 from the Uniform Data System using a mixed-methods approach.

This research studies the factors associated with potential barriers to the adoption of telehealth by Health Resources and Services Administration (HRSA) funded health centers through a mixed-methods approach that involves patient population served at each health center (Lin et al., 2018). It was initially noted that 14.2% of rural centers did not perceive a need for telehealth, despite the limited access to primary and specialty care in rural areas, because they felt that they were able to provide care onsite, were fully staffed, or had partnerships with visiting or local specialists.

The study concluded in identifying the barriers to using telehealth reported by health centers in eight categories such cost and reimbursement, technical issues aside from broadband, miscellaneous technical problems, partners and providers, unclear barriers, patient population and regulations/policies/scope of work, and broadband source (Lin et al., 2018). Additionally, the research findings suggest that telehealth adoption is partly driven by improving access. Health centers in rural areas are more likely to invest in telehealth and use it for mental healthcare than urban areas. Lastly, among health centers using telehealth, those in rural areas were more likely to utilize it to provide mental health care, thus reflecting both the shortage of mental health providers in many rural areas and the need to use it for care coordination.

Barriers to Participation and Adoption of Telehealth and Telecare

Valued as a strong health care support for the aging population, telehealth, however, studies show low participation that is not well understood. Sanders et al. (2012) put out this study to explore barriers to participation and adoption of telehealth or telecare from the perspective of people who declined to participate or withdrew from the randomized controlled trial in the U.K. known as the Whole System Demonstrator (WSD) project. Qualitative semi-structured interviews were conducted with 22 people who declined to participate in the trial following explanations of the intervention or who withdrew from the intervention arm. The study revealed many factors contributing to decisions to decline or remove. Such factors were requirements for technical competence and operation of equipment; threats to identity, independence, and self-care; expectations and experiences of disruption to services. There were also findings regarding perceptions of potential disruption of interventions to identity and services, concerns about privacy, and managing technology (Sanders et al., 2012). Sanders et al. (2012) concluded this study by raising important issues with policy implications emphasizing the increase in implementing telehealth and telecare interventions to support self-care for those with chronic conditions and social care needs.

Telehealth in Overcoming Barriers in Licensure and Improve Access to Care

Telehealth initiatives in the military and veterans' health system continue to thrive with technological developments while providing the best care to service members, veterans, and families (Stout & Martinez, 2011). The Department of Defense (DoD) and Veterans Health Agency (VHA) have credentialing systems to allow clinical practice between facilities. A legislation move is a process in the Servicemembers' Telemedicine and E-Health Portability (STEP) Act to potentially expand the implementation of telehealth clinical services across states into the homes of our service members and veterans. Stout and Martinez (2011) pointed out that the telehealth initiatives by the DoD, VHA, and Defense and Veterans Brain and Injury Center Office (DVBIC) of telemedicine, the development, and implementation of services have been rapidly growing.

The trouble which tele-practitioners throughout the United States face is the challenges of inter-state licensure barriers. The DoD and VHA, in collaboration with DVBIC, continue to forge ahead with the creation of new telehealth services (Stout & Martinez, 2011). The STEP Act will allow providers to see service members in their homes via telehealth technology, using their homes to extend the military facility capabilities. This would significantly increase access to specialty care for service members, decrease family burden, and increase family involvement in the service member's recovery process.

Crossing the Telemedicine Chasm: U.S. Barriers to Adoption of Telemedicine Reduced? Telemedicine is continuously challenged by barriers preventing it from full adoption and utilization by health care organizations for more than 40 years (LeRouge & Garfield, 2013). Such barriers were identified as technological, financial, and legal aspects, which involved business strategy and human resources. This report recognized that telemedicine would be an integral part of health care services and not as a stand-alone project in the future. It has to be recognized as necessary or equivalent to other health services within health care organizations. It serves as vital connective tissue for expanding health networks.

Telemedicine plays a role in the future strategy of the healthcare industry. Many barriers to the increasing adoption of telemedicine are slowly waning, paving a path for more ways to be utilized (LeRouge & Garfield, 2013). According to LeRouge and Garfield (2013), telemedicine's remaining issues, such as human and organizational policies, need attention for more research, practice, and policy discussions to promote understanding and action to overcome the remaining barriers that challenge the proliferation of these lifesaving services and networks. It should be at the forefront of Health I.T. research, which in the end can lead to better health care, lower costs and more equity in healthcare delivery in the United States.

Cost of Telemedicine in Diabetes Education

This study estimates the impacts on Medicare cost in providing home telemedicine to eligible Medicare beneficiaries with Type 2 diabetes (Moreno et al., 2009). Moreno et al. (2009) conducted this study using two cohorts of beneficiaries with an average age of 55 where telemedicine was utilized. Telemedicine was used through nurse education, coaching (televisits), and self-tracking of progress through other HTU functions to improve the participants' self-care behaviors, diet, exercise routines, foot care, and medication regimes. The study showed that for telemedicine to be cost-effective, the intervention-related costs would have to be drastically reduced while maintaining clinical impacts. Lastly, even if intervention costs were reduced by 50% and the program reduced hospitalizations by 50%, both unlikely scenarios, the program would still increase costs to the government (Moreno et al., 2009).

Telehealth in Veterans Affairs Mental Health Care

This paper scrutinized the successes and challenges of providing free, integrative treatment to veterans and military families through secure video connections into their homes (Price et al., 2019). In this study, there were two case studies of the mental health treatment conducted through the Greater NYC Military Family Consortium in conjunction with the Steven A. Cohen Military Family Center at NYU Langone Health in New York City illustrate the complexities and opportunities that emerge in the course of treatment, most of which was conducted remotely. According to Price et al. (2019), one aspect of mental health is dynamic with which it can change; ease of continuous provider access can continue to treat patients remotely. The prompt treatment of patients showing signs of mania, suicidal, or homicidal ideation, a switch to in‐person sessions may be advisable to assess and manage risk was also feasible. Researchers concluded that coordinating care with a local hospital, clinic, and psychiatrist is imperative if the patient lives too far away. Hence, mental health can do that with proper inclusion and exclusion criteria and risk management strategies. They closed the write-up stating that technology has opened new pathways to healing for people who face physical and psychological barriers to care (Price et al., 2019).

CHAPTER 3. METHODOLOGY

Introduction

This chapter provides a structure, particularly in conducting the systematic review to find equivalent answers to the study’s research questions. Furthermore, this describes how the related studies were collected and the methods used to collect research articles.

Research Questions

This systematic review of articles aims to answer the following research question: How effective is Telehealth/Telemedicine in addressing access to care problems and increasing patient satisfaction before, during, and maybe after the pandemic? What are the possible barriers and other benefits it brings to health care systems?

Description of Participants

The included articles related to the main topics of this systematic review consisted of medical-related services provided through telehealth or telemedicine to the general population; for example, routine check-ups, mental health counseling sessions, follow-up care, prescription refills, and COVID-19 triage care. There were no other criteria used to determine target groups.

Instrumentation

This systematic review was conducted from January to February 2022 using comprehensive and general searches throughout the National University Smart Search, EBSCO Host, ProQuest, and Google Scholar databases. General and extensive searches were performed in the National University Smart Search, EBSCO Host, ProQuest, and Google Scholar databases using the following keywords: ‘virtual medical appointment,’ ‘virtual appointment,’ ‘virtual versus face-to-face appointments’, ‘telehealth’, ‘telemedicine’, ‘telehealth in COVID-19’, ‘telemedicine in the military’, ‘virtual medicine’, ‘virtual pharmacy’, ‘virtual clinic’, ‘group virtual mental health appointment’, ‘patient satisfaction measures,’ ‘military access to care,’ ‘virtual medical appointment in the military,’ ‘history of telehealth’ and ‘telehealth as access to care.’ The publication date range was from 2008 to 2022. After collecting articles from databases, further selection was performed by reading the abstract and results. The chosen articles were further studied by reading the entire text to analyze the research questions.

Ethical Considerations

The study did not require institutional review board (IRB) approval as the study was a systematic literature review. To achieve the highest level of credibility when conducting the review, only peer-reviewed and scholarly research articles were chosen for analysis.

CHAPTER 4. DATA COLLECTION, ANALYSIS AND RESULTS

Introduction

This chapter discusses the methods and procedures undertaken to gather and examine published articles and related data pertinent to this study. Additionally, this section includes the details of the results from the careful review of included articles.

Data Collection Procedures

This comprehensive study is regarding the effectiveness of telehealth/telemedicine in improving access to care and increasing patient satisfaction. Included in the process was the gathering of articles to build a group of related research studies available to support the idea that telehealth and telemedicine have contributed to improving access to care and increasing patient satisfaction of several medical services. At the early gathering stage, aggregate articles were pulled from searchable terms related to this study and subjected to further screening ( n = 108). Furthermore, articles subject to a more detailed analysis were selected after reading each abstract, results, and discussion section ( n = 66). Some articles were excluded for not meeting the criteria stated for this review ( n = 16). The remaining articles ( n = 50) were grouped into three; one group talked about access to care ( n = 28); the second group was all about patient satisfaction ( n =16); the third group tackled access to care and patient satisfaction ( n = 6). Figure 1 provides a detailed description of the process of selecting the articles for this project (Appendix A). Table 1 contains the list of articles used for this study (Appendix B). In general, all authors concluded that telehealth and telemedicine increased access to care and significantly improved patient satisfaction. A few articles stated suggestions and recommendations on how telehealth and telemedicine can positively impact providing care to patients; however, subject to further studies. Some articles also stated various barriers that hinder telehealth and telemedicine from maximizing positive impact in patient care. The role of telehealth and telemedicine in every included research presents a unique avenue where these system/s were used to address patient needs, but the focus of this study was access to care and patient satisfaction.

Data Analysis and Results

The list of reviewed articles has been provided in Appendix A, including the authors, publication year, and title. Based on the articles studied for this systematic review, the authors strongly expressed and magnified that telehealth and telemedicine play an essential role in widening access to care and high satisfaction rate for the care of patients. However, they pointed out many barriers to utilizing the full potential of the systems. During the COVID-19 pandemic, telehealth and telemedicine were deployed unprecedentedly, providing continuous care for patients with pre-existing conditions, follow-up care, counseling, referrals, triage, and others. Some of the included articles are highlighted in this section, citing the authors' views regarding telehealth and telemedicine's positive impact on access to care and patient satisfaction.

Pre COVID-19 Pandemic

Globally, telehealth and telemedicine offer potential benefits for better health outcomes by increasing access to healthcare, collaboration, timely care, and reduced costs. According to Jong et al. (2019), in a study conducted in northern Canada, telehealth significantly enhanced care availability for many people in the area. In the survey conducted in Newfoundland and Labrador, Canada, it was found that physician users of telemedicine consistently reported that telehealth resulted in improved patient care, reduced transfers, and collaboration and support for the patients and remote health providers (Jong et al., 2019). Furthermore, the authors explained that the cost of providing health care in northern Canada is higher than the rest of Canada, and telehealth can reduce health care expenditures.

Telehealth may be particularly well-suited to patients who have difficulty accessing timely, convenient care (Polinski et al., 2016). A study conducted by Polinski et al. (2016) compared face-to-face visits and telehealth visits in eleven clinics in Texas and California to measure patient satisfaction. With 1,734 telehealth patients surveyed, 32% expressed a preference for receiving care via telehealth. An additional 57% rated a telehealth visit as just as good as a traditional visit, while only 1% of patients rated the telehealth visit as worse than a traditional visit (Polinski et al., 2016). Furthermore, over half of the patients expressed shorter to no wait time as their primary motivation for using telehealth, 95% of all patients were very satisfied, 98% rated the assisting nurse as highly capable, and 94% were very satisfied with the treatment plan and educational materials they received (Polinski et al., 2016).

A study conducted by Dean et al. (2019) between September 2014 and November 2017 for 80 patients seen in 19 remote telehealth centers, 23 as new referrals, and 57 in follow-up consultation. This study showed that almost all 98% of patients who used telehealth indicated high overall satisfaction with their experience. Additionally, the providers' satisfaction was similarly high in terms of both the technology user interface and clinical effectiveness. The authors also noted that overall pediatric surgical consultation wait times were unaffected and that implementation of telehealth technology in a pediatric surgical practice offered high value to patients/families and, from the provider's perspective, yielded an acceptable alternative to in-person assessment (Dean et al., 2019).

Powell et al. (2018) conducted a study describing implementing a scheduled synchronous video visit program over 18 months. The authors used 3,018 scheduled and completed video visits across multiple clinical departments. The authors provided that 91.6% reported satisfaction with the planned visits among survey respondents, and 82.7% reported perceived quality similar to an in-person visit. According to the research, 86.0% responded that the scheduled video visit made it easier to access healthcare. The study concluded that an extensive urban multihospital health system that implemented an enterprise-wide scheduled telehealth video visit program across various clinical specialties provided a positive patient experience and expanded access to care (Powell et al., 2018). Lastly, the authors mentioned that the use of scheduled video visits made it easier to get the care and that the majority perceived time-saved, suggesting that the use of telehealth for scheduled visits can potentially improve access to care across a range of clinical scenarios with favorable patient experiences (Powell et al., 2018).

During COVID-19 Pandemic

The study conducted by O’Donovan et al. (2020) about the delivery of hemophilia comprehensive care during the pandemic described an increase in the implementation of digital care pathways by 52% since 2019, which was attributed to the heightened restrictions due to COVID-19. However, the authors noted high satisfaction and patient engagement with a 60% reduction in non-attendance. On the research, they also stated that patients who had participated in medical/nursing teleconsultations displayed an improvement in access by 79%, reduced inconvenience by 82%, ease of use at 94%, and facilitation of good communication with the HCP at 97% (O’Donovan et al., 2020). In closing, O’Donovan et al. (2020) expressed that telehealth has enabled continued access to specialized hemophilia comprehensive care with the COVID-19 pandemic as an unprecedented public health emergency.

Garvin et al. (2021) presented a study following veterans issued telehealth tablets for video visits. The study found out that about 45.9% of Veterans experiencing homelessness who received a tablet had a video visit within six months of receipt, most frequently for telemental health. The authors have solidified that telehealth provides a connection for vulnerable populations to avail themselves of medical care, particularly during the COVID-19 pandemic and beyond (Garvin et al., 2021). They mentioned that the VA’s distribution of video telehealth tablets offers healthcare access to Veterans experiencing homelessness; however, barriers remain for subpopulations. The study recommended tailored training and support for these patients to optimize telehealth tablet use and effectiveness.

According to Layfield et al. (2020), telemedicine is an increasingly important option for ambulatory patient care during COVID‐19 with implications for medical practice beyond the end of the pandemic. The authors defined telemedicine as an effective means to conduct a variety of outpatient encounter types of care with high patient satisfaction, including new patient, return, postoperative, and oncologic follow‐up visits in a head and neck otolaryngology practice (Layfield et al., 2020). They stated that patients reported high satisfaction with interaction quality, indicating that the telemedicine visit was effective for provider‐patient interactions.

In the study conducted by Jhaveri et al. (2020) about the conversion to telehealth of cancer survivorship program during COVID-19, they highlighted that the participation surged as the program became instantly accessible to more survivors. Furthermore, they identified that the average attendance to the mandatory monthly orientation tripled when it moved online, with the highest recorded orientation attendance in May 2020 over the 2.5-year history of the program (Jhaveri et al., 2020). There were fundamental aspects that the research elaborated on; it was mentioned that telehealth removed previously cited barriers of distance and dependent care scheduling conflicts. The increase in attendance also coincided with patient reports regarding a greater need for behavioral health and social support services in the context of COVID-19, and high satisfaction ratings were sustained across the transition to telehealth (Jhaveri et al., 2020).

Telehealth and telemedicine positively impact the issues of access to care and patient satisfaction, which is well highlighted during the pandemic to keep people safe in the corners of their home while getting the care they need, and all the authors of the included articles emphasized this idea. Virtual care can become an efficient way to provide remote access to quality healthcare services.

CHAPTER 5. CONCLUSIONS AND RECOMMENDATION

Introduction

This chapter provides the implications for the research hypothesis: Telehealth or Telemedicine has improved access to care and increased patient satisfaction in various health care services before, during, and maybe after COVID 19 Pandemic.

The systematic review consisted of 50 articles that acknowledged a number of evidence that telehealth and telemedicine contributed to the expansion of access to healthcare in various locations and health services. Additionally, telehealth and telemedicine elevated patients' satisfaction in many aspects of healthcare. In rural health areas, telehealth can assist healthcare systems, organizations, and providers expand access to and improving healthcare quality. The use of telehealth in rural areas as a healthcare delivery avenue can reduce or minimize challenges and burdens patients encounter, such as transportation issues related to travel for specialty care (Fortney et al., 2013). Hence, telehealth can also improve monitoring, timeliness, and communications within the healthcare system.

Telehealth became a more prominent platform for providing healthcare during the COVID -19 pandemic when patients and providers sought to decrease in-person contact for routine visits. The implementation and continued expansion of telehealth services assist various healthcare organizations in delivering care during the COVID-19 global pandemic.

The study conducted by Bate et al. (2021) in Melbourne, Australia, revealed an excellent overall acceptance, satisfaction, and willingness for patients, parents, and clinicians to use telehealth in the future. The authors then added that as more and more people are exposed to telemedicine and the rapid cyclical disruption of COVID‐19 eventually plateaus, telehealth should be looked at for further mass expansion in the digital era (Bate et al., 2021).

According to Demeke et al. (2021), while the resumption of in-person health care visits is anticipated when COVID – 19 pandemic subsides, telehealth will still be a critical factor in improving access to health care, especially among populations with limited access to care and enhancing the U.S. health care system's capacity to continue in future pandemics. For example, funded health centers have played a critical role as primary care providers by providing testing, treatment, and preventive care, including vaccination. Sustaining expanded use of telehealth visits in health centers during and after the pandemic might require continuation of existing flexibilities provided under Centers for Medicare & Medicaid Services telehealth reimbursement policies and local level considerations of additional support and resources (Demeke et al., 2021).

Sundstrom et al. (2019) conducted a study about the role of telehealth in providing access to women needing contraceptives in Rural South Carolina. Telehealth paved the way for health communicators to inform rural women of their choices in contraceptive methods, implementing effective campaigns and interventions to decrease unplanned pregnancy through improved access. They found out that telehealth initiatives address barriers to contraceptive entry in rural locations. Furthermore, participants discussed the advantages of telehealth, such as reduced travel distances and saving costs such as gas and transportation to access contraceptive services. These findings provide theoretical and practical opportunities to guide telehealth interventions and health communication campaigns to increase contraceptive uptake and decrease unintended pregnancies among women living in rural areas (Sundstrom et al., 2019).

To show that telehealth improves patient satisfaction, a study conducted by Wilkinson et al. (2016) proves high patient satisfaction with telehealth use in patients with Parkinson's disease. The authors stated that telehealth showed similar results to clinical outcomes. It was found in the research that greater satisfaction for the telehealth modality was found in assessments of convenience and accessibility/distance. Although certain aspects of the neurologic examination cannot be completed remotely (e.g., pull test and muscle tone assessment), most movement disorder–related exams are conducive to an audiovisual approach using the modified version of test models (Wilkinson et al., 2016). In conclusion, researchers stated that as the need for Parkinson's disease subspecialty care increases, innovative patient-centered solutions to overcoming barriers to access, such as video telehealth, will be invaluable to patients and provide high patient satisfaction.

A study by Cho et al. (2021) stated that cardiology patients reported overall satisfaction with telehealth during the COVID-19 pandemic. The research identified factors associated with patient convenience, gender, younger age, and non-white ethnicity correlated with greater satisfaction. The authors then stated that further research into telehealth's impact on patient satisfaction, safety, and clinical outcome is needed.

Waqar-Cowles et al. (2021) identified that there are encouraging signs that telehealth may be a viable method to deliver pediatric rheumatology care in the future. The research explained that most patients and caregivers reported positive experiences across all telehealth assessment sub-scales. Furthermore, patients and families familiar with telehealthcare were more likely to consider telehealth equal or preferable to in-person visits. Acceptability may increase with greater exposure to video visits and application in more targeted cases and when pediatric rheumatology providers have more familiarity with telehealth delivery and identify more optimal use cases (Waqar-Cowles et al., 2021). Research and innovation are needed to determine how evolving telehealth technology can help providers perform virtual exams with high fidelity and safety, thereby improving pediatric rheumatology telehealth delivery.

The study conducted by Ruelos et al. (2021) about the perception of orthopedic patients regarding telehealth use stated that the majority of patients expressed that the system was easy to use (90.0%), is convenient (86.7%), and saves them time (83.3%). Additionally, nearly all (95%) patients agreed that their surgeon could answer their questions using the technology. Patient perspectives on the widespread adoption of telehealth, such as ease of use, privacy protection, and convenience, showed that these anticipated barriers might be some of the most significant advantages of telehealth (Ruelos et al., 2021).

The COVID-19 pandemic may have provided the momentum for telehealth to become a mainstay of many healthcare services as a form of care delivery in the future. However, many aspects need to be addressed so that the benefits of this technology can be maximized.

Limitations

The articles included in this study were all peer-reviewed articles published from 2008 to 2022. Credible online resources and books were not included as they posed potential coding complications and data analysis issues. For these reasons, the review may not have examined other pertinent articles. The majority of the included research was conducted in the U.S., Canada, Australia, and Great Britain. Due to this, this study may not have captured the whole picture as results from other places may not have been accounted. Although, there is the certainty that the results may not have differed significantly if more articles had been included.

Conclusion

Telehealth and telemedicine play an essential part in widening access to care and improving patient satisfaction. COVID – 19 pandemic has launched the popularity and usefulness of this technology in many facets of healthcare. Telehealth has poised not only for convenience for patients, but it has the potential to provide so many further benefits, including improving public health, relieving pressure on the healthcare workforce, and helping to reduce financial stress to many. Some of the studies identified barriers that hinder the telehealth/telemedicine system; such barriers were human factors in using the technology, training, conflicting state policies, and privacy. These barriers are worth visiting for future studies to address and perhaps draw a bigger picture of telehealth and telemedicine as valuable assets to the healthcare system.

Recommendations for Further Study

In this study, many articles focused on the patient, yet patient care does not only include patients, but also consists of the system and providers. Future studies may include looking at the other side of patient care on how telehealth affects doctors, nurses, and other healthcare providers. It is also essential to study how a unified telehealth system in the United States can be achieved. This will assist lawmakers and advocates in pressing the approval of existing policy proposals waiting for debates and discussions in the senate and congress. Some examples of proposed telehealth acts are S. 1704/H.R. 5981 (Telehealth Expansion Act 2021), H.R. 5506 (Rural Telehealth Access Task Force Act), and H.R. 4480 (Telehealth Coverage and Payment Parity Act). Along with many other proposed laws, it is crucial to public health professionals and advocates to keep awareness of the benefits of the telehealth system in the open to address any gaps in health not just for people living in remote places but for all who want to avail these kinds of services.

REFERENCES

Abiero, B., Beamer, S., Roshwalb, A., Sackett, A., Gliner, M., Marshall-Aiyelawo, K., Ellison, J., McDavid, T., Bannick, R., & Muraida, D. (2020). Military health system access to Care: Performance and perceptions. Military Medicine, usz463. https://doi.org/10.1093/milmed/usz463

Adams, L., Lester, S., Hoon, E., Haak, H. van der, Proudman, C., Hall, C., Whittle, S., Proudman, S., & Hill, C. L. (2021, July 2). Patient satisfaction and acceptability. ProQuest. https://www.proquest.com/docview/2548327404?pq-origsite=primo

Appireddy, R., Khan, S., Leaver, C., Martin, C., Jin, A., Durafourt, B. A., & Archer, S. L. (2019). Home virtual visits for outpatient follow-up stroke care: Cross-sectional study. Journal of Medical Internet Research, 21(10), e13734. https://doi.org/10.2196/13734

Ashwood, J. S., Mehrotra, A., Cowling, D., & Uscher-Pines, L. (2017). Direct-to-Consumer telehealth may increase access to care but does not decrease spending. Health Affairs, 36(3), 485–491. http://dx.doi.org/10.1377/hlthaff.2016.1130

Aziz, A., Zork, N., Aubey, J. J., Baptiste, C. D., D’Alton, M. E., Emeruwa, U. N., Fuchs, K. M., Goffman, D., Gyamfi-Bannerman, C., Haythe, J. H., LaSala, A. P., Madden, N., Miller, E. C., Miller, R. S., Monk, C., Moroz, L., Ona, S., Ring, L. E., Sheen, J.-J., Friedman, A. M. (2020). Telehealth for high-risk pregnancies in the setting of the COVID-19 pandemic. American Journal of Perinatology, 37(8), 800–808. https://doi.org/10.1055/s-0040-1712121

Bate, N. J., Xu, S. C., Pacilli, M., Roberts, L. J., Kimber, C., & Nataraja, R. M. (2021, February). Effect of the COVID‐19 induced phase of massive telehealth uptake on end-user satisfaction . ProQuest. https://www.proquest.com/docview/2493760268?pq-origsite=primo

Bhatia, R. (2021). Telehealth and COVID-19: Using technology to accelerate the curve on access and quality healthcare for citizens in India. Technology in Society, 64, 101465. https://doi.org/10.1016/j.techsoc.2020.101465

Bove, A. A., Homko, C. J., Santamore, W. P., Kashem, M., Kerper, M., & Elliott, D. J. (2013). Managing hypertension in urban underserved subjects using telemedicine—A clinical trial. American Heart Journal, 165(4), 615–621. https://doi.org/10.1016/j.ahj.2013.01.004

Bradford, N. K., Caffery, L. J., & Smith, A. C. (2015). Awareness, experiences and perceptions of telehealth in a rural Queensland community. BMC Health Services Research, 15(1), 427. https://doi.org/10.1186/s12913-015-1094-7

Brenes, G. A., Ingram, C. W., & Danhauer, S. C. (2011). Benefits and challenges of conducting psychotherapy by telephone. Professional Psychology: Research and Practice, 42(6), 543–549. https://doi.org/10.1037/a0026135

CDC. (2020, February 11). Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html

Cang, J. E., Lai, A. Y., Gupta, A., Nguyen, A. M., Berry, Carolyn A., & Shelley, D. R. (2021, June 1). Rapid transition to telehealth and the digital divide: Implications for primary care access and equity in a post-COVID era. ProQuest. https://www.proquest.com/docview/2536260714?pq-origsite=primo

Dean, P., O’Donnell, M., Zhou, L., & Skarsgard, E. D. (2019). Improving value and access to specialty medical care for families: A pediatric surgery telehealth program. Canadian Journal of Surgery. Journal Canadien De Chirurgie, 62(6), 436–441. https://doi.org/10.1503/cjs.005918

Federal Legislation (n.d.). Telehealth policies. Alliance for Connected Care. Retrieved February 10, 2022, from https://connectwithcare.org/telehealth-legislation/

Fortney, J. C., Pyne, J. M., Mouden, S. B., Mittal, D., Hudson, T. J., Schroeder, G. W., Williams, D. K., Bynum, C. A., Mattox, R., & Rost, K. M. (2013). Practice-based versus telemedicine-based collaborative Care for depression in rural federally qualified health centers: A pragmatic randomized comparative effectiveness trial. American Journal of Psychiatry, 170(4), 414–425. https://doi.org/10.1176/appi.ajp.2012.12050696

Garvin, L. A., Hu, J., Slightam, C., McInnes, D. K., & Zulman, D. M. (2021). Use of video telehealth tablets to increase access for veterans experiencing homelessness. Journal of General Internal Medicine, 36(8), 2274–2282. https://doi.org/10.1007/s11606-021-06900-8

Gilkey, M. B., Kong, W. Y., Huang, Q., Grabert, B. K., Thompson, P., & Brewer, N. T. (2021). Using telehealth to deliver primary Care to adolescents during and after the COVID-19 pandemic: National survey study of US primary care professionals. Journal of Medical Internet Research, 23(9), e31240. https://doi.org/10.2196/31240

Gonçalves, M. R., Umpierre, R. N., D’Avila, O. P., Katz, N., Mengue, S. S., Siqueira, A. C. S., Carrard, V. C., Schmitz, C. A. A., Molina-Bastos, C. G., Rados, D. V., Agostinho, M. R., Oliveira, E. B., Roman, R., Basso, J., Pfeil, J. N., Mendonça, M. V. A., Moro, R. G., Frank, T., Stürmer, P. L., & Harzheim, E. (2017). Expanding primary care access: A telehealth success story. The Annals of Family Medicine, 15(4), 383–383. https://doi.org/10.1370/afm.2086

Gordon, A. S., Adamson, W. C., & DeVries, A. R. (2017). Virtual visits for acute, nonurgent Care: A claims analysis of episode-level utilization. Journal of Medical Internet Research, 19(2), e6783. https://doi.org/10.2196/jmir.6783

Graziano, S., Boldrini, F., Righelli, D., Milo, F., Lucidi, V., Quittner, A., & Tabarini, P. (2021). Psychological interventions during COVID pandemic: Telehealth for individuals with cystic fibrosis and caregivers. Pediatric Pulmonology, 56(7), 1976–1984. https://doi.org/10.1002/ppul.25413

Hobson, E. V., Baird, W. O., Bradburn, M., Cooper, C., Mawson, S., Quinn, A., Shaw, P. J., Walsh, T., & McDermott, C. J. (2019). Using telehealth in motor neuron disease to increase access to specialist multidisciplinary Care: A UK-based pilot and feasibility study. BMJ Open, 9(10), e028525. https://doi.org/10.1136/bmjopen-2018-028525

Hong, Z., Li, N., Li, D., Li, J., Li, B., Xiong, W., Lu, L., Li, W., & Zhou, D. (2020). Telemedicine during the COVID-19 pandemic: Experiences from Western China. Journal of Medical Internet Research, 22(5), e19577. https://doi.org/10.2196/19577

Howren, A., Aviña-Zubieta, J. A., Rebić, N., Dau, H., Gastonguay, L., Shojania, K., Davidson, E., & De Vera, M. A. (2020). Virtual rheumatology appointments during the COVID-19 pandemic: An international survey of perspectives of patients with rheumatic diseases. Clinical Rheumatology, 39(11), 3191–3193. https://doi.org/10.1007/s10067-020-05338-3

Imlach, F., McKinlay, E., Middleton, L., Kennedy, J., Pledger, M., Russell, L., Churchward, M., Cumming, J., & McBride-Henry, K. (2020). Telehealth consultations in general practice during a pandemic lockdown: Survey and interviews on patient experiences and preferences. BMC Family Practice, 21(1), 269. https://doi.org/10.1186/s12875-020-01336-1

Jeste, S., Hyde, C., Distefano, C., Halladay, A., Ray, S., Porath, M., Wilson, R. B., & Thurm, A. (2020). Changes in access to educational and healthcare services for individuals with intellectual and developmental disabilities during COVID‐19 restrictions. Journal of Intellectual Disability Research, 64(11), 825–833. https://doi.org/10.1111/jir.12776

Jhaveri, K., Cohen, J. A., Barulich, M., Levin, A. O., Goyal, N., Loveday, T., Chesney, M. A., & Shumay, D. M. (2020). “Soup cans, brooms, and zoom:” rapid conversion of a cancer survivorship program to telehealth during COVID ‐19. Psycho-Oncology, 29(9), 1424–1426. https://doi.org/10.1002/pon.5473

Jeste, S., Hyde, C., Distefano, C., Halladay, A., Ray, S., Porath, M., Wilson, R. B., &

Thurm, A. (2020). Changes in access to educational and healthcare services for

individuals with intellectual and developmental disabilities during COVID‐19 restrictions. Journal of Intellectual Disability Research, 64(11), 825–833. https://doi.org/10.1111/jir.12776

Jones, M. D., Etherage, J. R., Harmon, S. C., & Okiishi, J. C. (2012). Acceptability and cost

effectiveness of military telehealth mental health screening. Psychological Services, 9(2), 132143. https://doi.org/10.1037/a0026709

Jong, M., Mendez, I., & Jong, R. (2019). Enhancing access to care in northern rural communities via telehealth. International Journal of Circumpolar Health, 78(2), 1554174. https://doi.org/10.1080/22423982.2018.1554174

Kaplan, B. (2021). Access, equity, and neutral space: Telehealth beyond the pandemic. The Annals of Family Medicine, 19(1), 75–78. https://doi.org/10.1370/afm.2633

Kellerman, A. (2017, April 27). Rethinking the United States' military health system/health affairs. https://www.healthaffairs.org/do/10.1377/hblog20170427.059833/full/

Kruse, C., Fohn, J., Wilson, N., Nunez Patlan, E., Zipp, S., & Mileski, M. (2020). Utilization barriers and medical outcomes commensurate with the use of telehealth among older adults: Systematic review. JMIR Medical Informatics, 8(8), e20359. https://doi.org/10.2196/20359

Layfield, E., Triantafillou, V., Prasad, A., Deng, J., Shanti, R. M., Newman, J. G., & Rajasekaran, K. (2020, June 1). Telemedicine for head and neck ambulatory visits during COVID-19: Evaluating usability and patient satisfaction . ProQuest. https://www.proquest.com/docview/2408452105?pq-origsite=primo

LeRouge, C., & Garfield, M. J. (2013). Crossing the telemedicine chasm: Have the U.S. barriers to widespread adoption of telemedicine been significantly reduced?. International Journal of Environmental Research and Public Health, 10(12), 6472–6484. https://doi.org/10.3390/ijerph10126472

Lieneck, C., Garvey, J., Collins, C., Graham, D., Loving, C., & Pearson, R. (2020). Rapid Telehealth Implementation during the COVID-19 global pandemic: A rapid review. Healthcare, 8(4), 517. https://doi.org/10.3390/healthcare8040517

Lin, C.-C. C., Dievler, A., Robbins, C., Sripipatana, A., Quinn, M., & Nair, S. (2018). Telehealth in health centers: Key adoption factors, barriers, and opportunities. Health Affairs, 37(12), 1967–1974. https://doi.org/10.1377/hlthaff.2018.05125

Ly, B. A., Labonté, R., Bourgeault, I. L., & Niang, M. N. (2017). The individual and contextual determinants of the use of telemedicine: A descriptive study of the perceptions of Senegal’s physicians and telemedicine projects managers. PLOS ONE, 12(7), e0181070. https://doi.org/10.1371/journal.pone.0181070

Maurice, A. P., Punnasseril, J. E. J., King, S. E., & Dodd, B. R. (2020). Improving access to bariatric surgery for rural and remote patients: Experiences from a state-wide bariatric telehealth service in Australia. Obesity Surgery, 30(11), 4401–4410. https://doi.org/10.1007/s11695-020-04804-w

Mayo Clinic. (2020, May 15). Managing your health in the age of wi-fi. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/telehealth/art-20044878

McGrail, K. M., Ahuja, M. A., & Leaver, C. A. (2017). Virtual visits and patient-centered Care: Results of a patient survey and observational study. Journal of Medical Internet Research, 19(5). https://doi.org/10.2196/jmir.7374

McMahon, K. D., & Duncan, J. (n.d.). Ironshore—telehealth care platform presents new insurance challenges. Ironshore. Retrieved August 29, 2020, from http://www.ironshore.com/blog/telehealth-care-platform-presents-new-insurance-challenges

MHS. (2020a, April 13). Military hospital dials in virtual healthcare to combat COVID-19. Military Health System. https://www.health.mil/News/Articles/2020/04/13/Military-hospital-dials-in-virtual-healthcare-to-combat-COVID-19

MHS. (2020b, May 19). DHA increases access to telehealth during COVID-19 pandemic. Military Health System. https://health.mil/News/Articles/2020/05/19/DHA-increases-access-to-telehealth-during-COVID-19-pandemic

Moffatt, J. J., & Eley, D. S. (2010). The reported benefits of telehealth for rural Australians. Australian Health Review, 34(3), 276–281.

Monaghesh, E., & Hajizadeh, A. (2020). The role of telehealth during COVID-19 outbreak: A systematic review based on current evidence. BMC Public Health, 20(1), 1193. https://doi.org/10.1186/s12889-020-09301-4

Moreno, L., Dale, S. B., Chen, A. Y., & Magee, C. A. (2009). Costs to medicare of the informatics for diabetes education and telemedicine (IDEATel) home telemedicine demonstration: Findings from an independent evaluation. Diabetes Care, 32(7), 1202–1204. https://doi.org/10.2337/dc09-0094

Nandra, K., Koenig, G., DelMastro, A., Mishler, E. A., Hollander, J. E., & Yeo, C. J. (2019). Telehealth provides a comprehensive approach to the surgical patient. The American Journal of Surgery, 218(3), 476–479. http://dx.doi.org/10.1016/j.amjsurg.2018.09.020

Nettesheim, N., Powell, D., Vasios, W., Mbuthia, J., Davis, K., Yourk, D., Waibel, K., Kral, D., McVeigh, F., & Pamplin, J. C. (2018). Telemedical support for military medicine. Military Medicine, 183(11–12), e462–e470. https://doi.org/10.1093/milmed/usy127

Nicosia, F. M., Kaul, B., Totten, A. M., Silvestrini, M. C., Williams, K., Whooley, M. A., & Sarmiento, K. F. (2021). Leveraging telehealth to improve access to Care: A qualitative evaluation of veterans’ experience with the VA TeleSleep program. BMC Health Services Research, 21(1), 77. https://doi.org/10.1186/s12913-021-06080-5

O’Connor, M., Asdornwised, U., Dempsey, M. L., Huffenberger, A., Jost, S., Flynn, D., & Norris, A. (2016). Using telehealth to reduce all-cause 30-day hospital readmissions among heart failure patients receiving skilled home health services. Applied Clinical Informatics, 07(02), 238–247. https://doi.org/10.4338/ACI-2015-11-SOA-0157

O’Donovan, M., Buckley, C., Benson, J., Roche, S., McGowan, M., Parkinson, L., Byrne, P., Rooney, G., Bergin, C., Walsh, D., Bird, R., McGroarty, F., Fogarty, H., Smyth, E., Ahmed, S., O’Donnell, J. S., Ryan, K., O’Mahony, B., Dougall, A., & O’Connell, N. M. (2020). Telehealth for delivery of haemophilia comprehensive care during the COVID‐19 pandemic. Haemophilia, 26(6), 984–990. https://doi.org/10.1111/hae.14156

Orlando, J. F., Beard, M., & Kumar, S. (2019). Systematic review of patient and caregivers’ satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients’ health. PLOS ONE, 14(8), e0221848. https://doi.org/10.1371/journal.pone.0221848

Pal, T., Hull, P. C., Koyama, T., Lammers, P., Martinez, D., McArthy, J., Schremp, E., Tezak,

A., Washburn, A., Whisenant, J. G., & Friedman, D. L. (2021). Enhancing Cancer care of rural dwellers through telehealth and engagement (ENCORE): Protocol to evaluate effectiveness of amulti-level telehealth-based intervention to improve rural cancer care delivery. BMC Cancer, 21(1), 1262. https://doi.org/10.1186/s12885-021-08949-4

Palen, T. E., Price, D., Shetterly, S., & Wallace, K. B. (2012). Comparing virtual consults to traditional consults using an electronic health record: An observational case–control study. BMC Medical Informatics and Decision Making, 12, 65. https://doi.org/10.1186/1472-6947-12-65

Paterson, C., Bacon, R., Dwyer, R., Morrison, K. S., Toohey, K., O’Dea, A., Slade, J.,

Mortazavi, R., Roberts, C., Pranavan, G., Cooney, C., Nahon, I., & Hayes, S. C.

(2020). The role of telehealth during the COVID-19 pandemic across the

interdisciplinary cancer team: Implications for practice. Seminars in Oncology

Nursing, 36(6), 151090. https://doi.org/10.1016/j.soncn.2020.151090

Perez, D. L. (2021). Expanding access to specialty care using video-telehealth: The

case for functional neurological disorder. Journal of the Academy of Consultation-Liaison Psychiatry, 62(6), 667–668. https://doi.org/10.1016/j.jaclp.2021.07.002

Polinski, J. M., Barker, T., Gagliano, N., Sussman, A., Brennan, T. A., & Shrank, W. H. (2016). Patients’ satisfaction with and preference for telehealth visits. Journal of General Internal Medicine; New York, 31(3), 269–275. http://dx.doi.org.nuls.idm.oclc.org/10.1007/s11606-015-3489-x

Price, L. E., Noulas, P., Wen, I., & Spray, A. (2019). A portal to healing: Treating military families and veterans through telehealth. Journal of Clinical Psychology, 75(2), 271–281. https://doi.org/10.1002/jclp.22720

Powell, R. E., Stone, D., & Hollander, J. E. (2018). Patient and Health System Experience With Implementation of an enterprise-wide telehealth scheduled video visit program: Mixed-methods study. JMIR Medical Informatics, 6(1), e10. https://doi.org/10.2196/medinform.8479

Ruelos, V. C. B., Puzzitiello, R. N., Menendez, M. E., Moverman, M. A., Pagani, N. R., Rogerson, A., Ryan, S. P., & Salzler, M. J. (2021). Patient perceptions of telehealth orthopedic services in the era of COVID-19 and beyond. Orthopedics (Online), 44(5), e668–e674. http://dx.doi.org/10.3928/01477447-20210817-07

Seto, E., Smith, D., Jacques, M., & Morita, P. P. (2019). Opportunities and challenges of

telehealth in remote communities: Case study of the Yukon telehealth system. JMIR Medical Informatics, 7(4), e11353. https://doi.org/10.2196/11353

Stingley, S., & Schultz, H. (2014). Helmsley Trust support for telehealth improves access to Care in rural and frontier areas. Health Affairs, 33(2), 336–341. https://doi.org/10.1377/hlthaff.2013.1278

Sundstrom, B., DeMaria, A. L., Ferrara, M., Meier, S., & Billings, D. (2019). “The closer, the better:” The role of telehealth in increasing contraceptive access among women in rural South Carolina. Maternal and Child Health Journal, 23(9), 1196–1205. http://dx.doi.org/10.1007/s10995-019-02750-3

Reisinger‐Kindle, K., Qasba, N., Cayton, C., Niakan, S., Knee, A., & Goff, S. L. (2021). Evaluation of rapid telehealth implementation for prenatal and postpartum Care visits during the COVID ‐19 pandemic in an academic clinic in Springfield, Massachusetts, United States of America. Health Science Reports, 4(4). https://doi.org/10.1002/hsr2.455

Rutherford, E., Noray, R., HEarráin, C. Ó., Quinlan, K., Hegarty, A., Ekpotu, L., Arize, C., Fabamwo, F., Alrubaiaan, A., Bhupalan, A., Alshehhi, A., Power, C., & Hill, A. D. K. (2020). Potential benefits and drawbacks of virtual clinics in general surgery: Pilot cross-sectional questionnaire study. JMIR Perioperative Medicine, 3(1), e12491. https://doi.org/10.2196/12491

Sanders, C., Rogers, A., Bowen, R., Bower, P., Hirani, S., Cartwright, M., Fitzpatrick, R., Knapp, M., Barlow, J., Hendy, J., Chrysanthaki, T., Bardsley, M., & Newman, S. P. (2012). Exploring barriers to participation and adoption of telehealth and telecare within the whole system demonstrator trial: A qualitative study. BMC Health Services Research, 12(1), 220. https://doi.org/10.1186/1472-6963-12-220

Schulder Rheuban, K., & Krupinski, E. A. (2018). Understanding telehealth access medicine. McGraw-Hill Medical. https://accessmedicine.mhmedical.com/book.aspx?bookID=2217#187794411

Scott, R., & Mars, M. (2015). Telehealth in the developing world: Current status and future prospects. Smart Homecare Technology and TeleHealth, 2015, 25. https://doi.org/10.2147/SHTT.S75184

Sharma, A., Bowman, R., Ettema, S. L., Gregory, S. R., Javadi, P., Johnson, M. D., Butcher, M. L., Mutua, E., Stack, B. C., & Crosby, D. L. (2021). Rapid telehealth implementation into an otolaryngology practice during the COVID ‐19 pandemic. Laryngoscope Investigative Otolaryngology, 6(3), 386–393. https://doi.org/10.1002/lio2.552

Steindal, S. A., Nes, A. A. G., Godskesen, T. E., Dihle, A., Lind, S., Winger, A., & Klarare, A. (2020). Patients’ experiences of telehealth in palliative home care: Scoping review. Journal of Medical Internet Research, 22(5), e16218. https://doi.org/10.2196/16218

Stout, K. A., & Martinez, K. (2011). Telehealth forging ahead: Overcoming barriers in licensure to improve access to Care for service members. International Journal of Telerehabilitation, 3(2), 23–26. https://doi.org/10.5195/IJT.2011.6081

Waqar-Cowles, L. N., Chuo, J., Weiss, P. F., Gmuca, S., LaNoue, M., & Burnham, J. M. (2021). Evaluation of pediatric rheumatology telehealth satisfaction during the COVID-19 pandemic. Pediatric Rheumatology, 19(1), 170. https://doi.org/10.1186/s12969-021-00649-4

Watts, K. A., Malone, E., Dionne‐Odom, J. N., McCammon, S., Currie, E., Hicks, J., Tucker, R. O., Wallace, E., Elk, R., & Bakitas, M. (2021). Can you hear me now?: Improving palliative care access through telehealth. Research in Nursing & Health. http://dx.doi.org/10.1002/nur.22105

Weissman, R. S., Bauer, S., & Thomas, J. J. (2020). Access to evidence‐based Care for eating disorders during the COVID ‐19 crisis. International Journal of Eating Disorders, 53(5), 639–646. https://doi.org/10.1002/eat.23279

White, J., Byles, J., & Walley, T. (2022). The qualitative experience of telehealth access and clinical encounters in Australian healthcare during COVID-19: Implications for policy. Health Research Policy and Systems, 20(1), 9. https://doi.org/10.1186/s12961-021-00812-z

Wilkinson, J. R., Spindler, M., Wood, S. M., Marcus, S. C., Weintraub, D., Morley, J. F., Stineman, M. G., & Duda, J. E. (2016). High patient satisfaction with telehealth in Parkinson disease: A randomized controlled study. Neurology: Clinical Practice, 6(3), 241–251. https://doi.org/10.1212/CPJ.0000000000000252

Young, J. D., & Badowski, M. E. (2017). Telehealth: Increasing Access to High Quality Care by Expanding the role of technology in correctional medicine. Journal of Clinical Medicine, 6(2), E20. https://doi.org/10.3390/jcm6020020

Young, L. B., Foster, L., Silander, A., & Wakefield, B. J. (2011). Home telehealth: Patient satisfaction, program functions, and challenges for the care coordinator. Journal of Gerontological Nursing, 37(11), 38–46. https://doi.org/10.3928/00989134-20110706-02

APPENDIX A. ARTICLE SELECTION PROCESS

Figure 1. Study Selection Flow Diagram

APPENDIX B. SYSTEMATIC LITERATURE REVIEW

Table 1. List of Reviewed Articles

Author, Year	Article Title	Focus of study
Jones et al., 2012	Acceptability and cost-effectiveness of military telehealth mental health screening.	Access to Care
Weissman et al., 2020	Access to evidence-based Care for eating disorders during the COVID-19 crisis	Access to Care
Jester et al., 2020	Changes in access to educational and healthcare services for individuals with intellectual and developmental disabilities during COVID‐19 restrictions	Access to Care
Jong et al., 2019	Enhancing access to care in northern rural communities via telehealth	Access to Care
Pal et al., 2021	Enhancing Cancer care of rural dwellers through telehealth and engagement (ENCORE): protocol to evaluate effectiveness of a multi-level telehealth-based intervention to improve rural cancer care delivery	Access to Care
Bate et al., 2021	Effect of the COVID‐19 induced phase of massive telehealth uptake on end‐user satisfaction	Access to care & Patient satisfaction
Reisinger-Kindle et al., 2021	Evaluation of rapid telehealth implementation for prenatal and postpartum Care visits during the COVID-19 pandemic in an academic clinic in Springfield, Massachusetts, United States of America	Access to care
Goncalves et al., 2017	Expanding Primary Care Access: A Telehealth Success Story	Access to Care
Young et al., 2011	Home Telehealth: Patient Satisfaction, Program Functions, and Challenges for the Care Coordinator	Patient satisfaction
Dean et al., 2019	Improving value and access to specialty medical care for families: a pediatric surgery telehealth program	Access to care & Patient satisfaction
Nicosia et al., 2021	Leveraging Telehealth to improve access to Care: a qualitative evaluation of Veterans’ experience with the VA TeleSleep program	Access to Care
Polinski et al., 2016	Patients’ Satisfaction with and Preference for Telehealth Visits	Access to Care
Chang et al., 2021	Rapid Transition to Telehealth and the Digital Divide: Implications for Primary Care Access and Equity in a Post-COVID Era	Access to Care
Jhaveri et al., 2020	"Soup cans, brooms, and Zoom:" Rapid conversion of a cancer survivorship program to telehealth during COVID-19	Access to care & Patient satisfaction
Imlach et al., 2020	Telehealth consultations in general practice during a pandemic lockdown: survey and interviews on patient experiences and preferences	Access to care & Patient satisfaction
O’Donovan et al., 2020	Telehealth for delivery of hemophilia comprehensive care during the COVID-19 pandemic	Access to care & Patient satisfaction
Aziz et al., 2020	Telehealth for High-Risk Pregnancies in the Setting of the COVID-19 Pandemic	Access to care
Gadenz et al., 2021	Telehealth to support referral management in a universal health system: a before-and- after study	Access to Care
Young et al., 2017	Telehealth: Increasing Access to High Quality Care by Expanding the Role of Technology in Correctional Medicine	Access to Care
Powell et. Al., 2018	Patient and Health System Experience with Implementation of an Enterprise-Wide Telehealth Scheduled Video Visit Program: Mixed-Methods Study	Access to care & Patient satisfaction
Garvin et at., 2021	Use of Video Telehealth Tablets to Increase Access for Veterans Experiencing Homelessness	Access to Care
Layfield et al., 2020	Telemedicine for head and neck ambulatory visits during COVID‐19: Evaluating usability and patient satisfaction	Patient satisfaction
White et al., 2022	The qualitative experience of telehealth access and clinical encounters in Australian healthcare during COVID-19: implications for policy	Access to Care
Hobson et al., 2019	Using telehealth in motor neuron disease to increase access to specialist multidisciplinary Care: a UK-based pilot and feasibility study	Access to Care
Gilkey et al., 2021	Using Telehealth to Deliver Primary Care to Adolescents During and After the COVID-19 Pandemic: National Survey Study of US Primary Care Professionals	Access to Care
Bradford et al., 2015	Awareness, experiences and perceptions of telehealth in a rural Queensland community	Patient satisfaction
Jeste et al., 2020	Changes in access to educational and healthcare services for individuals with intellectual and developmental disabilities during COVID‐19 restrictions	Patient satisfaction
Adams et al., 2021	Patient satisfaction and acceptability with telehealth at specialist medical outpatient clinics during the COVID-19 pandemic in Australia	Patient satisfaction
Steindal et al., 2020	Patients’ Experiences of Telehealth in Palliative Home Care: Scoping Review	Patient satisfaction
Rutherford et al., 2020	Potential Benefits and Drawbacks of Virtual Clinics in General Surgery: Pilot Cross-Sectional Questionnaire Study	Patient satisfaction
Sharma et al., 2021	Rapid telehealth implementation into an otolaryngology practice during the COVID-19 pandemic	Patient satisfaction
Paterson et al., 2020	The Role of Telehealth During the COVID-19 Pandemic Across the Interdisciplinary Cancer Team: Implications for Practice	Patient satisfaction
O’Connor et al., 2016	Using Telehealth to Reduce All-Cause 30-Day Hospital Readmissions among Heart Failure Patients Receiving Skilled Home Health Services	Patient satisfaction
Gordon et al., 2017	Virtual Visits for Acute, Nonurgent Care: A Claims Analysis of Episode-Level Utilization	Patient satisfaction
Graziano et al., 2021	Psychological interventions during COVID pandemic: Telehealth for individuals with cystic fibrosis and caregivers	Patient satisfaction
Howren et al., 2020	Virtual rheumatology appointments during the COVID-19 pandemic: an international survey of perspectives of patients with rheumatic diseases	Patient satisfaction
Young et al., 2011	Home Telehealth: Patient Satisfaction, Program Functions, and Challenges for the Care Coordinator	Patient satisfaction
Bove et al., 2013	Managing hypertension in urban underserved subjects using telemedicine—A clinical trial	Patient satisfaction
Ly et al., 2017	The individual and contextual determinants of the use of telemedicine: A descriptive study of the perceptions of Senegal’s physicians and telemedicine projects managers	Patient satisfaction
Ashwood et al., 2017	Direct-To-Consumer Telehealth May Increase Access to Care but Does Not Decrease Spending	Access to Care
Watts et al., 2021	Can you hear me now? Improving palliative care access through telehealth	Access to Care
Stingley & Schultz, 2014	Helmsley Trust Support For Telehealth Improves Access to Care in Rural And Frontier Areas	Access to care
Nandra et al., 2019	Telehealth provides a comprehensive approach to the surgical patient	Access to Care
Sundstrom et al., 2019	“The Closer, the Better:” The Role of Telehealth in Increasing Contraceptive Access Among Women in Rural South Carolina	Access to Care
Perez, 2021	Expanding Access to Specialty Care Using Video-Telehealth: The Case for Functional Neurological Disorder	Access to Care
Maurice et al., 2020	Improving Access to Bariatric Surgery for Rural and Remote Patients: Experiences from a State-Wide Bariatric Telehealth Service in Australia	Access to Care
Moffat & Eley, 2010	The reported benefits of telehealth for rural Australians	Access to Care
Brenes et al., 2011	Benefits and Challenges of Conducting Psychotherapy by Telephone	Access to Care
Bhatia, 2021	Telehealth and COVID-19: Using technology to accelerate the curve on access and quality healthcare for citizens in India	Access to care
Seto et al., 2019	Opportunities and Challenges of Telehealth in Remote Communities: Case Study of the Yukon Telehealth System	Access to Care

2

2

,

6

Chapter 4. Data Collection, Analysis, and Results

Students name

National University

COH 694B

August 6, 2023

CHAPTER 4. DATA COLLECTION, ANALYSIS, AND RESULTS

Introduction

In the present chapter, I will discuss the study data collection methods, procedures, and considerations employed during data gathering and examination. The methods and steps to identify and select the selected articles used in this study will be explained. The reviewed articles' results are also presented in this chapter.

Data Collection Procedures

The current qualitative study using a grounded theory design was done to investigate some of the factors that lead to poor access to healthcare among the American communities living in rural America. Previous research has revealed that rural communities in the United States have challenges accessing proper health care. This study, therefore, focused on unearthing the reasons for the situation and providing recommendations. The study also examined how medical technology can improve healthcare access in rural areas. The study focused on a review of published literature on the topic and related subjects.

From the onset of the study, several articles were retrieved from different databases and were subjected to further scrutiny. A total of (n=77) articles were identified and selected initially. After reading the abstracts of the articles, which include article overview, results, discussion, and conclusion, (n=53) were identified but (n=13) articles were deleted from the list of identified because they did not meet the inclusion criteria. The remaining articles ( n = 40) were grouped into three; one group talked about access to care ( n = 19); the second group was all about how access can be improved ( n =11); the third group focused on access and improvement strategies ( n = 6). Figure 1: (Appendix 1) and Table 1: (Appendix 2) show the article identification, selection map, and articles incorporated in the review.

General overviews of the article findings indicate that many obstacles, including demography, terrain, poor internet connection, lack of insurance coverage, and poor staffing of the health facilities, hinder healthcare access in rural America. The authors agreed that mobile health, telehealth, and telemedicine technology could help increase healthcare access in rural areas. The role of medical technology in delivering health care to people in rural areas presents an exclusive avenue where this system/s was used to address patient needs. Still, the focus of this study was access to care and eliminating barriers.

Data Analysis and Results

The titles, authors' names, and the date of publication of the articles reviewed in this study are provided in Appendix 2. The findings of the studies indicate that lack of access to healthcare or limited access is a huge problem that the American healthcare system has to address. For instance, a study that Rural Health Information Hub did. (2022) that American citizens are entitled to access at least basic healthcare services such as primary care, behavioral care, dental care, and public health services, among others. However, this is not possible in rural America, where it is estimated that more than 45% of the population has no or limited access to healthcare services. Similarly, authors of the articles that were reviewed in this study agree that access to healthcare in rural America is imperative for several reasons presented in Table 1 below:

No	Importance Of Healthcare Services Access	Article In-Text Citation
1.	Improving overall physical, mental, and social health status	(Rural Health Information Hub, 2022)
2.	Prevention of diseases	(NCSL, 2020)
3.	Detection, diagnosis, and treatment of illnesses	(HRSA, 2022)
4.	Improving the quality of care	(Griffiths, 2009)
5.	Avoiding preventable loss of life	(Federal Emergency Management Agency (2022)
6.	Increasing life expectancy	(Singh & Siahpush, 2013)

Data and findings from the studies that have focused on understanding the impacts of limited or no access to health care services in rural areas in Table 1 above show an urgent need to solve the health care problem. For instance, a study by Singh and Siahpush (2013) noted that life expectancy in rural America was 76.7 years, while in urban was 79.1 years.

The article's authors found that telehealth is a significant solution to increase access to healthcare in rural communities in the United States. This innovative solution enables patients to receive healthcare services without necessarily meeting with providers. Telehealth is usually done online, implying that there needs to be a stable internet service on both ends (Mayo Clinic, 2022). Mobile health clinics are in place to increase access to healthcare in rural communities in the United States (Waldrop & Gee, 2022). Mobile clinics enable healthcare professionals to provide healthcare services where the patient is. In conventional healthcare, the patient visits the healthcare facility. The delivery of quality healthcare is a collective responsibility. It requires the input of different stakeholders to make it achievable. Rural communities are challenging to reach. Therefore, organizations need to play different roles in ensuring people access services.

An organization such as Families USA accesses the most rural areas in the United States and provides them with healthcare services (Tulane University School of Public Health and Tropical Medicine, 2023). The authors agreed that solutions could be implemented once the barriers have been addressed, and locals will start experiencing the benefits of accessing quality healthcare (Rural Health Information Hub, 2023). One of the barriers addressed is poor transportation. If this is handled, there will be better roads in the rural areas, which implies that it will be easier for locals to reach healthcare facilities to be treated for different needs.

References

AAMC. (2017). Health disparities affect millions in rural U.S. communities. Retrieved from https://www.aamc.org/news/health-disparities-affect-millions-rural-us-communities

Advent Health University (2022). How to improve healthcare in rural areas. Retrieved from https://www.ahu.edu/blog/improve-healthcare-in-rural-areas

Bergum, A. & Catlin, B. (2016). What works? Strategies to improve rural health. Retrieved from https://www.countyhealthrankings.org/reports/what-works-strategies-improve-rural-health

Bowling, A. (2023). Research methods in health: Investigating health and health services. Open University Press.

CDC. (2023). About rural health. Retrieved from https://www.cdc.gov/ruralhealth/about.html

Charalambous, P. (2023). Less staff, longer delays, and fewer options: Rural America confronts a healthcare crisis. Retrieved from https://abcnews.go.com/Health/staff-longer-delays-fewer-options-rural-america-confronts/story?id=97911613

CMS. (2022). Rural health strategy. Retrieved from https://www.cms.gov/files/document/rural-strat-guide-08-may.pdf

Federal Emergency Management Agency. (2022). The rural fire problem in the United States. Retrieved from https://www.usfa.fema.gov/downloads/pdf/statistics/rural.pdf

Griffiths, F. (2009). Research Methods for Healthcare Practice. Los Angeles: SAGE.

Harvard University (2019). Poll: Financial insecurity and limited access to health care plague many rural Americans. Retrieved from https://www.hsph.harvard.edu/news/hsph-in-the-news/poll-financial-insecurity-and-limited-access-to-health-care-plague-many-rural-americans/

HRSA (2022). Rural access to healthcare services request for information. Retrieved from https://www.hrsa.gov/rural-health/rfi-rural-health-care-access

Mayo Clinic (2022). Telehealth: Technology meets healthcare. Retrieved from https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/telehealth/art-20044878#:~:text=What%20is%20telehealth%3F,technology%20you%20use%20from%20home.

NCSL (2020). Improving rural health: State policy options for increasing access to healthcare. Retrieved from https://www.ncsl.org/health/improving-rural-health

PhRMA. (2022). Addressing health disparities – Addressing barriers in health. Retrieved from https://phrma.org/equity?utm_campaign=2023-q2-equ-acc&utm_medium=pai_srh_cpc-ggl-adf&utm_source=ggl&utm_content=clk-pat-tpv_scl-geo_std-usa-all-pai_srh_cpc-ggl-adf-EquityEvergreenSearchWCDCKeyStatesMemberCo2-pra_equ-edu-inf-lrm-soc_txt-std-vrb-adf&utm_term=&gclid=Cj0KCQjw8NilBhDOARIsAHzpbLD_iy8DNZDGQv_622Qw48OgVFy79se3wPj1a–2uRnhwg7SynBEUWEaAoYaEALw_wcB

Regis College. (2023). Improving access to rural healthcare. Retrieved from https://online.regiscollege.edu/blog/rural-health-care/

Rural Health Information Hub. (2022). Health access in rural Communities. Retrieved from https://www.ruralhealthinfo.org/topics/healthcare-access

Rural Health Information Hub. (2023). Families USA. Retrieved from https://www.ruralhealthinfo.org/organizations/968

Rushton, S. & Youde, J. (2017). Routledge Handbook of global health security. Routledge.

Samuels, K., McClellan, M., Patel, K., & Darling, M. (2014). Transforming rural healthcare: High-quality, sustainable access to quality care. Retrieved from https://www.brookings.edu/articles/transforming-rural-health-care-high-quality-sustainable-access-to-specialty-care/

Singh, G. & Siahpush, M. (2013). Widening rural-urban disparities in life expectancy, U.S., 1969-2009. American Journal of Preventive Medicine, 46(2): 19-29.

Strasser, R. (2003). Rural health around the world: Challenges and solutions. Family Practice, 20(4): 457-463.

Tulane University School of Public Health and Tropical Medicine. (2023). How to improve healthcare in rural areas. Retrieved from https://publichealth.tulane.edu/blog/how-to-improve-health-care-in-rural-areas/

United Nations (2015). A New U.N. report finds most of the world's rural populations excluded from healthcare access. Retrieved from https://www.un.org/sustainabledevelopment/blog/2015/04/new-un-report-finds-bulk-of-worlds-rural-populations-excluded-from-healthcare-access/#:~:text=The%20ILO's%20findings%20%E2%80%93%20published%20in,cent%20of%20rural%20inhabitants%20are

US Government Accountability Office. (2023). Why healthcare is harder to access in rural America. Retrieved from https://www.gao.gov/blog/why-health-care-harder-access-rural-america

Waldrop, T. & Gee, E. (2022). How states can expand healthcare access in rural communities. Retrieved from https://www.americanprogress.org/article/how-states-can-expand-health-care-access-in-rural-communities/

,

10

Chapter 5. Discussion and Conclusion

Student

National University

COH 694B

August 13, 2023

CHAPTER 5. DISCUSSION AND CONCLUSION

Introduction

The current chapter provides a discussion of the study findings, which answers the study question that focused on investigating some of the factors that lead to poor access to healthcare among the American communities living in rural America. The qualitative study using a grounded theory design reviewed 40 articles that answered the question of some factors contributing to poor healthcare service access in rural America. Some of the articles also suggested some of the strategies that can be implemented to enhance healthcare services access in rural America. The study findings indicate that people living in rural America have problems accessing medical services (Bergum & Catlin, 2016). The barriers to accessing medical services identified in the study include limited healthcare facilities, insufficient medical practitioners, healthcare facilities being located far from the people, and transportation to healthcare facilities being a problem (Rushton & Youde, 2017). The findings indicate that adopting healthcare technology such as telehealth and telemedicine will help increase access to healthcare services in rural America.

Most of the study findings that were reviewed in this study have confirmed that there is an urgent need to improve medical service access among the people living in rural America. Such strategies will reduce unwarranted deaths, reduce morbidity and mortality, and improve the well-being of the people living in rural America. Findings indicate that many obstacles, including demography, terrain, poor internet connection, lack of insurance coverage, and poor staffing of the health facilities, hinder healthcare access in rural America (Rushton & Youde, 2017). The authors agreed that mobile health, telehealth, and telemedicine technology could help increase healthcare access in rural areas. The role of medical technology in delivering health care to people in the rural area presents an exclusive avenue where this system/s were used to address patient needs. Still, the focus of this study was access to care and eliminating barriers.

Findings of a study by Rural Health Information Hub. (2022) noted that American citizens are entitled to receive access to at least basic healthcare services such as primary care, behavioral care, dental care, and public health services, among others. However, this is not possible in rural America, where it is estimated that more than 45% of the population has no or limited access to healthcare services. Indeed the listed healthcare services are basic and should be accessed by all Americans (Bergum & Catlin, 2016). However, many Americans cannot access the services because of the many barriers to healthcare services that are more prevalent in rural areas. The dangers or the impacts of limited access to healthcare in America were revealed in a study by Singh and Siahpush (2013). Singh and Siahpush (2013) noted that life expectancy in rural America was 76.7 years, while in urban was 79.1 years. This evidence proves the health disparities in America, yet technology can be used to bridge the disparities.

Findings indicate that although mobile health clinics are in place to increase access to healthcare in rural communities in the United States, many parts of the country cannot be accessed, limiting the use of mobile clinics (Waldrop & Gee, 2022). Mobile clinics enable healthcare professionals to provide healthcare services where the patient is. In conventional healthcare, the patient visits the healthcare facility. However, in this case, it is the reverse. Mobile health providers are always on the move to ensure patients get the services in the comfort of their homes or places of work. Mobile clinics have been found to solve the transportation problem as a barrier to healthcare access. Evidence from studies shows that telehealth is a significant solution to increase access to healthcare in rural communities in the United States.

Telehealth and telemedicine enable patients to receive healthcare services without necessarily meeting with providers. Telehealth is usually done online, implying that there needs to be a stable internet service on both ends (Mayo Clinic, 2022). Mobile health clinics are in place to increase access to healthcare in rural communities in the United States (Waldrop & Gee, 2022). Mobile clinics enable healthcare professionals to provide healthcare services where the patient is. In conventional healthcare, the patient visits the healthcare facility. The delivery of quality healthcare is a collective responsibility (CDC, 2023). It requires the input of different stakeholders to make it achievable. Rural communities are challenging to reach. Therefore, organizations need to play different roles in ensuring people access services.

An organization such as Families USA accesses the most rural areas in the United States and provides them with healthcare services (Tulane University School of Public Health and Tropical Medicine, 2023). The authors agreed that solutions could be implemented once the barriers have been addressed, and locals will start experiencing the benefits of accessing quality healthcare (Rural Health Information Hub, 2023). One of the barriers addressed is poor transportation. If this is handled, there will be better roads in the rural areas, which implies that it will be easier for locals to reach healthcare facilities to be treated for different needs.

A study by Strasser (2003) revealed that the modern world is digitally connected and heavily relies on the Internet for communication and research, among other essential activities. Communities in rural areas do not experience the full benefits of the Internet because of poor connectivity. Poor connectivity and limited internet connection are barriers to telemedicine and telehealth use in the United States (NCSL, 2020). Healthcare professionals in rural areas cannot utilize the benefits of telehealth without internet connectivity. In this way, the federal and state government should improve internet connectivity in rural areas to ensure that telemedicine and telehealth are utilized optimally to increase healthcare services access in rural areas. It is a service that requires stable and fast internet connectivity. However, most rural areas in the United States are not lucky enough to access high-speed Internet (CDC, 2023). This implies that the services they receive are limited. Accessing even the most basic of services without the Internet is difficult in the modern world. Healthcare facilities also need an internet connection to interact with other stakeholders. The lack of Internet makes this communication difficult and significantly limits the services that can be offered in the facility.

Limitations

The current study's limitations are that only articles published on the subject from 2003 to date were used to synthesize the findings. The study did not incorporate literature and research findings from books which may have provided a more professional and credible assessment of the current healthcare situation in rural areas. Similarly, the review did not include data from reliable state and federal government agencies to test the legitimacy of the findings from different publications reviewed herein. Again, the study used some articles not published in America, which may have provided or induced a different perspective on the American system; hence the actual pictures of the state of healthcare services access in America may have been compromised.

Conclusion

Healthcare is one of the basic human needs for people's health. Regardless of the situation, healthcare is a fundamental need that must be met. Despite the sensitivity of healthcare, millions of people across the globe still have challenges when it comes to accessing healthcare. Rural communities are among the most affected by the lack of proper access to healthcare. Findings indicate that American citizens are entitled to receive access to at least basic healthcare services such as primary care, behavioral care, dental care, and public health services, among others. However, this is not possible in rural America, where it is estimated that more than 45% of the population has no or limited access to healthcare services. The federal government should implement telehealth, mobile clinics, and telemedicine strategies in rural areas to increase access to medical services among the people living in rural areas. Implementing medical technology health programs in rural areas will play a significant role in bridging the healthcare disparities in America, which are caused by infrastructure and structural deficiencies.

Recommendations for Further Study

The current study focused on understanding some factors impeding medical services access in rural America. Many of the studies reviewed in this study investigated a range of barriers to medical service access, which may have limited the recommendations because of the broad scope of the study. Future studies should be done to focus on sociocultural factors that hinder healthcare services access in rural America. The findings of such a study will play a significant role in addressing healthcare disparities caused by social and cultural factors other than focusing on economic factors. Similarly, many studies have been done to investigate factors that hinder healthcare access in rural areas. However, most of these studies have adopted a qualitative approach to investigate the issue. Quantitative studies should be conducted in the future to investigate factors that impede access to healthcare services in rural America today. The findings of such a study will reveal current and practical aspects so that they can be mitigated through policy advocacy.

References

AAMC. (2017). Health disparities affect millions in rural U.S. communities. Retrieved from https://www.aamc.org/news/health-disparities-affect-millions-rural-us-communities

Advent Health University (2022). How to improve healthcare in rural areas. Retrieved from https://www.ahu.edu/blog/improve-healthcare-in-rural-areas

Bergum, A. & Catlin, B. (2016). What works? Strategies to improve rural health. Retrieved from https://www.countyhealthrankings.org/reports/what-works-strategies-improve-rural-health

Bowling, A. (2023). Research methods in health: Investigating health and health services. Open University Press.

CDC. (2023). About rural health. Retrieved from https://www.cdc.gov/ruralhealth/about.html

Charalambous, P. (2023). Less staff, longer delays, and fewer options: Rural America confronts a healthcare crisis. Retrieved from https://abcnews.go.com/Health/staff-longer-delays-fewer-options-rural-america-confronts/story?id=97911613

CMS. (2022). Rural health strategy. Retrieved from https://www.cms.gov/files/document/rural-strat-guide-08-may.pdf

Federal Emergency Management Agency. (2022). The rural fire problem in the United States. Retrieved from https://www.usfa.fema.gov/downloads/pdf/statistics/rural.pdf

Griffiths, F. (2009). Research Methods for Healthcare Practice. Los Angeles: SAGE.

Harvard University (2019). Poll: Financial insecurity and limited access to health care plague many rural Americans. Retrieved from https://www.hsph.harvard.edu/news/hsph-in-the-news/poll-financial-insecurity-and-limited-access-to-health-care-plague-many-rural-americans/

HRSA (2022). Rural access to healthcare services request for information. Retrieved from https://www.hrsa.gov/rural-health/rfi-rural-health-care-access

Mayo Clinic (2022). Telehealth: Technology meets healthcare. Retrieved from https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/telehealth/art-20044878#:~:text=What%20is%20telehealth%3F,technology%20you%20use%20from%20home .

NCSL (2020). Improving rural health: State policy options for increasing access to healthcare. Retrieved from https://www.ncsl.org/health/improving-rural-health

PhRMA. (2022). Addressing health disparities – Addressing barriers in health. Retrieved from https://phrma.org/equity?utm_campaign=2023-q2-equ-acc&utm_medium=pai_srh_cpc-ggl-adf&utm_source=ggl&utm_content=clk-pat-tpv_scl-geo_std-usa-all-pai_srh_cpc-ggl-adf-EquityEvergreenSearchWCDCKeyStatesMemberCo2-pra_equ-edu-inf-lrm-soc_txt-std-vrb-adf&utm_term=&gclid=Cj0KCQjw8NilBhDOARIsAHzpbLD_iy8DNZDGQv_622Qw48OgVFy79se3wPj1a–2uRnhwg7SynBEUWEaAoYaEALw_wcB

Regis College. (2023). Improving access to rural healthcare. Retrieved from https://online.regiscollege.edu/blog/rural-health-care/

Rural Health Information Hub. (2022). Health access in rural Communities. Retrieved from https://www.ruralhealthinfo.org/topics/healthcare-access

Rural Health Information Hub. (2023). Families USA. Retrieved from https://www.ruralhealthinfo.org/organizations/968

Rushton, S. & Youde, J. (2017). Routledge Handbook of global health security. Routledge.

Samuels, K., McClellan, M., Patel, K., & Darling, M. (2014). Transforming rural healthcare: High-quality, sustainable access to quality care. Retrieved from https://www.brookings.edu/articles/transforming-rural-health-care-high-quality-sustainable-access-to-specialty-care/

Singh, G. & Siahpush, M. (2013). Widening rural-urban disparities in life expectancy, U.S., 1969-2009. American Journal of Preventive Medicine, 46(2): 19-29.

Strasser, R. (2003). Rural health around the world: Challenges and solutions. Family Practice, 20(4): 457-463.

Tulane University School of Public Health and Tropical Medicine. (2023). How to improve healthcare in rural areas. Retrieved from https://publichealth.tulane.edu/blog/how-to-improve-health-care-in-rural-areas/

United Nations (2015). A New U.N. report finds most of the world's rural populations excluded from healthcare access. Retrieved from https://www.un.org/sustainabledevelopment/blog/2015/04/new-un-report-finds-bulk-of-worlds-rural-populations-excluded-from-healthcare-access/#:~:text=The%20ILO's%20findings%20%E2%80%93%20published%20in,cent%20of%20rural%20inhabitants%20are

US Government Accountability Office. (2023). Why healthcare is harder to access in rural America. Retrieved from https://www.gao.gov/blog/why-health-care-harder-access-rural-america

Waldrop, T. & Gee, E. (2022). How states can expand healthcare access in rural communities. Retrieved from https://www.americanprogress.org/article/how-states-can-expand-health-care-access-in-rural-communities/