This is an abbreviated version of a rural healthcare equity article that originally appeared in the Healthcare's Data Innovation LinkedIn newsletter. Click here to read the full piece and be sure to subscribe for future issues.
The United States has a healthcare problem: We've lost nearly 140 healthcare systems in rural America since 2015. Rural providers are balancing on a tight rope threaded with challenging financial truths, stagnated efforts to increase engagement with rural Americans, and delivering care outside their four walls.
Jacob Gower, Technology Partners practice director, recently sat down with Jeffrey A. Thompson, Chief Research Informatics Officer at the University of Kansas Medical Center, to hear his ideas on the future of rural healthcare in America.
Jacob first met Dr. Thompson through an introduction from a shared colleague and friend from Microsoft, Easan SeIvan. They worked together to build KUMC’s Digital Research Platform, and recently presented that work at the HIMSS 2023 conference in Chicago.
Dr. Thompson is known for his work at the University of Kansas Medical Center where he is focused on facilitating clinical research and improving the institution's research informatics infrastructure. He and his teams are developing intuitive informatics tools for researchers to extract meaningful information from unstructured data by leveraging cognitive services (AI/ML).
Dr. Thompson also spends his time in statistical genomics researching ways to create holistic cancer models that integrate a range of molecular data to improve prognostic modeling and help us better understand cancer etiology.
One item of focus not mentioned above is Dr. Thompson’s efforts to improve rural healthcare in America. Until now.
Jacob: I’ll kick us off with some statistics on American rural healthcare to help set the background for our readers. Eighteen percent of the US population lives in a rural area, that’s about 60 million Americans, about twice the population of Texas. Unfortunately, we’ve also seen nearly 140 hospitals close since 2015 in rural geographies with several more in distressed situations. That’s created a situation where the average rural American is now nearly 22 miles from a hospital and one third are more than 30 miles away.
Dr. Thompson: Sobering statistics.
Jacob: The above information along with other data points have created a concern about the benefits of healthcare innovations being reserved for those in urban population centers – what are your thoughts?
Dr. Thompson: That story and perception are partly true. Large investments must be made in some cases, and that financial fact will keep those concerns somewhat true. We know rural hospitals tend to have aging equipment and generally lack the same access to individuals with specialty training on that equipment. However, I wouldn’t lose sight of the fact that the future benefits of innovation will vary widely from region to region in rural America.
Jacob: This maybe a terrible comparison but I liken rural healthcare delivery to Dollar General and Walmart. Walmart relies on scalable operations while Dollar General can be nimbler and has a model built to survive where Walmart can’t. Is the future of rural healthcare delivering “just enough” or “just right” services?
Dr. Thompson: That comparison has some grounded reality, but it would need to stretch pretty far. The reality is that there are things that we can do (and are already doing) to stand up healthcare in the right place for the right people. There’s also a lot of things we can’t do. Emergency care for example is just something not easily delivered in small amounts, rural populations have long been aware of that in the U.S., but, these hospital closures and pending closures make the problem significantly worse.
Jacob: On the patient experience front, North Carolina Public Radio conducted an interesting study in 2021 that indicated rural Americans are 1.5 times more likely to have a negative view of their current healthcare system and primary care physician. They are also more than three times more likely to believe they will die from something preventable in comparison to urban Americans.
Dr. Thompson: Wow, there are a lot of factors at play here. Here is something to consider. Healthcare outcomes and engagement are better when the level of education an individual has is higher. This relationship holds true irrespective of income level. It’s not like education is a causal driver of healthcare outcomes, but there is a relationship that exists. The only explanation for me is that education is associated with a pattern of variables, and decisions that lead to better outcomes. Therefore, understanding that pattern would help us engage rural populations better. I know the pandemic is a touchy subject; but, look at the lower vaccination rates and higher mortality rates in rural areas directly related to COVID 19. Some of these outcomes were related to misinformation and lack of engagement with the healthcare system. Although different patterns might relate to other preventable causes of death, the overall idea is the same.
Jacob: These are healthcare systems built on fee for service models and delivering those services within their own institutions. How is delivering care at the edge going to change things for all of us? More importantly, who is responsible or should be responsible for driving those positive changes?
Dr. Thompson: That last one is hard, so why not start there. We can drive a lot of technical innovation, create population and precision health solutions, but one challenge that we have with delivering care at the edge, like colon cancer screenings, is seeing and treating the whole patient. You are generating a lot of good data in targeted preventative care solutions, but by nature they are targeted – we need that data to flow back where it can do even more good. That community level edge of care data needs to make its way to primary physicians, specialists, and the facilities they use.
Connecting things is something we know how to do, but building those institutional relationships is hard work. Responsibility for driving care innovations forward in my mind rests with state and local government entities. Someone must take charge of organizing partnership efforts across hospital and care systems that span rural geographies.
Jacob: Historically healthcare innovation has come from research and academia. Is the small amount of Academic Medical Centers that physically reside in rural America a contributing problematic factor?
Dr. Thompson: I think you are looking at this wrong. One of the challenging issues in rural healthcare delivery is that we can’t look at it through the scope of the U.S. as a whole. There are rural areas that are right next to Kansas City, but, they are certainly different than the rural areas on the west side of Kansas. In terms of the lower percentage of academic medical centers in rural America, that’s a research problem generally. R1 institutions require a tremendous number of people working on research and there’s a natural relationship that occurs with urban areas simply based on volume.
Jacob: Where did your focus on rural Americans come from? What drives you?
Dr. Thompson: Where I grew up (Maine) has largely impacted the research that I do.
Jacob: Do you think one problem with rural healthcare maybe that we don’t have enough doctors with your experience coming from rural America?
Dr. Thompson: This is actually really interesting; this is a question about DEI in general. To what extent do doctor’s personal experiences and the communities they come from inform their efforts in care and research. I strongly believe that a correlation exists, there are individuals that disagree with me though. I believe that the more we encourage individuals from underrepresented communities and populations to participate in healthcare, the better equality in care delivery we will see.
People are driven to give back to the communities they grew up in and participate in, I think we need to do a better job of arming them to do that just that. One of the projects I’m involved in is called the Frontiers Clinical and Translational Science Institute, for which, I serve as the co-Informatics core co-lead. We want to develop an inclusive future workforce by bringing informatics and data science to individuals who may not have thought about them as part of their future through early education awareness. Creating more inclusivity across racial backgrounds, lower incomes, and other statuses is an important step forward.
Jacob: How do you reconcile that work, likely driving individuals outside of their rural geographies for education and careers with the need to keep talent thriving in rural America? We need more farmers, teachers, and oil workers, too? Those latter positions keep people contributing to their hometowns and communities.
Dr. Thompson: That’s a great question and it actually reflects a bit about my personal journey. This subject is something people don’t think about enough. I’m from Maine, and that state is working hard to fight brain drain. Maine’s population is aging, young people are moving away for careers and they aren’t coming back. You know, I tried to go back to Maine and teach at the college level; but it was hard because they preferred external candidates to bring knowledge into the state. However, I did leave and haven’t gone back.
There’s an interesting aspect to one group you mentioned though, farmers. Think about the level of innovation that farmers lean into every day – their equipment, seeds, and operations are cutting edge. How do you latch into that mindset of embracing the latest and greatest innovations in farming and help drive that in healthcare? It's not a lack of willingness to embrace change, it must be in some way, how change is communicated.
Jacob: Insurance is a discussion on its own, but do you think insurance is a part of that negativity and difficulty of messaging proper healthcare engagement?
Dr. Thompson: Access to medical care is one part of the utilization story, but using data to understand the specific needs of a community is another part of the story. If we get back to community-based medicine, understand the root causes of health challenges at the community level and thoughtfully addressing those granular needs, then I think that’s something communities will get behind.
Jacob: What you’re saying is different than many of the conversations I take part in, read about, and get second hand. There’s a want to be technology-first and answer how AI, population health, precision health, and even quantum computing are going to change care delivery. What you are positioning is different and focused on community-driven medicine.
Dr. Thompson: Community-driven medicine is the key that will unlock better care for rural America, but what I’m saying is that technology provides no silver bullet. That’s important to keep in mind. AI and precision medicine and all things technology have their role, but we need to begin with the end in mind. Find those community level challenges, treat people holistically and deliver on our promise of better care. We need population health – giant models have their value, but they serve us, not vice versa.
Thank you to Dr. Thompson for sharing his amazing insights on the critical issue of rural healthcare equity.
