key: cord-0293564-11vcmxtf
authors: DeGuzman, P. B.; Siegfried, Z. C.; Leimkuhler, M. E.
title: Evaluation of Rural Public Libraries to Address Telemedicine Inequities
date: 2020-05-29
journal: nan
DOI: 10.1101/2020.05.27.20113001
sha: e9c04fc454c208ac74161dd5f3f0e11bf6bd31b6
doc_id: 293564
cord_uid: 11vcmxtf

Introduction: In the United States, access to home-based telemedicine is inequitably distributed due to the limited reach of fixed broadband in rural areas. Public libraries typically offer patrons free access to broadband. Libraries, particularly those in rural regions, need to be evaluated as a site for patients to connect to a health care provider over a video visit. The purpose of this research was to evaluate the technological readiness of public libraries to provide telemedicine support and to determine differences in readiness between rural and urban public libraries. Methods: We distributed a survey to members of the Virginia Library Association to evaluate technological readiness of Virginia public libraries to support telemedicine use in their facilities. The survey evaluated availability and speed of fixed broadband internet access, physical equipment, and private space for each library. Results: Respondents from 39 libraries completed the survey, approximately one-third of which were in rural or small urban areas. All respondents reported fixed broadband, at least four computers, and available staff to assist who technology in their libraries. Eighty-five percent of surveyed libraries reported sufficient broadband speed and a private room available to patrons. There were no significant differences between rural and urban status for any of the library characteristics. Discussion: Public libraries in Virginia are technologically ready to support patrons connecting to health care providers over telemedicine. Systematic guidelines for library-practice collaborations are needed to support implementation across geographic and socioeconomically diverse areas.

Although telemedicine offers tremendous promise to connect rural patients with healthcare providers, access to home-based telemedicine in the United States is inequitably distributed geographically due to the limited reach of fixed broadband (1) . The gap between people who have easy access to the internet and those who do not is commonly referred to as the digital divide (2, 3) . The 2019 coronavirus disease (COVID-19) pandemic has increased the urgency behind using technology to deliver health care remotely, particularly for video visits (VVs), a synchronous communication mechanism in which provider assessment is typically conducted using a privacy-enabled videoconferencing platform (4, 5) . The COVID-19 pandemic has rapidly escalated adoption of these systems (6) , but those who live in predominantly rural areas where home-based broadband is either insufficient or unaffordable are likely far less able to connect with providers than their urban counterparts (7) .

The ability to deliver VVs to rural populations is stifled by limitations in residents' accessibility to both the hardware and sufficient broadband speed necessary to stream a videoconferencing call. Several VV platforms use privacy-enabled connections which can be accessed from a cloud-based system or a downloaded application. Smartphones can be used to connect to a VV. While their screen size is far from ideal for connecting to a provider, their use effectively broadens the reach beyond those who own a video-enabled desktop or laptop computer, or tablet (8) . At the same time, even smartphones are not ubiquitous. The Pew

Research Center estimates that while 95% of U.S. rural residents own a cellphone, only 71% own a smartphone (9). Financial and geographic barriers similarly limit the reach of internet speeds fast enough to support a video call. In the U.S. fixed broadband requires at a minimum 25 megabits per second (Mbps) download and 3 Mbps upload transmission speeds (commonly referred to as "25/3 Mbps"). To successfully conduct to a VV, a fixed terrestrial broadband signal is required; satellite speeds are often too slow, and even in the context of sufficient . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint transmission speed, the several second delay inherent in satellite transmission is highly disruptive throughout a two-way call. Cellular signals often have sufficient video streaming speed, but lengthy video transmission can be highly costly to users (10). Although the availability of fixed broadband signal is increasing, these gains significantly lag in rural areas where perhaps the most generous estimates are that nearly 25% of rural households lack access to fixed broadband (11). In those rural areas where fixed broadband is available, the cost of access is often overly prohibitive to rural residents, who typically have lower incomes (12, 13) .

In light of healthcare organizations transitioning to VV during COVID-19 (6) , it seems clear that using telemedicine to provide assessment, education, and treatment recommendations can help maintain care delivery while reducing disease exposure for both patients and providers, regardless of geographic location. However, until fixed broadband access is both geographically and financially accessible, additional solutions are needed to connect residents with health care providers via telemedicine. A systematic evaluation of public libraries as sites from which populations without broadband can connect to VV is needed. Public libraries are a safe space for vulnerable populations (14). They are not only available across the urban-rural spectrum, but also their patrons reflect an aging America. There is an intersection between the age of those with complex health needs and those who visit and utilize internet assets in public libraries (15, 16) . Libraries are typically visited by older populations seeking health-related information (15) . At the same time, older populations are more likely to have multiple chronic conditions (17) , requiring care coordination to help manage their complex health needs (16, 18) . Assisting with access to health information online is already a significant component of libraries' support of patrons, particularly those post-retirement age (12) .

As of the writing of this paper, COVID-19 precautions have closed public libraries across the U.S. (19) , likely furthering the digital divide. However, in preparation for communities . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint emerging from social distancing restrictions, public libraries need to be evaluated as places where community members can connect to care providers while minimizing disease exposure.

Assessment of public libraries' organizational readiness is an important next step in evaluation of telemedicine implementation (20) . Equipment needed for telemedicine VVs includes adequate fixed broadband equipment and speeds; access to video-enabled devices, ideally at least one with a sufficiently large screen for a participant to view a provider (such as a computer or tablet); and a physical space where a participant can speak privately to a provider. The library must also have staff available who are trained in the support of digital technology use. The technological skills needed to assist a patron with a telemedicine connection are typically minimal for a frequent user of internet technology. Similar to connecting to a VV from home, patients are provided with instructions from the provider for connecting to the intervention.

Library staff might be called upon to assist to those unfamiliar with how to use a computer devices, or assisting with troubleshooting equipment or connectivity issues.

Once COVID-19 restrictions are eased, healthcare providers need to be ready with strategies to equitably connect populations to telemedicine services, and public libraries should be explored as potential partnering sites. To date, no research has systematically evaluated public libraries' readiness to provide telemedicine services to rural residents. Thus, the purpose of this research was to evaluate the technological readiness of public libraries to provide telemedicine support. A secondary purpose was to determine if rural public libraries have similar resources to those located in urban settings.

We used a quantitative correlational design to address the study aims. We distributed a survey to public librarians and library employees across Virginia to better understand libraries' readiness to support patients using telemedicine within their facilities, as well as to understand differences between readiness of rural and urban libraries. Similar to many areas of the United States, access to broadband is limited in rural Virginia. Over one-third of rural residents lack . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint homebased access to 25/3 Mbps speed, and 12.9% have no access at all (21) . Virginia has at least one public library in every county. Figure 1 shows the geographic distribution of all public library outlets in Virginia counties against a choropleth map shaded for Census tract-level population of older residents (22) . 

Data from public libraries within Virginia were included in the analysis. Location data were used to identify locations on a map and to classify libraries' rurality using the National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme for Counties (24) . Mapping was conducted using ArcGIS Online (Esri; Redlands, CA). Survey data was analyzed descriptively, with some categories collapsed for ease of interpretation. Frequencies were calculated by . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint rurality using NCHS designation status, and chi-square tests for independence were run to determine statistical differences in responses by rurality. Level of significance was set at alpha ≤ 0.05.

We received surveys from 39 respondents across Virginia. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint

Our study suggests that in Virginia, most public libraries have technology necessary to support a VV telemedicine intervention. Rural Virginia libraries do not appear to be different than urban libraries with respect to organizational readiness. However, because individual libraries across Virginia may lack a private space or sufficient broadband speeds to support a VV, individual libraries should be assessed before VV can be pursued. In our sample, 15% of libraries lacked a private space. Lack of space may be due to a small footprint, which is more common for rural libraries; however, the data revealed no differences between rural and urban libraries with respect to private space available. This may be explained by viewing the library through an historic lens. Whereas in the past, public library spaces were designed to support civic, open discourse, the predominant modern function is to be a source of digital information; thus the spatial layout of many of today's libraries may require adaptation to support current functions is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint low costs (26) ; thus allocating or raising funds to support additional tablet purchase in a rural county may be a reasonable option.

To our knowledge, this is the first research study to evaluate organizational readiness of public libraries to support VV telemedicine interventions. Important next steps are to evaluate librarians' perspectives on anticipated barriers and work in collaboratively to develop VV standard protocols that address and overcome these barriers. Librarians already regularly assist patrons with seeking health information online (15) , and with training, are open to expanding their roles beyond their foundational training as information specialists (27) . Already librarians across the U.S. encounter stark health and social issues including homelessness and opioid overdoses (14,28). While the highly personal nature of these issues may cause librarians to report discomfort with being inadequately trained (29) , assisting patrons with connecting to a VV aligns closely with librarians' traditional roles as information specialists.

The generalizability of our results are limited due to several factors. We used a small, convenience sample of librarians and library staff from Virginia public libraries who self-selected to participate in the survey. The results, including comparison between rural and urban libraries may not be representative of all Virginia libraries or those in other states, and should be interpreted cautiously. We utilized county-level codes to distinguish rural and urban libraries, which may not appropriately reflect differences in library capabilities. The majority of library funding is typically allocated from its local community tax base (12) , and county codes do not distinguish between smaller localities that may widely vary by socioeconomic characteristics.

Future research evaluating these differences should consider including small area-level socioeconomic status as a factor to identify distinctions in local financial support.

COVID-19 has brought the social distancing benefit of video visits to the forefront of health care, at the same time as exacerbating the digital divide. As social distancing is eased across the . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint U.S., urgent solutions are needed to ensure those without broadband, most notably rural populations, have equal access to telemedicine. This research study identifies that in many communities, public libraries have the organizational readiness to support telemedicine interventions. Further research to develop systematic guidelines to evaluate and guide librarypractice collaborations to implement telemedicine across broad geographic and socioeconomic diverse areas.

The authors wish to thank Dr. Brian Real at Southern Connecticut State University for his guidance in developing this work.

The Authors declare that there is no conflict of interest . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint c Chi-square analysis for video-enabled tablets conducted only using data from those who responded . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20113001 doi: medRxiv preprint

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