Seventeen health care providers from 6 different clinics were included in this analysis. Primary care providers accounted for three-fourths of our sample, with 10 primary care physicians (10/17, 58.9%) and 3 advanced practice providers (3/17, 17.6%). The remaining one-fourth were cardiologists (4/17, 23.5%). Our study sample consisted of more women than men (11/17, 64.7% women vs 6/17, 35.3% men), and participants’ average age was 47 years. All participants self-identified as White, and one participant self-identified their ethnicity as Hispanic/Latino (1/17, 5.9%). Most providers practiced in Idaho (12/17, 70.6%), followed by 3 in Alaska (3/17, 17.6%) and 2 in Washington (2/17, 11.8%). Participants’ clinics varied in rurality, with more than two-thirds (11/17, 64.7%) practicing at a clinic in a nonmetro county with an urban population of fewer than 20,000. Participants’ demographic characteristics are displayed in
Demographic characteristics of rural and rural-serving health care providers who manage cardiovascular disease (N=17).
| Characteristic | Value | ||
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Cardiologist | 4 (23.5) | |
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Primary care physician | 10 (58.9) | |
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Advanced practice providera | 3 (17.6) | |
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Man | 6 (35.3) | |
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Woman | 11 (64.7) | |
| White race, n (%) | 17 (100) | ||
| Hispanic/Latino ethnicity, n (%) | 1 (5.9) | ||
| Age (years), mean (SD) | 46.8 (11.4) | ||
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Alaska | 3 (17.6) | |
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Idaho | 12 (70.6) | |
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Washington | 2 (11.8) | |
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3–Metro: Counties in metro areas <250,000 population | 4 (23.5) | |
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4–Nonmetro: Urban population ≥20,000, adjacent to a metro area | 2 (11.8) | |
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7–Nonmetro: Urban population 5000-20,000, not adjacent to a metro area | 3 (17.6) | |
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8–Nonmetro: Urban population <5000, adjacent to a metro area | 8 (47.1) | |
aAdvanced practice providers include nurse practitioners and physician assistants.
Most participants agreed that they were open to using new technology to manage their patients with CVD (15/17, 88.2%). Participants were largely neutral about the openness of their patients and clinics to use new technology, with two-thirds slightly agreeing or slightly disagreeing (11/17, 64.7%) regarding their patients’ openness and half slightly agreeing or slightly disagreeing (9/17, 52.9%) regarding their clinics’ openness to implementing new technology. No participants strongly agreed that their patients would be open to using new technology (
Rural and rural-serving health care providers’ perceptions of openness to using new technology in the management of cardiovascular disease (N=17).
All participants had experience using digital health technologies in their practice, but their use was limited and inconsistent. Most participants discussed using some form of telehealth, while fewer discussed using remote patient monitoring technology or smartphones with their patients. In interviews, participants drew on past experiences with digital health and offered thoughts about adopting digital health in the future.
Operationalized definitions of the 5 factors influencing adoption (from Diffusion of Innovations theory).
| Factor | Operationalized definition |
| Relative advantage | The degree to which digital health technologies are better (or worse) than nondigital modalities in the delivery of rural care |
| Compatibility | The degree to which digital health technologies are consistent (or inconsistent) with the values, past experiences, and needs of rural care providers |
| Complexity | The degree to which digital health technologies are perceived as difficult to understand and use |
| Trialability | The degree to which digital health technologies may be experimented with on a limited basis |
| Observability | The degree to which the results of digital health technologies are visible to others |
Subthemes related to the 5 factors that influence adoption (from Diffusion of Innovations theory), derived from semistructured interviews with rural and rural-serving health care providers who manage cardiovascular disease.
| Factor | Subthemes |
| Relative advantage |
Decreased need for patient travel Ability to leverage nonphysician health care workers Availability of objective data from remote patient monitoring Digital health equipment is not up to standard, leads to unsatisfactory care |
| Compatibility |
Increased patient compliance and follow-up Direct involvement from cardiologists or emergency providers in patient care Concerns about patient age, ability, and access Inability to perform physical examinations |
| Complexity |
Connectivity issues Concerns about fit and distribution of remote monitoring equipment Questions about billing and data management |
| Trialability |
Remote blood pressure monitoring programs Use of other remote patient monitoring technology Telehealth during the COVID-19 pandemic |
| Observability |
Observation of telehealth in cardiology and other disciplines Use of telehealth as a patient |
For this analysis, we defined relative advantage as the degree to which digital health technologies are better than nondigital modalities in the delivery of rural cardiovascular care. The identified subthemes address issues that seemed to be essential or most likely to represent direct advantages or disadvantages of using digital health technology. We found 3 subthemes related to the relative advantage of digital health in caring for patients with CVD, including the decreased need for travel, increased use of nonphysician health care workers, and availability of objective data for patient management. We also identified one relative disadvantage to using digital health: digital health is not up to standard and can lead to substandard care.
Participants felt digital health was useful for decreasing the need for patients to travel long distances for care that can be managed remotely and specifically cited the desire for a telehealth heart failure clinic. Travel and weather were concerns for participants, who felt digital health may help alleviate transportation challenges for both patients traveling to see providers and providers traveling to see patients. One participant described the difficulties of traveling to and from remote locations in Alaska during the winter:
I'd love to be able to do more of this [digital health] for people on [a remote] island because we can't get there all year long because the weather is too bad. That's another barrier. You can only go certain months because it gets just too treacherous to travel by air over there. And they don't want to travel by boat either because the water is also rough. So part of the year they just are out of care.
Participants appreciated that digital health provided opportunities to involve nonphysician health care workers in the delivery of telehealth and remote patient monitoring, as this can help ease physicians’ busy schedules and reach more patients. Some clinics already had programs in place, such as one clinic that used community health workers for a remote blood pressure monitoring program to “address the disparities” and reach people “outside the bricks and mortar of our buildings.”
Participants also appreciated that remote patient monitoring provided objective data from outside the clinic setting and specifically noted that remote blood pressure monitoring can help clinicians accurately titrate medications, as blood pressure readings are often different at home compared with clinic readings. Participants who had not used remote patient monitoring recognized its benefits and spoke favorably about using it in the future.
[Remote blood pressure monitoring] would be really helpful […] I think it, obviously, would give us a much better picture of the patient's condition if we had a reliable source of what their blood pressure is running outside of that one moment in time, just because blood pressure fluctuates so much depending on what people are doing, and stress levels, and whether or not they're taking their medicines.
Speaking specifically about experiences with telehealth, participants felt that a disadvantage of using digital health was that it can lead to unsatisfactory patient care due to issues with technology not working correctly. Participants also noted the digital health equipment was not always up to their standards and, in some cases, had regressed in quality compared with several years ago. One cardiologist shared that telehealth visits were often a hassle to conduct:
Trying to coordinate telehealth sometimes is more work than it's worth. It's a big uphill battle. Despite lining everything up, it doesn't have the same flow as your office, so a 15 or 20-minute visit oftentimes takes 45 or 50 minutes, so it's very challenging. It disrupts your patients here. It sometimes doesn't feel like it's worth the hassle. I mean, as much as you empathize for the patients and you want to provide a convenience for them, I think that our practice just is not as streamlined as we wish it was.
We defined compatibility as the degree to which digital health technologies are consistent with the values, past experiences, and needs of rural health care providers. The identified subthemes address issues that seemed valuable to participants but were distinct from the essential advantages likely to result from their use. We identified 2 subthemes highlighting the compatibility of using digital health in the delivery of rural cardiovascular care: increased patient compliance and follow-up, and the ability to involve specialist physicians and emergency providers in patients’ care.
Additionally, we identified 2 subthemes related to the incompatibility of using digital health to deliver rural cardiovascular care: provider concerns about patient age and ability to use digital health technologies, and the inability to perform physical examinations.
Participants with experience using telehealth felt that digital health technology increased patient compliance and reduced the likelihood of losing a patient to follow-up. They regularly used telehealth as a tool for following up with patients and keeping them on track with their care plan. One participant shared their perspective on the benefits of telehealth:
In chronic disease management and follow-up, telehealth visits can be very beneficial for both me checking on my patients where they’re at, catching a heart failure exacerbation before it’s hospital admission time, when a patient can’t come or would normally cancel an appointment, and we lose the follow-up.
Participants appreciated that digital health technologies provide opportunities for involvement, such as through telehealth visits, by providers who are more experienced in emergency or complex cardiovascular cases, including heart failure transplant–boarded cardiologists, electrophysiologists, and emergency providers.
So if I am sitting in [rural] Idaho in the little ED [emergency department] and I have an acute cardiac patient, we have the ability to wheel in an iPad and have a telehealth visit, either with the ED provider or the cardiologist on call to talk to the patient, really look at the patient, how sick they are and provide recs right then and there. And so that acute care is amazing.
Participants’ concerns about their patients’ older age and general ability to use technology highlight how digital health can be incompatible with the delivery of rural cardiovascular care. Some participants also shared that not all of their patients have the ability to access or use digital health tools:
The most recent generations of CGMs [continuous glucose monitors] require smartphone integration, whereas older ones have their own little magic wand you hold up to them. And there are some of our patients who need the older system, they’re just like, ‘I cannot use this cell phone integration thing.’ Is that the majority of patients? No. But sometimes they just don’t have that cell phone or they don’t have access to a plan.
The inability to perform a physical examination using digital health was incompatible with participants’ needs in providing patient care. One participant shared that she “hates” telehealth because she likes “laying my hands on a patient and basically evaluating them, listening to their heart, talking to them, checking their blood pressure, that kind of stuff.” She later noted that she likes using telehealth for ongoing patient management, such as ensuring correct dosing for blood pressure medications.
We defined complexity as the degree to which digital health technologies are perceived as difficult to understand and use. Subthemes related to the complexity of digital health technologies highlighted the difficulties and concerns participants have experienced or felt were likely to result from using digital health in their practice. They were largely concerned with difficulties at the patient and clinic levels. We identified 3 subthemes related to the complexity of digital health: connectivity issues, concerns about the fit and distribution of remote monitoring equipment, and questions about billing and data management.
Participants shared past experiences with connectivity issues related to unreliable internet and telephone access, both in the clinic and for their patients at home. They described instances in which issues with internet and technology led to substandard visits and sometimes interrupted the flow of their schedules with in-clinic patients. One cardiologist felt that fewer than half of their telehealth visits ran smoothly:
I mean, it’s probably less than 50% goes smoothly as far as a patient logs on, you have a visit, and it accomplishes the goal. Probably at least half the time when we weren’t bringing them into the office, the internet wouldn’t work. The video was such poor quality. It would disconnect and then you were calling on the phone and the next. It just took a lot more time. Ultimately at the end of the day, you didn’t accomplish what you were really hoping for. As a provider, I felt like that was a substandard visit.
Participants were concerned about the distribution of remote patient monitoring equipment and ensuring that the equipment they provided to patients fits correctly, is used correctly, and is returned by patients. One primary care physician shared that her clinic had to stop offering remote treatment of bilirubin because patients were not returning the equipment. She felt that remote patient monitoring would work best if patients were able to keep the equipment:
We do give out blood pressure cuffs, but we basically have had a difficult time I think over time having people return equipment. […] But if it was something that was given to the patient, I think that would be great.
The complexity of managing remote patient monitoring data and difficulties with billing for digital health were clinic-level concerns for participants. They were worried about the volume of remote patient monitoring data, taking responsibility for it, and entering it into the electronic health record (EHR). Participants mentioned that billing for digital health is more restrictive than for in-person visits. They also noted that restrictions on billing and providing telehealth across state lines were less restrictive during the COVID-19 pandemic but have since returned to stricter regulations. One primary care physician noted that the modern practice of medicine requires one to consider billing for remote patient monitoring:
I think probably the biggest barrier is how does that information get into the EHR. And then, when are you monitoring that? Who’s monitoring it? If somebody’s blood pressure is 240, when does that get seen and what is the advice, having time set aside to do that, is there a way to bill for it that? Which I hate to think about that, but that’s kind of the modern practice of medicine and employed practice.
We defined trialability as the degree to which digital health technologies may be experimented with on a limited basis. Subthemes related to trialability highlighted participants’ past or current experiences using digital health tools. We identified 3 subthemes related to the trialability of digital health: use of remote blood pressure monitoring programs, use of other remote patient monitoring technology (ie, continuous glucose monitors [CGMs], Zio patches, and Holter monitors), and use of telehealth during the COVID-19 pandemic.
As noted above in the relative advantage section, participants who had used remote patient monitoring in the past generally reported positive experiences. One participant described their experience using remote blood pressure monitoring to manage medication:
I’ve had a couple of patients who have pretty normal looking blood pressures when they’re in office, but then I see that they’re markedly hypertensive most of the time when they’re at home. And so I’ve actually increased meds for people more often than I’ve decreased, I think.
Participants had used several other types of remote monitoring technology in their practice, including Zio patches, CGMs, and Holter monitors. The success of using these technologies was mixed. As noted above in subtheme 2c, some participants felt their patients had difficulties using smartphone-integrated remote patient monitoring technology. Other participants, however, had success using different remote patient monitoring technologies with their patients. One primary care physician described the benefits of being able to monitor data from patients’ CGMs and felt those benefits would translate to using remote blood pressure monitoring:
[…] Continuous glucose monitors for patients change everything with diabetes. I mean, it’s so much easier when I can just log on and see exactly what is going on. I think ambulatory blood pressure monitoring would be amazing.
Participants who used telehealth during the COVID-19 pandemic had mixed feelings about its success. Many participants noted that telehealth use was higher during the pandemic and has since declined. One advanced practice provider noted, “they aren’t doing a lot of telehealth anymore for cardiac patients, so there is that delay” in delivering cardiovascular care. Some participants were very satisfied with their experiences using telehealth and wished they could conduct telehealth visits as frequently as they did during the pandemic. Others noted frequent technical difficulties (highlighted above in the incompatibility and complexity sections). One cardiologist shared that he and some of his colleagues abandoned telehealth during the pandemic due to difficulties:
During COVID, I found that trying to do telemedicine with patients in their home was not worth it. I abandoned it, most of us did.
We defined observability as the degree to which the results of digital health technologies are visible to others. Subthemes related to observability highlighted opportunities for participants to see successful digital health programs. We identified 2 subthemes related to observability: observation of telehealth in cardiology and other disciplines, and use of telehealth as a patient.
Participants who had seen heart failure telehealth clinics through cardiology groups spoke highly of such programs, and some expressed a desire to have these programs in their community to reach more patients. Participants had also seen telehealth used to deliver behavioral health care. One participant shared that primary care providers in his clinic observed the benefits of having psychiatry support for complex cases and would like more telehealth access to specialty care:
[…] I think all of our patients and our providers are starving for access to specialty care. So we actually implemented adult and pediatric psychiatry in 2009 […] which has had a huge impact on the population. At least the high needs population, like the severely mentally ill patients that were being managed by primary care like myself. So the primary care team really appreciates things on those harder problems.
In addition to observing successful telehealth in cardiology and other disciplines, participants also observed successful telehealth programs as patients. One participant, who was not happy with his experience using telehealth in his own practice, mentioned using telehealth successfully as a patient and noted that the technology he used as a patient worked very well, but he does not feel that he has provided that level of care to his rural patients.
Although that being said, as a patient, I've done telehealth through [urban healthcare facility], and my experiences were great. I don't know if it's because I was in a place and understood how to use technology, but they were able to share screens, and I thought it was very effective. […] I don't feel like I've provided the same service to our rural areas.