Rural e-patients face access challenges

Golden grass and a wooden fence in Sonoma, CADavid Gorn, a reporter for California Healthline, contacted me after the release of the Pew Internet/California HealthCare Foundation’s Mobile Health 2012 report and asked if there were interesting findings on rural Americans. Indeed there are and I wish I’d thought to include them since they tell an important story about who is still cut off from online health resources.

I provided the data for Gorn’s story, “Smartphones Might Aid Health Effort in Rural California,” and now I’m sharing the data here, too, since I think there are important realities to discuss when we look at technology trends in health: rural residents lag behind suburbanites and urbanites.

So there’s no confusion, here is the exact question wording and results for each group:

Do you use the internet, at least occasionally?/Do you send or receive email, at least occasionally?/Do you access the internet on a cell phone, tablet or other mobile handheld device, at least occasionally? (We now combine all three to come up with our estimate of internet users — for more on this decision, see this short report.)

  • 81% of urban adults use the internet
  • 84% of suburban adults use the internet
  • 74% of rural adults use the internet

Note: this represents a statistically significant difference for urban/suburban vs. rural residents.

Do you have a cell phone… or a Blackberry or iPhone or other device that is also a cell phone?

  • 85% of urban adults have a cell phone
  • 86% of suburban adults have a cell phone
  • 77% of rural adults have a cell phone

Again, a statistically significant difference for urban/suburban vs. rural.

Some cell phones are called “smartphones” because of certain features they have. Is your cell phone a smartphone, such as an iPhone, Android, Blackberry or Windows phone, or are you not sure?

  • 56% of urban cell phone owners say they have a smartphone
  • 57% of suburban cell phone owners say they have a smartphone
  • 38% of rural cell phone owners say they have a smartphone

Yes, that is a statistically significant difference for urban/suburban vs. rural.

Do you ever use your cell phone to look for health or medical information online?

  • 32% of urban cell phone owners say yes
  • 32% of suburban cell phone owners say yes
  • 18% of rural cell phone owners say yes

Yep, statistically significant difference for urban/suburban vs. rural.

Do you receive any text updates or alerts about health or medical issues, such as your doctors or pharmacists?

  • 10% of urban cell phone owners
  • 10% of suburban cell phone owners
  • 11% of rural cell phone owners

Note: no statistically significant differences.

On your cell phone, do you happen to have any software applications or “apps” that help you track or manage your health, or not?

  • 12% of urban cell phone owners
  • 11% of suburban cell phone owners
  • 11% of rural cell phone owners

Note: no statistically significant differences. And there are no statistical differences among groups when it comes to the types of health apps they have on their phones.

Now, this isn’t “news” to anyone who has been following the FCC’s rural broadband initiative or Pew Internet’s previous reporting on the digital divide. But I think the data is an important reminder for anyone interested in the impact of the internet on health and health care. Imagine being a newly-diagnosed patient in a rural area, where you don’t have access to all the information and community that many of us take for granted. How would your life be different?



Posted in: policy issues | trends & principles





11 Responses to “Rural e-patients face access challenges”

  1. Susannah Fox says:

    A hazard of posting something the day before Thanksgiving is that people may be too busy to comment (but luckily not too busy to tweet). So, here’s my packaging up of a conversation I had with Christy Collins, aka @ruraldreams, on Twitter:

    Christy wrote:
    Does the survey account for economic and age differences between rural and urban populations?

    I answered:
    No, we haven’t had time to do regression analysis so this is just “plain” data. Rural residents are likely older, etc.

    Christy replied:
    Anecdotally I see economics as an issue and suspect age also, not necessarily that older people can’t use tech, but are perhaps less likely to invest in current tech that works smoothly. My observations are not related to health, just rural Internet use in general.

    My reply (here only, not on Twitter) is to quote from a 2006 Pew Internet report, “Home Broadband Adoption in Rural America”:

    “Rural Americans are, on average, older, less educated, and with lower incomes than people living in other parts of the United States – all factors associated with lower levels of online use.”

    Here’s the link in case anyone’s interested in 6-year-old broadband data:

    I’m going to talk with my colleagues after the holiday to see if we’ve done more recent analysis of the rural/urban/suburban differences. If we haven’t, we need to.

  2. Finally digging into this. You’re right about Thanksgiving, especially for anything that requires careful thinking.

    First, your first set of bullets above (81%/84%/74%) didn’t seem to match the “85% of all adults” figure that I’ve been using, so I’m SO happy to see the detail in the Lee Rainie report you linked to, Counting Internet Users.

    It still gets confusing, with all the precise variations, especially when talking to an general audience. I refer to your “tip sheet” so often that I created a friendly link for it: “-)

    The difference between the August & September numbers was unsettling; thanks to Lee for this reminder:

    “…this group is a relatively small one – with a margin of sampling error of approximately +/-7 percentage points … we need to track this question over a number of surveys before we feel comfortable drawing any firm conclusions”

    Yeah, ±7% is broad! Wouldn’t it be great if we had graphing software that would show a time series (e.g. Pew’s internet usage over time) with fading edges, sized to the margin of error or Confidence Interval, instead of hard lines?? Hard edges suggest that usage dropped, and maybe fuzzy edges would help.)

    Anyway, that’s what I love about reading Pew reports – they’re the best reminder I get re being careful about conclusions. Who else devotes so much to possible limitations of conclusions from their data?

  3. Imagine being a newly-diagnosed patient in a rural area, where you don’t have access to all the information and community that many of us take for granted. How would your life be different?

    I’ll risk a quick first response:

    1. This is the same as asking “How was a patient’s life different before the internet,” right? (Wrong?)

    2. Since e-patients so often find resistance from clinicians (“Stay off the internet”), the difference should define the gap between reality and what some clinicians think, right?

    Said differently: Online e-Patients are actually doing x, and finding resources a-b-c, which were not available pre-internet, and are not available today to the offline, and which some observers STILL think is not possible. Right?

    btw, wouldn’t it be great to have some Pew research (carefully designed, by definition) tracking industry employees’ views of e-patient activity? A record of how “stay off the internet” changes? I’d segment it by role, e.g.
    – administrators
    – health policy people
    – physicians
    – nurses
    – insurance employees

    This could shed light on rates of acceptance and encouragement of e-patient activities, which would probably influence spread of those behaviors, and bring them out of the shadows and into open dialog with clinicians.

    • Susannah Fox says:

      Thanks, Dave!

      I’m very happy to hear that you like Lee’s explanation. He’d written it for internal use and we all decided it was well worth publication for all the geeks out there who care about using our data correctly.

      In some ways, the access question is one that is falling by the wayside EXCEPT as a measure of the small number of have-nots. We will keep tracking it, but you’ll notice that we lavish more attention and time on research related to impact, engagement, etc.

      Which brings me to your excellent suggestion for a new line of questioning: changing attitudes toward the internet among health care “industry employees” (not just clinicians – a key distinction). I am shoulder-deep in data from our 2012 health survey but will put this on the docket for discussion for our NEXT health survey.

      As for your first question: Is being offline today the same as being offline 15 years ago? I’d argue no, but without a lot of concrete data to back me up. Here’s what I’ve got:

      Pew Internet has documented that some people who are currently offline were once online — they lost access when they moved, when their computer broke, when they lost their job, etc.

      We also know that there is more general awareness of the internet, even among people who are “truly offline” (have never been online, say they don’t know anyone who has access).

      I wonder if there is a “fear of missing out” among people who do not have access but who have a sense that if they did, they could research their condition, etc. I think it would be a neat typology project to explore people’s technology assets, attitudes, and actions around health. Pew Internet did that with general tech users in 2009. Here’s a quiz:

      What kind of tech user are you?

  4. Rohini Sigireddi says:

    I think that this post should look at the issues facing e-patients through a wider lens. While it is true that rural patients are facing more challenges that urban patients, we must remember that the Internet is a relatively new invention.

    Only within the last twenty or so years have we truly seen the rise of personal computers, and within the last ten years have we seen the introduction of dial-up and wireless internet, and broadband connection. Furthermore, smartphones, particularly the notable Apple iPhone have only surface in the last five years. To expect that a nation, even one as advanced and wealthy as the United States, would have such widespread access to something as targeted as online health-care applications is a bit shocking.

    However, we cannot ignore the fact that the word, “e-patient” has certainly risen in the past few years at an exponential rate. Biomedicine, a novel concept that only gained widespread popularity in the last fifty or so years when medical treatments became more safe and effective, and our collection of antibiotics and medical procedures became incredibly powerful in targeting disease. Biomedicine has since translated into a booming industry. Not only are individuals seeking medical care at alarming rates, but also we have seen the approval of national health care, and the many efforts to bring biomedicine abroad, through global health missions. The adoption of biomedicine has even spread to the relatively new technological community, a nod to the fact that patients want to apply the newest technologies to serving their health needs. Alongside their text messages and large video files, patients expect to monitor their blood sugar and blood pressure on their iPhones. This post and website illustrate the fact that biomedicine is inextricably tied to all elements of our life, and particularly to our adoption of new technologies.

  5. Peter Cabeceiras says:

    My family and I live in a rural part of Northern California. There are twelve people who live on our street, and beyond that we are surrounded by hills, grass and happy California cows. I am used to the lack of technology and wireless connections where I live. I also am not surprised by the statistics presented here. I would agree that it is more inconvenient to be an e-patient in a rural area, but I wonder if that actually has adverse consequences for the rural population’s health. The rural population’s older average age compared to the suburban and urban population average age could contribute to the deficiency in technology. Maybe the suburban and urban populations are younger and are adjusted to the current technology more than the rural population is.

    Being an e-patient is an advantage because they have the internet, which is the most abundant source of health information. It is highly unlikely that a patient will absorb and understand everything that was said in a doctor’s office. Face-to-face communication is important to many patients, but questions will always present themselves after the doctor visit is over, and it may be very difficult to get into contact with the physician again. E-patients can contact other patients, or even their physician, online through e-mail, facetime, Google+, Skype and many other ways. Rural patients are resigned to their telephone most of the time. When the number of e-patients grows in the urban and suburban areas, I would expect to see a significant health discrepancy between the rural and the urban/suburban areas because it is a well established finding that the more informed patients and more likely to manage their health conditions better.

  6. Ben Kwan says:

    I would like to expand on what E-patient Dave was pointing out, specifically in regards to e-patients and the changes in healthcare with the advent of the internet. He brings up a certainly valid point, that healthcare was certainly different before usage of the internet, but it is always important to recognize how. Firstly, I would like to mention that indeed, rural healthcare is a completely different realm than healthcare in urban areas. Urbanites are able to sufficiently get quick and varied types of healthcare within a quick drive, whereas rural residents, I would assume, would plan way in advance for an office visit, have to arrange for some sort of home-health visit plan, and probably only seek immediate medical attention in times of extreme emergency. While this may seem naïve in assumption, as an urban resident, I think about all of the random doctor’s visits I go on for something simple or just curious. I sometimes will go to the clinic for something as simple as a cough or flu, just to “get checked out.” Are rural residents hardier than the rest of us? No, they simply just utilize healthcare in a much more sparingly fashion. This difference in how healthcare is approached between rural residents and urbanites has nothing to do with the e-patient revolution. It is a matter of logistics, in terms of how these residents see their health (that is not to say that rural residents do not take their health seriously, but perhaps have a more trusting sense of their ability to take care of minor medical occurrences). The e-patient revolution has allowed for medicine to finally evolve to a level that the rest of the world follows technologically, as I would observe, in simply enabling persons at home to understand the field, better treat themselves and understand their symptoms, and possibly connect with other patients for a communal forum of related experiences. The internet and technology will surely improve the differences that rural residents face, such as possibly camera- clinical visits, that I imagine would reduce the need for office visits by rural residents to only the most urgent scenarios, should they choose to live in that manner. As a student pursuing physical therapy, I think about how such technology will enable these rural residents. In one manner, this will reduce the need for clinical visits for simple physical therapy routines, as patients will be able to perhaps watch instructional videos at home or webcam with healthcare professionals during treatment times. Will this possibly reduce costs of the medical field? I can only imagine, but it is surely a possible change that e-patients and the internet will bring to medicine.

  7. Anonymous says:

    The research definitely shows the great differences between urban/ suburban vs. rural residents. These significant differences in the use of Internet/ Smartphone in general and for health related issues seem to pose a barrier in the development of the e-patients networks. I grew up in a very little town and the contact with doctors or Medicare was extremely limited there. Another issue was that the majority of the available health care professionals were general, family doctors, and not as many specialists. It seems that living in rural areas puts constraints on people as to what information and resources they can access. It would be beneficial if the use of online resources in these areas was increased. It would help not only to develop the patients’ engagement but also greatly benefit their self-treatment resources. However, what came to my attention in this report was the fact that only app. 10% of people receive medical alerts from health professionals, and only app. 11% use phone apps for health related purposes. These numbers are relatively low, indicating there is a need for the development of better communication systems, which may combine both health applications and the communication with the doctors or pharmacists. Health Smartphone apps may be one of the best solutions for the need of personalized medical assistance, available anytime and anywhere you go. Eric Topol presents a handful of great ideas related to this matter, including the use of biosensors, which can directly detect body vitals and communicate with the phone App as well as the doctors.

  8. […] What do we know about how rural residents use online health resources? […]

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