The Influence of Telehealth for Better Health Across Communities

Jane A. McElroy, PhD; Tamara M. Day, DNP; Mirna Becevic, PhD


Prev Chronic Dis. 2020;17(7):e64 

In This Article

Abstract and Introduction


Rapid spread of coronavirus disease 2019 (COVID-19) forced an abrupt shift in the traditional US health care delivery model to meet the needs of patients, staff, and communities. Through federal policy changes on telehealth, patient care shifted from in-person to telephone or video visits, and health care providers reached out to patients most at risk for exacerbation of chronic disease symptoms. ECHO (Extension for Community Healthcare Outcomes), a videoconferencing peer learning application, engaged health care providers across Missouri in the treatment and management of complex COVID-19–positive patients. Re-envisioning health care in the digital age includes robust utilization of telehealth to enhance care for all.


In December 2019, an infection caused by a bat-origin novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was detected in Wuhan, China.[1] Within less than 3 months, coronavirus disease 2019 (COVID-19), the disease caused by SARS-CoV-2, had spread across China and worldwide. The World Health Organization declared COVID-19 a pandemic on March 11, 2020.[2] As of May 30, 2020, more than 1 million infections had been laboratory-confirmed in the United States with more than 100,000 case fatalities.[3] An estimated 80% of people infected with COVID-19 during this time did not require hospitalization, and approximately 5% to 12% of hospitalized patients were admitted to intensive care units.[3] Hospitalization rates were highest among adults aged 65 years or older, people with multiple chronic conditions, and men.[3] Among younger patients (18–49 y), obesity, underlying chronic lung disease (primarily asthma), and diabetes were the most prevalent chronic disorders.[3] Because COVID-19 is a pandemic, the virus is expected to cause multiple waves of infection in future months and to persist to cause seasonal outbreaks.[2]

Patients exhibiting severe symptoms related to COVID-19 were urged to seek immediate care; however, this was challenging for people in rural areas of the United States, who make up about 20% (60 million residents) of the total population.[4] Rural populations in the United States face significant challenges in accessing health care and have poorer health outcomes than urban or suburban populations, including higher rates of chronic disease, higher death rates, and delayed diagnoses for cancers and other diseases.[5–7] These challenges are likely due to less accessible care related to lower rates of insurance; maldistribution of the health care workforce, particularly specialists; an older population; a greater proportion of patients with multiple comorbidities; and higher levels of socioeconomic need.[8]

Missouri is a predominantly rural state. More than 97% of its land area is classified as rural, and from 30% to 37% of its population currently live in rural areas.[9,10] Enriquez et al reported that at least 50% of patients in their Missouri study had one or more chronic diseases, and that "patients with multiple chronic conditions were the norm".[11] These comorbid conditions among rural Missouri residents put them most at risk of fatal complications from COVID-19, in particular those with predisposing conditions, such as diabetes, chronic pulmonary disease, and hypertension.[3] As cases of COVID-19 increased exponentially once the pandemic reached the United States, clinicians and researchers became particularly concerned about its impact on the most vulnerable rural and underserved people with chronic conditions. Our objective is to describe the multipronged approach used in Missouri to provide quick response to the COVID-19 pandemic along with preliminary trend data, including disruptive technology applications that created an environment for widespread adoption of telemedicine.

Taking advantage of the experiences of US coastal cities where the COVID-19 pandemic hit hard and fast, an incident command team was created on March 9, 2020, at a tertiary referral hospital system, University of Missouri Health Care (MU Health Care), serving a 25-county, predominantly rural, catchment area. The team was co-led by the hospital's chief nursing officer and chief medical officer because each profession brought a unique perspective. Policies were rapidly implemented that greatly reduced or suspended medical and surgical services to reserve personal protective equipment, reduced the clinical staff's COVID-19 exposure, limited the number of patients and visitors in hospital, re-deployed staff, and extensively expanded the telemedicine infrastructure.

In this commentary, we use telehealth as an umbrella term referring to telemedicine and other health-related virtual activities, such as distance continuing medical education, training, and patient portals. Telemedicine will refer to providing medical care at a distance, which includes audio–video care or audio care only.