VCU analysis of millions of records reveals telehealth surge, persistent barriers to access

By Christopher Richmond

While telehealth transformed from a niche service to a lifeline for millions during the pandemic, a massive new study from Virginia Commonwealth University researchers is sounding a cautionary note: The same technology that continues to bridge distances can also widen health care disparities if policy and infrastructure do not keep pace.

To understand the scale of the shift to telemedicine, the VCU research team, led by Jong Hyung Lee, Ph.D., in the School of Medicine's Department of Family Medicine and Population Health, analyzed an enormous dataset from the Virginia All-Payer Claims Database. Supported by the VCU Wright Center for Clinical and Translational Research, the team identified more than 41 million initial records, and its final analysis covered more than 21 million primary care visits - including more than 2.6 million specific telehealth encounters - across Virginia between 2016 and 2021.

The study, recently published in JMIR Formative Research, reveals a staggering transformation: a dramatic surge in telehealth at the onset of the pandemic that, unlike many other emergency measures, never fully receded. By 2021, telehealth use remained substantially higher than pre-pandemic levels.

Crucially, this wasn't just a trend for tech-savvy urban patients. Older adults and rural populations also leaned on these services to consult with providers without the burden of travel.

"Telehealth use expanded rapidly across Virginia, and it was encouraging to see rural communities making progress," Lee said. "Our spatial analysis, however, shows a more complex picture. Where someone lives - and whether they have reliable broadband - still strongly affects who can use these services."

The new analysis revealed that a lack of broadband infrastructure and other structural barriers continue to hinder rural areas. The research found a direct correlation between higher poverty levels and lower telehealth utilization, suggesting that socioeconomic barriers became even more pronounced as the pandemic progressed.

"Many rural areas continue to struggle with consistent access, making it clear that digital health equity depends on more than simply having the technology available," Lee said.

For the VCU researchers, the findings underscore that telehealth is not a one-size-fits-all solution. Factors including educational attainment, poverty and, most critically, broadband availability remain the primary predictors of whether a patient successfully connects with their doctor.

The researchers note that the timing of their study is critical. Emergency authorizations that allow Medicare to cover a broad range of telehealth services at the same rates as in-person visits, regardless of a patient's location or diagnosis, could expire Jan. 30 this year. Without reauthorization, coverage could be restricted once again to only a few specific illnesses or limited to patients living in rural areas.

"Telehealth is a critically important service that expands access for patients," said study co-author Alex Krist, M.D., a professor in the Department of Family Medicine and Population Health and a Wright Center lead. "Losing the ability to offer these services to people with Medicare would be a major setback for the day-to-day care physicians deliver."

The researchers say a multifaceted approach could help ensure that telehealth remains a viable mode of care, such as permanent coverage policies, heavy investment in broadband infrastructure and the development of more user-friendly digital platforms.

The C. Kenneth and Dianne Wright Center at VCU is part of a premier national network of institutions dedicated to accelerating the transformation of scientific discoveries into lifesaving treatments for patients. This study was funded by the National Center for Advancing Translational Sciences RC2TR005115 and UM1TR004360.