Data-Visualization-Portfolio

View Part 2

Final Project Part 1

Outline

Audience: Public health officials and community

Project Overview: Rural areas experience relatively poor health outcomes. Barriers to healthcare access and utilization contribute to these poor outcomes, and telehealth can help overcome these barriers. However, we must first establish the digital infrastructure necessary to support telehealth in rural communities. The strategies presented in this article can help you improve digital infrastructure and the feasibility of telehealth in your rural community.

Strengthening Digital Infrastructure and Telehealth Capabilities for a Healthier Rural America

1.Introduction (Pull in the audience, establish the problem, and inform the audience that you will be sharing solutions)

• Brief overview introducing the concept of health disparities in rural America
• Introduce access to care and care utilization as mechanisms as contributors to poor health outcomes
• Suggest telehealth technologies as potential tools to bridge gaps in healthcare for rural citizens
• Caution that existing digital infrastructure and digital literacy must be improved for rural populations to benefit from these advances
• Conclude with the notion that this story will help public health professionals and community advocates build an understanding of key policies/programs we should pursue in order to support the adoption of telehealth tools in rural America and address the underlying health disparities

2.Health disparities (Break down into the outcomes (i.e. motivation for taking action) and contributors (problems that need to be resolved))

• Disparities in health outcomes
  • Higher mortality, lower life expectancy, higher heart disease, unintentional injury, stroke, respiratory disease
• Barriers to healthcare access and utilization, which contribute to poor health outcomes
  • Healthcare infrastructure
    • Provider shortages
      • “Less than 8% of physicians practice in rural areas”
      • Less specialists
    • Financial problems among hospitals and other healthcare providers
      • More than 130 closures of rural hospitals since 2010
      • Lower hospital beds, physicians, and specialists per capita
    • Geographic challenges * Distance to providers (i.e. time and transportation) * Lower density of emergency medical services
    • Socio-economic and cultural
      • Lower education and health literacy
        • High rates of poor health related behaviors (smoking, drinking, stress, sleep)
        • High rates of unemployment
        • Low incomes
        • High rates of Medicaid enrollment

3.Telehealth as a solution to rural healthcare access (Show audience why they should consider telehealth as a tool for rural communities)

• Explain what telehealth is
• Why is telehealth particularly suitable for rural areas?
  • Address physician shortage by connecting patients to providers outside the immediate area
    • Access to primary care
    • Access to specialists
  • Timely care
  • Reduce transportation barriers
  • Support continuity of care by providing easier, less time consuming access to providers to facilitate consistent use
  • Economic benefits for rural areas from reduced wage losses, reductions in use of higher cost emergency services

4.Barriers to telehealth in rural areas (Briefly introduce challenges to using telehealth as a solution, and clarify that these are the areas where the audience can make an impact in order to support telehealth adoption)

• Digital divide
  • Explore national data map and then zoom in and focus on a specific state as a case study - Pennsylvania
  • Lower broadband access
  • Lower access to personal devices needed for telehealth
  • Low digital health literacy
    • Low rates of computer literacy
    • Limited health education/literacy overall
    • Difficulties navigating online resources and tools for health purposes
    • Slow rates of provider adoption
      • Limited knowledge
      • Limited clinic infrastructure
      • Limitations on reimbursement and services
        • Slow regulation development

5.Addressing the Digital Divide (Give examples of policies and programs that can help address the digital divide barriers to telehealth in rural areas caused by the digital divide and point out what more needs to be done in each of these policy areas)

• Note: Area where there is ongoing progress, and the investment has shown demonstrable improvements in things like broadband infrastructure and personal device ownership, though disparities still exist (show that these policies and programs can make a difference and should continue
• Expanding rural broadband infrastructure
  • Task force of USDA, FCC, and HHS working to expand infrastructure to support telehealth
    • Rural Digital Opportunity Fund
      • 20.4 billion over 10 years
      • Partner with service providers to build broadband infrastructure for 5.2 million locations lacking broadband (still millions more who need coverage)
      • HOWEVER, the quality of this infrastructure and internet speeds are limited and not forward looking
      • While these policies have built some base infrastructure, there are still areas that need more infrastructure
      • This infrastructure needs to be high-quality and high-speed in order to be sustainable and not simply a short term fix
    • Affordability of broadband and personal devices
      • Emergency Broadband Benefit Program for the duration of COVID-19 pandemic
        • Subsidize costs of broadband up to $50 per month for low-income households
        • One time offer for $100 in assistance purchasing computer or tablet
        • Addresses the personal device disparity and should be expanded beyond COVID as it addresses economic barriers to using digital infrastructure (if the broadband is there, but people can’t afford it, the problem is not fixed)
    • Improving digital health literacy
      • Practice is key, so this ties back to ensuring people have access to personal devices
      • Educational campaigns and programs
        • Right now, most digital education campaigns are run in rural areas, so make sure to involve rural community members in the development of the programs, so that the program addresses the unique needs of the population
          • What do they need
          • What are they unsure of or nervous about
          • What barriers have they encountered trying to use
        • Ensure new telehealth resources in the community follow guidelines for plainlanguage (see plainlanguage.gov and the cdc communication resources
        • Partner with local organizations to make digital health literacy accessible and grounded in the community (examples to include libraries and churches)

6.Increasing Rates of Provider Adoption of Telehealth Services in Rural Communities (Give examples of policies and programs that can help address the provider related barriers to telehealth in rural areas caused by the digital divide and point out what more needs to be done in each of these policy areas)

• Riding the wave of telehealth legislation in the wake of COVID-19
  • Many examples of legislation to allow more services to be provided via telehealth and establish reimbursement for telehealth
    • HIPAA flexibility
    • Telehealth waivers through CMS
      • Telehealth across state lines
      • New patients
      • Bill for many telehealth services
      • Expanded range of telehealth services covered by FQHCs and rural health clinics
      • Expand list of telehealth services covered by Medicare
      • Allow private insurers to modify benefits mid-year to expand telehealth coverage
      • Allow for initiation of and continuous prescribing of medication assisted treatment for substance use disorders
    • Many of these have not been permanently legislated and are still temporary policies during COVID, so efforts should be made to establish permanent policies for telehealth as these regulations supported the uptake of telehealth across the country
• Connecting local providers with resources to improve the uptake of telehealth
  • Distance Learning and Telemedicine Grants
    • Providing funds for health systems to acquire video conferencing equipment and software
    • Funding for more and higher quality broadband infrastructure for health systems
    • Establishing resources for telecommunication at local community hubs like schools
  • Establishing workforce training programs

7.Call to Action: As a public health official or community advocate, you can work to improve telehealth access in your rural communities (Next steps for the audience)

• Building Digital Readiness for Telehealth in Rural Communities Requires Multi-sector Effort and Long-Term Investment
  • Assess the needs of your community
    • What kind of digital infrastructure does the community have? What kind does it need?
    • What level of digital health literacy does the community have?
    • Who are the providers in the community? Are they using telehealth? Do they have the resources and knowledge to use telehealth?
  • Know the stakeholders – who do you have connections with
    • Federal, state, and local government
    • Local health care providers
    • Information technology companies
    • Churches, libraries, and other community institutions
    • Community residents
  • Understand the scope of what needs to be done to make telehealth feasible and sustainable in rural communities – think about which of these areas would benefit the community most and which areas you can feasibly impact
    • Clear and well-developed regulations to give structure to telehealth as a service
    • Funding for expanding broadband, telehealth infrastructure, and telecommunication devices
    • Cooperation with telecommunication providers
    • Educational support for digital health literacy
    • Educational support for providers adopting telehealth technologies
    • Research on effective methods for transforming typical care to telehealth (specifically in rural areas to promote useful and accessible adoption of telehealth)
    • IT workforce to maintain infrastructure
  • Identify the best strategies to address your community’s needs given your resources
    • Conduct a formal needs assessment for a more comprehensive understanding of the community’s needs and to collect baseline data to help establish goals and measure progress
    • Advocacy – advocate to policy makers at higher levels of government to support legislation that:
      • Provides funding to broadband expansion and other telehealth infrastructure
      • Make new COVID-10 related telehealth expansions permanent
      • New legislation, policies, and procedures that help standardize and structure telehealth to facilitate service provision and reimbursement
    • Apply for grants to help the community access resources that may be cost prohibitive
      • Broadband grants
      • Distance Learning and Telemedicine Grants
    • Partner with community organizations to develop programs that teach health literacy, promote healthy behaviors, and improve computer/ digital skills to improve community health literacy
  • Rural communities have unique needs, and the resource intensive nature of improving telehealth access in rural communities means every problem can’t be solved at once. Find the best place to get started for your community, and get started.

Sources:

1. Rural Health Information Hub. Rural Health Disparities. Available from: https://www.ruralhealthinfo.org/topics/rural-health-disparities.

2. Rural Health Information Hub. Specific Rural Populations that May Benefit from Telehealth. Available from: https://www.ruralhealthinfo.org/toolkits/telehealth/1/benefits-for-specific-populations.

3. Ellison, A. State-by-state breakdown of 130 rural hospital closures. 2020. Available from: https://www.beckershospitalreview.com/finance/state-by-state-breakdown-of-130-rural-hospital-closures.html.

4. One in 10 Americans Use Telehealth, But Nearly 75% Lack Awareness or Access, J.D. Power Finds, in PRNewsWire. 2019, J.D. Power. Available from: One in 10 Americans Use Telehealth, But Nearly 75% Lack Awareness or Access, J.D. Power Finds (prnewswire.com)

5. Perrin, A., Digital gap between rural and nonrural America persists. 2019. Available from Digital gap between rural and nonrural America persists Pew Research Center

6. National Rural Health Association. About Rural Health Care. Available from: https://www.ruralhealthweb.org/about-nrha/about-rural-health-care.

7. Rural Health Information Hub, Barriers to Telehealth in Rural Areas. Available from: Barriers to Telehealth in Rural Areas - RHIhub Toolkit (ruralhealthinfo.org)

8. Schadelbauer, R., Anticipating Economic Returns of Rural Telehealth. 2017. Available from Microsoft Word - Report - Final Times Roman.docx (ntca.org)

9. Rural Health Information Hub. Telehealth Use in Rural Healthcare. Available from: https://www.ruralhealthinfo.org/topics/telehealth.

10. Weigel, G., et al., Opportunities and Barriers for Telemedicine in the U.S. During the COVID-19 Emergency and Beyond, in Kaiser Family Foundation. 2020. Available from: Opportunities and Barriers for Telemedicine in the U.S. During the COVID-19 Emergency and Beyond KFF

11. HHS. Telehealth: Delivering Care Safely During COVID-19. Available from: https://www.hhs.gov/coronavirus/telehealth/index.html.

12. Cooper, T. Rural Digital Opportunity Fund (RDOF) – Map, Auction and Analysis. 2021; Available from: https://broadbandnow.com/report/rural-digital-opportunity-fund/.

13. USDA. Distance Learning & Telemedicine Grants. Available from: https://www.rd.usda.gov/programs-services/distance-learning-telemedicine-grants.

14. FCC. Emergency Broadband Benefit. Available from: https://www.fcc.gov/broadbandbenefit.

15. HHS and USDA, Rural Action Plan. 2020. Available from Department of Health and Human Services - Rural Action Plan - September 2020 (hhs.gov)

16. Jaret, P. Attracting the next generation of physicians to rural medicine. 2020; Available from: https://www.aamc.org/news-insights/attracting-next-generation-physicians-rural-medicine.

Visualizations

The first visualization shows rates of diabetes in rural and urban counties. This will help show how high rates of diabetes are in rural counties in particular as they will show the highest rates. I will use this visualization to help support my discussions about health disparities in rural areas by showing that the majority or rural counties have high rates of diabetes. I plan to also include several other health conditions of relevance such as substance use disorders, and unintentional injuries to showcase health conditions that are particularly prevalent in rural populations. As of now, I am consistently using orange to represent rural populations because it is an earthy color and purple to represent urban counties because it is a modern color. I carry this theme throughout my visualizations for consistency. These charts will serve as a visual emphasis for textual data that discusses the high average rates of these health conditions for rural areas compared to urban and suburban areas.

The second visualization shows broadband adoption in rural counties around the country. This will be a series of three maps which were hard to draw with only sketches. The first map as you see here will show broadband adoption in rural counties utilizing county averages, and while there will be many counties with somewhat low rates, there will not be that much variance. The next two maps (not pictured here due to limitations of sketching by hand) will display the same data at the census tract and census block level. Each increasingly local level of geography will reveal how much more broadband varies by community rather than just by county. In a way, the county level only maps paint a deceptively bright picture. This will help explain why this is largely geared toward public health officials and advocates looking to make a difference in a particular community because though funding is often federal or state level, the unique problems are very local.

The third visualization shows a dot plot comparing rural and urban providers and what they view as barriers to telehealth in their communities. Rural providers tend to worry more about clinic infrastructure, long-term affordability of telehealth infrastructure, patient engagement, and whether their patients will be able to access telehealth. This not only provides support to the problem of slop provider uptake, but also connects the provider uptake back to the infrastructure and literacy issues that will be discussed in the sections before. I chose to use a dot plot with percentages rather than a bar plot because the dot plot will emphasize the difference between the two dots more spatially as it lies along the axis and can be more easily compared to the difference between rural and urban among different issues. This allows the viewer to see more clearly which issues the rural and urban providers differ in opion on more so than others without the total magnitude of the percentages being as distracting as it would in a bar chart. I also maintained the use of the purple orange color scheme throughout this visualization to maintain the same color themes, so viewers are more readily able to interpret the visualization and understand which responses are associated with rural versus urban providers.

Data

Rural Health Disparities Overview - Rural Health Information Hub

I will use data from the rural health information hub to describe health disparities in rural areas. This source contains several tables that communicate disparities in key health indicators like mortality, obesity, and heart disease. Additionally, it contains summary research that describes other rural health disparities that will support the story telling aspect of this project. Should I decide to include visualizations that require health statistics not available directly on this page, there are several links to additional useful pages.

Demographics of Internet and Home Broadband Usage in the United States | Pew Research Center

This data from Pew contains longitudinal data on overall internet use, broadband availability, and smartphone reliance. I plan to use each of these characteristics to examine recent trends in digital infrastructure accessibility and use among rural, suburban, and urban populations in my visualizations. This data will help explain how limited broadband availability has played a role in the limited use of telehealth and low levels of digital literacy in rural communities.

Mapping Broadband Health in America | Federal Communications Commission (fcc.gov)

The FCC data contains county level measures of broadband and many health statistics and utilization factors. I will use this data to help map characteristics of rural counties such as patient to population ratio, the number of beds available, and the average speed of broadband available.

Indicators - Census Blocks CSV - Overview (arcgis.com)

Indicators of Need - Tract CSV - Overview (arcgis.com)

Data from the National Telecommunications and Information Administration provides better data than the FCC for exploring the availability of broadband in local communities. The county level data provided by the FCC can be deceptive when there are high levels of variation in a county. I will use this data to produce a series of maps that explore how the disparities in broadband availability among rural communities become more visible as you drill down to more localized geographic regions. Additionally, I utilize this map to spotlight Pennsylvania in a case study example exploring broadband limitations in an individual state and how these variations correspond with other characteristics like health statistics and health providers.

Rural vs. urban telehealth: a look at the stats | RingCentral

This website contains publicly accessible data from a survey on the trend of increased telehealth uptake during COVID-19 split by rural and urban groups. Much of this data focuses on the provider’s view of telehealth, and I plan to use this to support my section on provider related barriers to telehealth uptake. Specifically, I will use this to build a visualization that communicates the barriers rural providers (versus urban providers) cite to telehealth uptake and tie these in to my recommendations.

Method and Medium

I will utilize shorthand to develop my final project. Shorthand allows for visualizations to be smoothly integrated with text, such that the visualizations are immersive. I plan to start by conducing background research and improving my outline for the written content. Next, I will continue exploring my data and create first drafts of my visualizations. I will integrate the visuals into my outline so I can assess how well they support one another.

Once I have drafts of all my materials, I intend to seek feedback from my peers on the quality of the visualizations and how well they support my story. This will help me improve my current visualizations and identify any areas where additional data and visualizations could support my story. I will incorporate this feedback into my visualizations and further build out my story, so that it is fully written. Once I have incorporated all this feedback, I will integrate my second round of drafts into shorthand.

Similarly to the first round of feedback, I will seek peer feedback for my second drafts. I will focus the questions for this feedback more directly on the impact of the written text and data visualizations by asking questions like ‘How motivating do you find this section?’ and ‘How could this be more impactful?’. I will then incorporate this feedback into my final shorthand project to ensure that it is clear and impactful.