by Dr. Kay Sackett – Senior Editor
Sackett, K. (2012). Urban, rural, frontier and technology: Defining terms and setting the stage for future columns. Online Journal of Nursing Informatics (OJNI), 16 (3), Available at http://ojni.org/issues/?p=2006
Technology has fascinated me for quite a few years. As I’ve moved between urban, rural and international locations, the cost, quality, availability of and access to technology have been variable. My latest move has stimulated my interest in exploring the impact of technology on rural and frontier areas in first the United States and, ultimately, internationally.
In the column titled, “The Frontier: Floating in the Cloud and Networking in an Internet Connected World” I set the stage with my first piece “Urban, rural, frontier and technology: defining terms and setting the stage for future columns.” I’ll begin with the United States and define the terms urban, rural, frontier, and technology. Subsequent pieces may be oriented toward the rural and frontier status of electronic health record (EHR) adoption and meaningful use, diffusion of technology innovations and healthcare providers, social networks and healthcare, and the economics and cost of providing technology. Interspersed will be pieces discussing what is happening with technology in the international, rural and frontier arena. How we are, in fact, living in a globally connected world where we can use technology to improve healthcare for everyone everywhere. There may even be a piece describing healthcare informatics conceptual models, schemata and theory development as we build and conceptualize our healthcare knowledge to share with the world.
In the United States, the definitions of rural and frontier (a subset of rural) are inextricably entwined with the definitions of urban. Three governmental agencies, the U.S. Census Bureau, The Office of Management and Budget (OMB), and the Economic Research Center (ERC) of the U.S. Department of the Agriculture have the most frequently used definitions of urban and rural although often these definitions are parsed even further by the collaborative work of the Washington, Wyoming, Alaska, Montana, Idaho (WWAMI) Rural Health Research Center at the Washington School of Medicine and the ERC. As a nation our demographics are constantly changing. We’re a mobile society urban and rural counties expand and contract, we reside in geographically diverse areas, yet are connected, for the most part with instantaneous communication. Federal, state and local policymakers as well as researchers require redefinition and refinement of the terms rural and urban to prevent disparities related to constant population changes. Continued application of the refined terms urban and rural have the potential to better serve the needs of urban and rural populations.
In order to understand the context of rural and frontier, the terms or phrases related to urban must first be defined. According to the U.S. Census Bureau, two types of urban areas have been identified, urbanized areas and urban clusters. Urbanized areas are comprised of large densely populated land seen from the air that may or not be classified as cities. A total of 50,000 or more residents must form the urban nucleus that includes a core population density of 1,000 persons per square mile. An additional adjoining area with 500 persons per square mile may also be included in the urbanized area. In 2000, 68% of the U.S. population lived in urbanized areas. Urban clusters, sometimes also called the urban fringe, are defined as populated areas with at least 2,500 but less than 50,000 residents. The 2000 U.S. Census data identified 11% of the U.S. population lived in urban clusters. The Office of Management and Budget (OMB) uses the term metropolitan to describe combined urban areas and urban clusters of counties with political jurisdiction related to taxation, eligibility for federal and state dollars, and demographic and statistical information. The 2010 Urban and Urban Area Census data identified urbanized areas with a population of 219,922,123 (71%) and urban clusters with a population of 29,331,148 (9.5%) for a total U.S. urban population of 249,253,271 (80.7%) (US Census Bureau, 2010).
The U.S. Census Bureau defines the term rural to mean open or sparsely settled land with settlements of less than 2,500 residents. According to this definition, all land outside of any urbanized areas or urban clusters are considered rural. The term non-metropolitan may also be used to describe the rural landscape. The OMB further defined the term non-metropolitan to describe two smaller subset into micropolitan areas with urban clusters of 10,000 residents. This includes noncore counties with political jurisdiction related to taxation, eligibility for federal and state dollars, demographics and statistical information. The 2010 Rural Census data identified the rural population as 59,492,267 or 19.3% of the total U.S. population ((US Census Bureau, 2010). For those who may be interested in further definitions of rural, I refer you to the June 2008 Amber Waves publication from the USDA, Economic Research Service. This publication provides insight into rural definitions with an article “Defining the ‘Rural’ in Rural America: The use of different definitions of rural by Federal agencies reflects the multidimensional qualities of rural America” (ERS, 2008).
There are multiple definitions for the term frontier and seldom are they in agreement. Frontier may be interpreted as a subjective state of mind or an objective quantitative measure. In essence, the definition of frontier means sparsely populated rural areas with a population density of six or fewer people per square mile. The frontier may be defined at the county level, by zip code or census tract and be dependent on the project being researched or funded. People who live in the frontier are isolated from urbanized areas, urban clusters and micropolitan counties. Rural-Urban Commuting Areas (RUCAs) are also used to identify very remote areas. Under the RUCA definition, types of rural and urban are defined by proximity to urban areas and the portion of the population that commute for work from place to place. For instance, a RUCA code of 10 is assigned to isolated, small rural census tracts. Here people travel great distances in miles and time to acquire goods and services; and, the availability of paved roads, and seasonal access are also issues. It is estimated there are 440 frontier counties that cover 770,00 square miles with a total population of 2.9 million people. Approximately 56% of U.S. land mass has been identified as frontier with less than 4% of our population that reside in these isolated regions (Rural Assistance Center (RAC), n. d.).
The preceding paragraphs defined the terms and phrases related to urban, rural and frontier. You might ask how all of this information relates to technology and healthcare. Providing healthcare to rural and particularly frontier areas poses some serious challenges. Isolation and long travel distances for school, purchasing groceries, accessing healthcare, as well as limited or non-existent public transportation for the elderly, low income and/or disabled populations are fraught with difficulty. Seasonal travel may be impacted by poor roads, torrential downpours, flooding, snow, ice and blizzard conditions. Vehicular travel may be impossible with air travel the only option.
Economically, frontier areas are based on resources such as mining, logging or farming. They are often impacted by economic upswings and downturns. More remote, desolate and isolated areas may also be comprised of federally-owned land with an inadequate tax base. These areas as also common places for nuclear and other waste disposal that is harmful to the population and the frontier environment. Low wages, poor education, and migration to the urbanized areas or urban clusters are also problematic (explain why?).
Over 30% of frontier counties do not have a hospital. For hospitals that may exist in the frontier there are higher costs and fewer patients who travel longer distances to access care. There are shortages of all types of healthcare providers whose salaries are poor in comparison to the urban areas. Seasonal fluctuations in population, limited volunteer health services and costly medical air evacuations strain already limited resources. Remote frontier areas have high rates of youthful substance abuse, tobacco use, hypertension, motor vehicle accidents, suicide, obesity and death from serious injuries (Rural Assistance Center, n. d.).
The question becomes then, how can we improve the lives of people who reside in frontier areas of the U.S.? A huge $31.2 billion dollars investment in technology is the answer. The Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law on February 17, 2009. As part of the larger 2009 American Recovery and Reinvestment Act, the purpose of the HITECH Act is to promote the adoption and meaningful use of health information technology to 90% of physicians and 70% for hospitals, expand the current U.S. healthcare IT infrastructure, and promote electronic data exchange by 2019 (HITECH Data Centers, 2012).
I will briefly mention a few of the loans and grant programs that may have expanded technology access to the frontier. A Distance Learning and Telemedicine Loan and Grant Program (DLT) was available. It is designed to use advanced telecommunications technologies for rural and frontier populations educational and healthcare needs. To further quantify the meaning of frontier, a new definition specific to telehealth was developed “ZIP code areas whose calculated population centers are more than 60 minutes or 60 miles along the fastest paved road trip to a short-term non- federal general hospital of 75 beds or more, and are not part of a large rural town with a concentration of over 20,000 population.” The Economic Research Service summarized the definition changes in New Definitions 2003 (ERS, 2003).
The Recovery Act Broadband Initiatives Program (BIP) was implemented to rapidly expand the access and quality of broadband services throughout rural America.
By September 30, 2010 there were 320 awards obligated that total $3.529 billion. The total awards were 285 last-mile projects that total over $3 billion, the 12 middle-mile awards total $172.6 million, four satellite awards for $100 million, and 19 technical assistance awards for over $3.4 million. Awards were made in 45 states and one territory. The awards will provide access to 2.8 million households, 364,000 businesses, and 32,000 anchor institutions across more than 300,000 square miles. The projects also overlap with 31 tribal lands and 125 persistent poverty counties (USDA Rural Development, 2003).
The U.S. Department of Health and Human Services’ (HHS) Rural Health Information Technology (Health IT) Task Force, specifically the Office of the National Coordinator for Health Information Technology and the Health Resources and Services Administration, has been working with the U.S. Department of Agriculture (USDA) to ensure that rural health care providers can use USDA’s Rural Development grants and loans to support the acquisition of health IT infrastructure.
Frontier areas can access grants and enhanced reimbursement via shortage designations, including the Health Professional Shortage Area (HPSA) and Medically Underserved Area (MUA) designations; and, The Community Health Center program gives special consideration to sparsely populated or frontier areas. In addition, frontier communities are rural and so qualify for many rural-specific funding programs, such as the Office of Rural Health Policy’s Rural Health Care Services Outreach Grant Program and Rural Health Network Development Grant Program (RAC, n. d.)
Clearly, technology in the form of telehealth has great potential to help frontier communities become connected to the wider urban world. Access to healthcare services and specialists that would otherwise be unavailable or require travel include but are not limited to, telemedicine, telepharmacy, telehealth, telepsychiatry and telehome health.
The stage has been set for future dialogue about the healthcare frontier: a subset of rural healthcare. Urban, rural, and frontier definitions were provided. A description of challenges to providing healthcare to frontier populations was presented. And, lastly, financial resources to enhance technology use in the frontier were provided. Circling back to my introduction, I look forward to the development of further pieces about the rural and frontier status of electronic health record (EHR) adoption and meaningful use, diffusion of technology innovations and healthcare providers, social networks and healthcare, and the economics and cost of providing technology. Interspersed will be pieces discussing what is happening with technology in the international rural and frontier arena.
HITECH Data Centers. (2012). HITECH Act of 2009 FAQs. Retrieved from http://www.hitechdatacenters.com/hitech-faqs/
Morrill, R., Cromartie, J., & Hart G. (1999). Metropolitan, urban, and rural commuting areas: Toward a better depiction of the United States Settlement System. Urban Geography, 20, 727-748.
Rural Assistance Center (RAC). (n. d.). Frontier frequently asked questions. Retrieved from http://www.raconline.org/topics/frontier/frontierfaq.php
United States Census. (2010). Metropolitan and micropolitan. Retrieved from http://www.census.gov/population/metro/
US Census Bureau. (1995). Urban and rural definitions. Retrieved from http://www.census.gov/population/censusdata/urdef.txt
US Census Bureau. (2000). Census 2000 urban and rural classification. Retrieved from http://www.census.gov/geo/www/ua/ua_2k.html
US Census Bureau. (2010). 2010 census urban and rural classification and urban area criteria. Retrieved from http://www.census.gov/geo/www/ua/2010urbanruralclass.html
USDA Economic Research Service (ERS). (2003). Rural classifications. Retrieved from http://www.ers.usda.gov/briefing/rurality/NewDefinitions/
USDA Economic Research Service (ERS). (2011). Rural America at a glance. Economic Information Bulletin Number 85. Retrieved from http://www.ers.usda.gov/media/123318/eib85.pdf
USDA Economic Research Service (ERS). (2008). Defining the “rural” in rural America. Retrieved from http://webarchives.cdlib.org/sw1vh5dg3r/http://ers.usda.gov/AmberWaves/June08/Features/RuralAmerica.htm
USDA Economic Research Service (ERS). (2012). Rural classifications overview. Retrieved from http://www.ers.usda.gov/topics/rural-economy-population/rural-classifications.aspx
USDA Economic Research Service (ERS). (2012). What is rural? Retrieved from http://www.ers.usda.gov/topics/rural-economy-population/rural-classifications/what-is-rural.aspx
USDA Economic Research Service (ERS). (n. d.). Rural classifications. Retrieved from http://www.ers.usda.gov/briefing/rurality/RuralUrbCon/