Video and Telephone Telehealth Use and Web-Based Patient Portal Activation Among Rural-Dwelling Patients: Retrospective Medical Record Review and Policy Implications

Background: Telehealth may redress rural health care shortages in the United States and improve related rural health disparities. However, following the expansion of telehealth related to the COVID-19 pandemic, telehealth use has been lower among rural populations compared to urban populations. Certain populations are also more likely to use audio-only telehealth, with implications for care quality. Objective: The aim of this study is to describe demographic and telehealth use characteristics of a population of rural-dwelling adult patients and explore relationships of these characteristics with patients' level of rurality and with modality of patients' most recent telehealth encounter. Methods: We conducted a retrospective medical record review of adults who lived in rural California zip codes and used telehealth at an urban medical center from December 2021 to December 2022. Rural-Urban Commuting Area codes were used to assign rurality and group patients by 3 levels of rurality. Telehealth visits were defined as video-enabled and telephone encounters. Variables included age, race or ethnicity, preferred language, payer, web-based patient portal activation status (as proxy for digital health literacy), video or telephone modality, and visit provider. Chi-square and Fisher exact tested associations of demographic and encounter characteristics with patient level of rurality and telehealth encounter modality. Results: A total of 9359 patients were included. Telehealth patients living in the most rural zip codes were older, and a higher proportion were White compared to those in less rural zip codes. Patients who were American Indian, Asian, Black, and Latino together comprised 18.8% (n=1760) of the sample, lower than that in rural California counties. Video visit use was significantly lower among patients who were 65 years of age or older (n=3183, 91.3% vs n=5507, 93.8% for younger than 65 years; χ21=19.3; P<.001), Latino race or ethnicity (n=1229, 90.9% vs n=6078, 93.4% among White patients; χ23=12.0; P=.008), primary Spanish speakers (n=336, 87.7% vs n=8305, 93% among English speakers; Fisher exact, P<.001), and publicly insured (Medicare: n=3843, 91.7%; Medicaid: n=1717, 92.2%; privately insured: n=3130, 94.7%; χ22=27.9; P<.001). Patient portal activation was lower among Latinx patients (n=1183, 87.5% vs n=6099, 93.7% among White patients), Spanish speakers (n=295, 77% vs n=8241, 92.3% among English speakers; Fisher exact: P<.001), and Medicaid patients (n=1635, 87.8%; Medicare: n=3802, 90.7%; privately insured: n=3140, 95%; χ24=106.3; P<.001). Conclusions: Findings substantiate concerns of rural telehealth access disparities, particularly among patients who are older, of minoritized race or ethnicity, and Spanish-speaking. Ongoing research is needed to understand how underserved rural populations use telehealth. To address telehealth use disparities, policy should address patient-level barriers by supporting measures such as health care navigation resources, culturally tailored telehealth patient outreach, digital access assessment, and patient digital education. Evidence-based telehealth reimbursement policy is essential to support access and address provider-side barriers.