Proceedings of a Workshop—in Brief

Convened October 14, 2025

Advancing Diagnostic Excellence in Rural Areas
Proceedings of a Workshop—in Brief

To explore opportunities to improve diagnosis in rural areas across the United States, the Forum on Advancing Diagnostic Excellence at the National Academies of Sciences, Engineering, and Medicine hosted a hybrid public workshop on October 14, 2025.^1,2 The workshop explored potential strategies to address diagnostic challenges for rural populations, which included expanding diagnostic access and mitigating geographic disparities, strengthening and supporting the rural health workforce and professional pathways, and implementing innovative models and technologies that enable better diagnosis for rural communities. Saul Weingart from Tufts Medical Center opened the meeting by describing how the workshop builds on the consensus report Improving Diagnosis in Health Care (NASEM, 2015) and a workshop series on Advancing Diagnostic Excellence.³ “The purpose of these workshops is to create a map to lay out the topography of a particular field and to identify promising paths forward,” Weingart noted, describing rural areas as communities that are resilient and resourceful but also facing significant health care challenges.

Kathryn McDonald from Johns Hopkins University described the complex, collaborative, and cyclical nature of the diagnostic process highlighting that diagnosis occurs within a broader work system that includes the physical environment, external environment, diagnostic team members, and technologies and tools that can either support or impede diagnosis (see Figure 1). McDonald emphasized that the physical and geographic environment including challenges with access, distance, and infrastructure in rural areas play a critical role in shaping diagnostic quality and outcomes. This Proceedings of a Workshop—in Brief highlights the presentations and discussions that occurred at the workshop.⁴

THE RURAL HEALTH CARE LANDSCAPE

Meggan Grant-Nierman from Heart of the Rockies Regional Medical Center delivered the keynote address on behalf of Tom Morris from the Health Resources and Services Administration (HRSA),⁵ describing the complex landscape of rural health and health care service delivery in the United States. Grant-Nierman explained there are

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many definitions of the term rural, but federal agencies and most organizations use the common data points of counties and census tracts saying, “The challenge is [these measures] are not uniform, and both increase greatly in size as you move from east to west.” These varying definitions can result in some undercounting or overcounting of rural areas but generally describe about 19 percent of the population living across 80 percent of the United States (HRSA, 2025).

Grant-Nierman broadly described the challenges in rural clinical practices compared to urban areas, including a more limited health infrastructure, health care provider shortages, geographic and professional isolation, and economic instability tied to small populations and high fixed costs. Rural towns, particularly in the western United States, face structural economic challenges attributable in part to the large amounts of federally owned land that reduce local tax bases and limit revenue to support public services, she said. In addition, employment in rural communities is often dependent on a single industry such as agriculture, energy, or small manufacturing, leaving communities economically vulnerable. Rural hospitals and clinics also rely more on public insurance programs like Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) than their urban counterparts.

Grant-Nierman noted that rural residents face higher rates of chronic disease, cancer mortality,⁶ and overdose deaths, along with lower access to essential services such as obstetric (OB) care (CDC, 2024; GAO, 2021; Henley et al., 2017; RHI Hub, 2025). She also highlighted the demographic reality that rural areas have a higher proportion of older adults aged 65 and older, many of whom live with complex, chronic conditions (Monnat, 2025). A key aspect of rural health care is the federal role in supporting its infrastructure. Of the roughly 2,000 rural hospitals, about 1,300 are designated as critical access hospitals which are located at least 35 miles from another hospital, have a maximum of 25 inpatient beds, and are limited to an average patient stay of no more than 96 hours, in exchange for Medicare cost-based reimbursement and federal grant support.⁷ Federally Qualified Health Centers (FQHCs) serve about one in five rural residents,⁸ while Certified Rural Health Clinics operate under a separate Medicare payment designation with distinct funding and service requirements (see Figure 2).

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Rural hospitals face a growing threat of closure because of several factors, including decreasing populations, health care consolidation, and lost revenue as patients choose larger health care facilities at greater distances. This issue particularly impacts the number of rural hospitals able to maintain labor and delivery units. However, Grant-Nierman noted some opportunities to maintain OB services and access, including partnerships with upstream tertiary centers, partnerships with rural family medicine OB residency programs, coordination with FQHCs, and community-based maternal care programs that focus on prenatal care coordination, risk reduction, and risk triaging to identify appropriate places for delivery.

Grant-Nierman discussed telehealth and technology-enabled collaboration in expanding diagnostic capacity. She said once a “low-volume, almost exclusively rural service,” telehealth has become an expected part of care, although reimbursement, licensure, and broadband access remain barriers. She described growing interest in health care provider-to-provider telehealth models that connect clinicians together to coordinate, share knowledge, and expand diagnostic capacity (NIH, 2023). Grant-Nierman concluded that while emerging technologies could expand diagnostic capacity in rural areas, designing technologies to consider the rural context is important to ensure they will work for rural clinicians and patients, especially when resources and budgets are limited. Rural clinicians, she said, exemplify a model of practice that depends on versatility, collaboration, and trust built across communities and care settings. “The everyday champions of rural health care,” she affirmed, “will have you leaving this meeting feeling inspired and hopeful about the future of rural health care and diagnostic excellence.”

PERSPECTIVES ON ADVANCING DIAGNOSTIC EXCELLENCE IN RURAL AREAS

The first panel featured three individuals from rural and frontier communities who spoke about their experiences as patients, clinicians, and community members navigat-

ing diagnosis and health care. Sue Sheridan from Patients for Patient Safety US shared how her lived experience as a patient in frontier Idaho informs her approach to seeking diagnoses and her sense of agency and self-advocacy. When she developed sudden facial paralysis and body pain that was dismissed as stress at a distant regional hospital, she returned home with urgent concerns about addressing her symptoms and used ChatGPT to find answers.⁹ The artificial intelligence (AI) chatbot suggested Bell’s palsy as a potential explanation for her symptoms.¹⁰ With this information, she sought care at her local hospital, where clinicians immediately made the correct diagnosis and began treatment that led to a rapid recovery.

Lyn Behnke, a rural nurse practitioner, with the University of Michigan-Flint shared the story of a local farmer and friend who sought care in a primary care clinic for frequent falls. He had several serious health conditions, including chronic lung disease requiring oxygen, heart disease, diabetes, kidney disease, and mild depression. Behnke described the many barriers to his timely diagnosis including the long distance to the tertiary hospital, limited access to cardiologists, delays due to insurance approvals, and the lack of a systematic management process for diagnostics. These systemic failures led to a rapid deterioration in his physical and mental health and ultimately to his death. She highlighted the importance of potential opportunities such as mobile cardiology units, mobile intensive care units, insurance coverage of inpatient rehabilitation, and the development of systems to track diagnostics. Behnke reflected on the emotional burden such cases place on rural clinicians and underscored that timely, accurate diagnoses depend on relationships, continuity, and community trust.

Jennifer Bacani McKenney, a rural family physician in Fredonia, Kansas, described her role as a “full-spectrum provider,” taking on several roles and responsibilities to meet her communities’ needs including as an ER (emergency room) physician, hospitalist, nursing home doctor, county health officer, hospice director, and educator. In addition to her primary care work, she serves as the associate dean for rural medical education at the University of Kansas School of Medicine, where all students are required to experience rural practice. McKenney emphasized the importance of adaptability, creativity, and teamwork in ensuring patients receive comprehensive, high-quality care despite limited resources. McKenney described a story of diagnosing a friend with appendicitis late in the day, when the radiologist was off duty. Determined to confirm the diagnosis, she reached out to multiple radiologists and surgeons after hours until she was able to successfully diagnose and treat the issue. This story exemplified the strength of professional relationships, persistence, and deep community connections that allow rural clinicians to deliver timely and effective diagnostic care.

Panel Discussion

During the discussion, panelists described persistent challenges they encounter in rural practice and pragmatic workarounds that enable care continuity. Behnke noted that logistical challenges often intensify during care transitions, describing a patient discharged home without food, family, or support services. She explained how her team stepped in to assist, buying her food and ensuring mobility in her home to prevent readmission. Sheridan reflected on the humility and adaptability she sees among rural clinicians who “don’t pretend to know it all,” using AI tools, telehealth, and professional networks to bridge gaps in specialty access. She also noted how remote monitoring and home-based diagnostic tests empower patients to participate actively in their own diagnostic processes. McKenney spoke about the persistent challenges in ensuring patients receive timely screenings and procedures, explaining that she performed colonoscopies locally to spare patients’ long travel after preparation, adding,

Sometimes we just figure it out. Our MRI (magnetic resonance imaging) machine is only there on Sundays… Our specialists, our cardiologists, our orthopedic surgeons are there once a month, and we figure it out in between.

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When asked how they each defined diagnostic excellence, Sheridan called for an updated framework that recognizes patient agency and equal access to information that clinicians have. Behnke emphasized the enduring value of physical examination and clinical reasoning, and McKenney stressed that diagnostic excellence is ultimately about access to clinicians, data, and community infrastructure. McKenney closed by reminding the audience that achieving excellence also requires sustained investment in the places where rural people live: “We stopped investing in small towns and started investing in big hospitals and research centers. We forgot about investing in the communities themselves.”

EXPANDING ACCESS AND MITIGATING HEALTH DISPARITIES

Johnna Nynas, an OB gynecologist from Sanford Health, discussed a program focused on improving maternal diagnosis in rural Minnesota. The Families First program, a collaborative initiative among several health organizations in Northern Minnesota, prioritizes high-quality care for pregnant women and their families. With funding through the Rural Maternity and Obstetrics Management Strategies (RMOMS) initiative,¹¹ Families First is particularly important for American Indian communities, which represent only 2 percent of Minnesota’s population yet account for 12 percent of pregnancy-related deaths, said Nynas. More than half of American Indian women in the state report receiving inadequate prenatal care (Minnesota Department of Health, 2024). To address these health disparities, Families First connects patients with prenatal care and OB specialists through both local and virtual support.

The goal of the OB Virtual Hospitalist program is to improve timely diagnosis and response for OB emergencies in critical access emergency rooms across the network, explained Nynas. When patients present to a critical access ER with OB emergencies such as vaginal bleeding, decreased fetal movement, labor concerns and hypertensive emergencies, the local health care provider and nursing team conducts the initial triage, assesses vital signs, begins fetal monitoring, and orders lab tests and imaging. Then, the local ER provider connects the virtual OB consult through a video interface to guide patient evaluation and management, stabilization prior to maternal transfer, and disposition in real time. Nynas emphasized this remote expertise enhances local capacity and quality, saying,

I need those [health care] providers to feel supported, to feel like they can provide good care, that they have the resources and tools they need, because I need them where they are in order for me to do my best job where I am.

She said maintaining reliable access to evidence-based maternal care is central to the program’s mission. Because time is of the essence in OB emergencies, the program places particular focus on early recognition and management of hypertensive disorders and preeclampsia, preterm labor, and hemorrhage, which Nynas identified as “big drivers of adverse outcomes” among American Indian women. She noted several challenges, including upfront cost of telemedicine equipment, the need to expand rural broadband internet, multiple human dependent steps, contracting with a government agency, and reimbursement strategies for telemedicine with future sites. Nynas concluded that Families First shows how rural hospitals can sustain high-quality OB care through partnership, technology, and shared expertise. The model not only strengthens diagnostic capacity but also fosters trust and continuity of care for rural and Indigenous families—ensuring, as she noted, “Where you live shouldn’t determine the quality of care you receive.”

Emily D’Agostino of Duke University School of Medicine discussed efforts to expand access to hospital-level care in rural areas through the Mobile Access to Revolutionary Care Connecting US (MARCUS) unit, an integrated care delivery platform developed by Mission Mobile Medical to provide safe, high-quality medical services to different communities. Supported by the Advanced Research Projects Agency for Health under the Platform for Accelerating Rural Access to Distributed and Integrated Medical Care program,¹² MARCUS is an electric vehicle-based health unit equipped with reconfigurable

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medical suites that deliver diagnostics and specialized care to remote and underserved areas.¹³ Medical services include advanced imaging to laboratory testing, as well as specialty care. D’Agostino explained that the mobile units are built on a rugged chassis capable of navigating varied terrains from rural highways to mountainous areas. She emphasized that “rather than the one-size-fits-all or single-use cases that are typical with mobile units,” MARCUS has reconfigurable specialty care use cases including wound care, cancer and chemotherapy, and maternal health and obstetrics. Lastly, D’Agostino highlighted the importance of engaging the community to learn and understand the health unit’s barriers to care, including privacy, accessibility, continuity of care, safety, and trust.

Shawn Vainio of Yukon-Kuskokwim Health Corporation described his nearly 2 decades of experience as a family medicine physician delivering care across the Alaskan frontier and the strategies his organization uses to improve diagnostic accuracy. Vainio currently practices in the Yukon–Kuskokwim Delta in western Alaska, an area roughly the size of Oregon, serving approximately 26,000 people in more than 50 Native villages that are hundreds of miles from the nearest hospital. Eighty-five percent of residents are Native Alaskan, about half are children and adolescents, and many live in multigenerational homes. Roughly one-third lack running water and a sewage system. To address these challenges, Vainio emphasized the importance of culturally grounded and distributed systems of care.

The Community Health Aide Program, approved by the state of Alaska, trains local residents to deliver frontline care within their own villages. He explained that many of the community health aides have a high school education, but the program prepares “community members… to deliver health care in the communities they serve.” Community health aides use a structured manual that has been integrated into an electronic health record (EHR) to guide assessment and treatment and to report their findings to a physician, nurse practitioner, or physician associate (PA) who provides oversight and future directions on care delivery. Vainio stressed that recruiting and training aides from within their own villages ensures “culturally congruent care” and extends access to otherwise isolated communities.

Vainio also described several additional innovations to strengthen diagnostic accuracy, including telehealth and teleradiology services, point-of-care ultrasound training, and a digital tuberculosis screening project that brings mobile X-rays to villages. The health system maintains a universal EHR that connects village clinics, subregional centers, and referral hospitals, as well as allowing clinicians to view and coordinate patient care statewide. Within the Yukon-Kuskokwim Health Corporation, a strong learning culture supports diagnostic improvement through weekly conferences and more than 100 locally adapted clinical guidelines. Vainio also noted the use of an AI-supported dermatology diagnostic tool and the region’s Alaska Improving Diagnostic Accuracy in Medicine Conference, which reinforces a systemwide commitment to continuous learning. Through these approaches, Vainio highlighted how Alaska’s Native health system and community health aide model combine cultural alignment, technology, and local expertise to overcome extreme geographic and resource barriers—offering lessons that “have significant applicability to other care delivery settings.”

Panel Discussion

During the discussion, panelists were asked to reflect on medical conditions that are most challenging to diagnose in rural settings, the infrastructure gaps that limit diagnostic access, and the strategies needed to strengthen education and clinical support across rural systems. Vainio explained that one of the primary diagnostic limitations he encounters in Alaska is the gap between what community health aides can identify through a patient’s history and physical examination and the diagnoses that require patients to travel by air to access technology, testing, or imaging. Nynas later noted that even having access to the best technology and health care cannot overcome barriers in the built environment and infrastructure. “We can bring all of the [health care] providers and technology in the world to small communities,” she said, “but until we have built the infrastructure for healthier communities…we can only do so much.” Weather events and natural disasters can cause widespread destruction, critical loss, and disruptions to connection with health systems. Vainio described how a

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recent storm brought flooding and high winds, leaving an entire village of 587 people without their homes. “To be able to diagnose at the point of care, it’s vital that we’re able to communicate with the communities,” said Vainio, underscoring the importance of maintaining strong infrastructure, particularly reliable broadband access to ensure continuous telecommunication with remote villages.

SUPPORTING RURAL HEALTH CARE PROFESSIONALS

Mark Deutchman from the University of Colorado School of Medicine discussed point-of-care strategies that have long supported early detection and diagnosis in rural primary care and emphasized preserving the unique strengths of rural practice while integrating new technologies. Rural clinicians often serve as broad-scope generalists, he said, which promotes continuity across transitions, communication, and the defragmentation of care. Deutchman described diagnosis as a cyclical process and suggested integrating preventive care so patients can avoid re-entering the process for preventable conditions. He also said any innovations aimed at improving diagnosis need to preserve continuity, communication, and defragmentation especially since defragmentation can reduce costs, prevent duplication, and reduce diagnostic errors. Deutchman discussed the concept of structural urbanism or the tendency to apply urban-designed solutions in rural settings where they may not apply (Probst et al., 2019). He recognized telehealth as a valuable tool for supporting rural clinicians’ diagnostic decision making, improving access to care, and even helping in stabilizing the workforce because “it allows clinicians to stay where they work and where they live.”

Deutchman emphasized the value of point-of-care ultrasound in rural primary care noting that when used by the treating clinician, it enhances physical diagnostic skills, strengthens communication, and deepens the patient–provider relationship. He said ultrasound allows for real-time interpretation and is safe, relatively inexpensive, and can be readily repeated. Through these examples, Deutchman illustrated how diagnostic excellence in rural settings depends on empowering generalist clinicians with accessible, adaptable tools and technologies that reinforce their connection to patients and their communities.

Matthew Probst, a physician associate and primary care provider for the University of New Mexico, described a hub-and-spoke model that is expanding access to primary care and diagnostic services across rural and frontier regions of northern New Mexico. The model uses three hubs at school-based health centers with 24 spoke sites at frontier schools. Health care is delivered on a tripod platform through community health workers, virtual exam technology, and “circuit riders”—medical and behavioral health professionals who travel along a circuit to provide care. These local community health workers and circuit riders are equipped with virtual exam technology to connect patients with clinicians at the hub sites. Probst emphasized that community health workers have dual roles in addressing medical and social needs and are essential for “connect[ing] to patients socially, culturally, and linguistically.” The virtual exam kiosks and portable diagnostic kits enable community health workers and circuit riders to measure vital signs, perform point-of-care testing, and transmit real-time data to clinicians to make accurate diagnoses. Probst highlighted that diagnostic access is available each day school is open not only to students, but to school staff and family and community members.

Katherine Bennett from the University of Washington described how her team adapted the Project Extension for Community Healthcare Outcomes (ECHO) model to develop Project ECHO-Geriatrics as a learning platform to share specialty knowledge and support rural age-friendly care.¹⁴ Bennett explained that there are fewer than 7,000 geriatricians in the United States, despite a growing aging population (American Geriatrics Society, 2022). Many older adults live in rural areas where health care professionals already face limited access to geriatricians and lack adequate training in the specialized care of older adults. Through regular virtual sessions that combine short didactics with interdisciplinary case discussions, rural clinicians build skills in core geriatric topics and can tailor suggestions to their setting. Bennett noted the interdisciplinary panel includes social workers, nurses, geriatricians, pharmacists, geriatric psychiatrists, and individuals who can talk about resources for older adults to age in place.

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Age-friendly care organized around the 4Ms framework provides a foundation for Project ECHO geriatrics programs,¹⁵ and supports the existing workforce by increasing clinicians’ confidence, reducing professional isolation, and improving diagnostic accuracy through case-based discussion (Carrico et al., 2024). Since its launch, Project ECHO-Geriatrics has trained participants from nine different health professions programs with strong engagement among more than 3,000 participants throughout Washington state, as well as parts of Idaho and Oregon, with 30 percent of participating sites in rural areas. Bennett said the model not only enhances workforce retention by supporting clinicians where they live and practice but also improves diagnostic accuracy through shared case discussions and expert feedback.

Natasha Bray from Oklahoma State University (OSU) College of Osteopathic Medicine at the Cherokee Nation discussed how the OSU medical program builds pathways for future rural and tribal physicians to address the primary care shortage in rural, tribal, and underserved Oklahoma communities. Eighty-nine percent of Oklahoma is considered rural, and 75 of 77 counties are health professional shortage areas (Oklahoma State Department of Health, 2022) with several American Indian tribes and nations, including the Cherokee Nation, making up large parts of the state. Bray said this lack of access to care contributes to diagnostic delays and the ability to get the right care to patients at the right time. OSU is the only tribally affiliated medical school in the United States, and its distributive training model places students and residents in rural and tribal communities for education and practice because as Bray noted, “We want to train our students where they will practice” so they understand the community realities shaping diagnosis, from limited pharmacies to the long travel distances for hospitals or maternity care. OSU has three tracks to prepare students with a focus on specific care settings and populations: rural medical track; tribal medical track; and urban underserved medical track.

Students are intentionally recruited from the state’s American Indian tribes and nations and sometimes by way of nontraditional pathways (i.e., former military, community college, or emergency medical services pathways) to practice in rural, tribal, and urban underserved areas (Figure 3). Bray stressed the importance of placing students in the communities in which they will serve, saying further,

Until [the students] are in the community and experience it for themselves, they can’t really understand that when we discharge a patient from an urban center and send them back to that rural community, that they’re not going to get physical therapy or speech therapy, or occupational therapy without a huge disruption to their life.

She said despite potential concerns around retention and quality of care, students have success rates in passing their licensing exams and passing certification that are comparable to the general population of medical students, and the majority of OSU students continue to work within Oklahoma, either working in medically underserved areas or with underserved populations. Bray said the program maintains high quality, saying “We don’t lower standards. Just because you’re in a rural community, it doesn’t mean you need someone who’s not as well trained.”

Panel Discussion

During the panel discussion, panelists reflected on the workforce, training, and systems-level factors that shape diagnostic excellence in rural practice. Regarding the growing role of PAs and nurse practitioners (NPs), Probst emphasized the importance of interprofessional collaboration both in practice and education. He said PAs and NPs are integrated as teachers and evaluators, “We tell our students that the stripe of their preceptor does not determine what they can teach. The scope of care of their preceptor determines what they can teach.” Several panelists emphasized that primary care is the cornerstone of diagnostic capacity in rural systems. Probst underscored that strengthening primary care is key to improving population health and preventing diagnostic fragmentation. Bray built on this point, suggesting continuous learning across a clinician’s career: “We need to have opportunities for retraining across the scope of

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our careers—whether we’re talking about physicians, nurse practitioners, or PAs.” Bray’s comments echoed her broader message that distributed community-based training helps rural practitioners build diagnostic confidence through hands-on experience in resource-limited settings. Mark Deutchman linked these ideas to medical education, noting that the students he trains develop a wide range of diagnostic skills that prevents what he called “learned helplessness,” a mindset fostered by overly specialized or fragmented systems. By cultivating generalists who are capable of diagnosing and managing a broad array of conditions, Deutchman said rural training helps restore continuity and confidence in the diagnostic process. The panelists highlighted that diagnostic excellence in rural health depends on continuity, adaptability, and team-based care, supported by education models that prepare clinicians to diagnose broadly across settings and stages of practice.

INNOVATIVE RURAL HEALTH CARE MODELS

Paul Aslin of the Texas Organization of Rural and Community Hospitals (TORCH) discussed leveraging clinically integrated networks to support high-quality rural health care in Texas. He said Texas health care providers have not had wide access to value-based contracting opportunities and, as a result, have missed significant financial resources and related quality improvement opportunities. In response, TORCH developed a clinically integrated network in 2021 to create a path through which rural health care providers can participate in value-based contracting programs. The TORCH clinically integrated network is built on several guiding principles based on

• working together;
• reimagining rural care to achieve sustainable, high-value care delivery;
• financial sustainability;
• appropriate pacing or phased growth to strengthen quality and coordination in rural care delivery; and
• relieving administrative burden.

He emphasized that diagnostic excellence is integral to their value-based metrics, many of which focus on testing rates, documentation, and preventive screening. Aslin concluded that the TORCH clinically integrated network demonstrates how collaborative contracting, shared resources, and clinical integration can help rural hospitals and clinics sustain high-quality care. However, limited access to resources and tools such as AI-enabled clinical documentation support continue to hinder diagnostic performance compared to urban peers.

Colleen Durocher described the Rural OB Access and Maternal Services (ROAMS) Network, which is a partnership among three rural Northeast New Mexico coun-

ties working to increase access to maternal and OB care, where half of the counties are considered OB deserts or low OB access areas. With initial funding from HRSA’s RMOMS program and now foundation support, ROAMS expands maternal care access across five rural counties. Durocher highlighted the impact of the tele-OB program with 108 telehealth visits from 2021 to 2023 saving mothers around 270 hours of driving and 18,360 miles of travel. The program also improved prenatal care by reducing the percentage of mothers without a first-trimester visit from 41 percent to 25 percent over 2 years. The telehealth maternal fetal medicine (tele-MFM) program also improved diagnostic access for high-risk mothers who are typically assessed every other week or monthly. In 2024, 827 tele-MFM visits resulted in saving mothers 4,772 hours of driving and 341,150 miles of travel. The program requires advanced ultrasound equipment and uptraining a sonographer, but it fosters a valuable collaboration between the rural labor and delivery practitioners and the urban based MFM specialists. Durocher concluded that ROAMS allowed the hospitals to overcome silos and collaborate effectively to improve maternal health for rural patients.

Vida Passero of the U.S. Department of Veterans Affairs (VA) discussed the VA National TeleOncology (NTO) program that enables access to specialty cancer care for veterans living in rural and remote areas. “Every veteran with cancer has access to world-class hematology-oncology care, regardless of where the veteran lives and regardless of where the staff live, too,” said Passero, who described how VA’s integrated health care system creates a collaborative network of specialists to effectively diagnose and treat cancer patients. To illustrate how the system enables veterans access to health care providers across the country through its hub-and-spoke TeleOncology model, she described the case of a patient with prostate cancer living in rural North Dakota who connected with a medical oncologist in North Carolina to manage chemotherapy treatment and had an oncology-trained pharmacy specialist living in Kentucky.

Since its launch in 2020, NTO has delivered care to approximately 28,000 veterans, with 41.6 percent of patients living in rural areas and 87.7 percent of VA facilities actively partnering with NTO, reported Passero.

The program provides both synchronous telehealth care and asynchronous e-consults, supporting local clinicians and ensuring care continuity. Passero emphasized the importance of “gap coverage” (i.e., virtual health care providers temporarily filling in when on-site health care providers, including PAs, NPs, and clinical pharmacists, are on leave) to prevent care disruption and fragmented care. Passero also described VA’s national virtual tumor board, which remotely convenes pathologists, radiologists, oncologists, and surgeons to reach multidisciplinary consensus.

Other specialized initiatives include the Breast and Gynecologic Oncology System of Excellence, a comprehensive genetic counseling and testing service, and decentralized clinical trial models that enable veterans to participate in research closer to home. The Close to Me program is another innovative component of NTO that allows VA clinicians to travel and provide veterans with the full continuum of cancer care at nearby community-based outpatient clinics and at home. It serves over 4,000 veterans with a near 99 percent treatment adherence rate and saves an estimated one million driving miles for patients. Passero suggested improving rural access through applying a national operational clinical infrastructure that focuses on building and sustaining a responsive adaptable team, understanding the needs of the field, and learning about optimal use of telehealth in clinical care.

Panel Discussion

During the discussion, panelists highlighted challenges and strategies for sustaining diagnostic excellence in rural care. Passero, Aslin, and Durocher highlighted the digital divide as a major theme, noting it limits rural hospitals’ access to data and advanced tools. Passero described VA’s digital literacy programs that help veterans navigate telehealth, while Aslin noted that disparate EHRs and outdated data hinder timely feedback. Durocher added that community health workers can bridge gaps by helping families use home monitoring and telehealth tools, enabling better diagnostic follow-up even in low-resource settings.

Several panelists suggested that early and proactive information gathering can prevent missed or delayed diagnoses. Aslin said annual wellness visits have become

a cornerstone of diagnostic improvement in his network, uncovering hidden conditions and connecting patients to preventive screenings and mental health services. Durocher provided a compelling example from her tele–MFM program, where a trained rural sonographer detected a fetal heart defect that would have otherwise gone unnoticed, preventing a crisis delivery. Passero underscored that such diagnostic vigilance depends on team-based communication, where physicians, nurse coordinators, and pharmacists collaborate to ensure “everyone knows what is going on with this patient, so care doesn’t fragment.”

Speakers also reflected on program sustainability, observing that while many innovative diagnostic models begin with short-term grant support, longer-term financial structures may support their continued success. Aslin cited collective contracting through the clinically integrated network as one path forward, while Durocher described barriers for small programs deemed “too small” for payer contracts—calling rural health care a health equity issue. Passero contrasted these challenges with VA’s national telehealth infrastructure, which provides a more stable model for sustaining diagnostic access. Finally, the panel noted that patient and community engagement can play an important role in effective design. Durocher’s team gathered feedback from mothers living in rural areas to shape ROAMS services; Aslin noted that patient education increased the use of preventive visits, and Passero said VA’s tele-oncology model originated from veterans’ requests for local chemotherapy. Across the examples, Passero, Durocher, and Aslin emphasized that success often depended on shared data, patient input, and strong clinician collaboration.

ENVISIONING THE FUTURE OF DIAGNOSTIC EXCELLENCE

In the final session, moderated by Weingart, panelists highlighted key themes from the workshop. The panel included Kevin Stansbury of Lincoln Health in Colorado, Judy Zerzan-Thul of the Washington State Health Care Authority, Jennifer Stoll of OCHIN, and earlier workshop participants Meggan Grant-Nierman and Sue Sheridan.

Several panelists suggested that rural communities have important strengths such as deep trust between clinicians and patients, continuity of care, and the ability to do more with less, that can support diagnostic excellence. Stansbury described the “mission-oriented lifestyle” of rural clinicians who know their patients personally and the importance of building systems that support diagnosticians and community trust. Zerzan-Thul echoed that rural health care providers “nail the value of the trusted provider,” which strengthens both diagnosis and treatment.

Several panelists suggested that current Medicaid, Medicare, and commercial payment structures create challenges for the long-term financial stability of rural hospitals. Stansbury said that fee-for-service payment “does not work in rural areas” based on his experience, especially in low-volume facilities. He proposed outcome-based or value-based payment models that reward community-level improvements in conditions such as diabetes and heart disease. Stansbury, Zerzan-Thul, and Grant Nierman cited limited reimbursement or unequal reimbursement for health care in urban versus rural settings, lack of access to financial capital, and aging infrastructure as barriers to diagnostic capacity and technology adoption.

Stansbury identified the new Rural Health Transformation Program as a potential opportunity to align rural investment with sustainability and quality.¹⁶ Many panelists discussed the potential value of shared infrastructure and regional collaboration. Stoll described how OCHIN’s health-IT cooperative model enables rural hospitals and community health centers to share EHR platforms, data, and expertise, improving interoperability and enabling value-based care. Zerzan-Thul highlighted Washington State’s efforts to share equipment and resources across hospitals separated by long distances. Stansbury, Grant-Nierman, and Zerzan-Thul encouraged policies that allow “co-opetition,”¹⁷ allowing rural facilities to collaborate without violating antitrust or reimbursement rules.

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Panelists discussed the opportunities and risks of AI in supporting diagnosis and documentation. Sheridan emphasized that rural areas could benefit from AI because of persistent workforce and access gaps, noting that patients are already using AI tools to inform their diagnosis and care. Stoll cautioned that AI should be adopted responsibly, with local governance, transparency, and attention to bias, especially where staff take on multiple tasks and technical oversight may be limited. Stansbury warned that uneven AI deployment could widen the rural–urban gap unless policymakers ensure equitable access to digital infrastructure. In discussing what urban health systems might learn from rural practice, panelists emphasized contextual care and community accountability. Grant-Nierman described how rural care providers “see the whole person” and integrate social context into diagnostic decision making. Stansbury added that community hospitals retain agility and the ability to make quick decisions locally as needed, while Sheridan noted that rural clinicians regularly innovate by necessity or “do more with less.”

In closing, Weingart reflected that rural diagnostic excellence is about creating effective, human-centered solutions despite scarcity. The discussion underscored that rural medicine is not “little urban medicine” but a distinct ecosystem that delivers value by integrating continuity, creativity, and community engagement. Several participants summarized that sustaining diagnostic excellence in rural areas will require aligning payment and policy with community health outcomes, leveraging technology equitably, supporting the workforce, and ensuring that patient and community voices remain central to every stage of system design. Suggestions from workshop participants for improving diagnostic excellence in rural areas are outlined in Box 1.

REFERENCES

American Geriatrics Society. 2022. Current number of board certified geriatricians by state. New York: American Geriatrics Society.

Carrico, C. P., C. McKibbin, L. Waters, K. Thompson, J. Graupner, S. Cotton, A. Faul, P. G. Clark, J. Telonidis, F. Helm, T. Caprio, and K. A. Bennett. 2024. Growth and impact of Project ECHO for workforce development in age-friendly care. J Am Geriatr Soc 72(S3):S6-S13.

CDC (Centers for Disease Control and Prevention). 2024. Drug overdose in rural America as a public health issue. https://www.cdc.gov/rural-health/php/public-health-strategy/public-health-considerations-for-drug-overdose-in-rural-america.html (accessed October 29, 2025).

Division of Data and Information Service Office of Information Technology. 2021. Map of CMS Special Designations.

GAO (Government Accountability Office). 2021. Maternal mortality and morbidity additional efforts needed to assess program data for rural and underserved areas. Washington, DC: GAO.

Henley, S. J., R. N. Anderson, C. C. Thomas, G. M. Massetti, B. Peaker, and L. C. Richardson. 2017. Invasive cancer incidence, 2004-2013, and deaths, 2006-2015, in nonmetropolitan and metropolitan counties - United States. MMWR Surveill Summ 66(14):1-13.

HRSA (Health Resources & Services Administration). 2025. How we define rural. https://www.hrsa.gov/rural-health/about-us/what-is-rural#:~:text=Based%20on%202020%20Census%20data,the%20country%20to%20be%20rural (accessed October 28, 2025).

Minnesota Department of Health. 2024. The health of American Indian families in Minnesota: A data book. St. Paul, MN: Minnesota Department of Health.

Monnat, S. M. 2025. U.S. rural population health and aging in the 2020s. Public Policy Aging Rep 35(1):3-9.

NASEM (National Academies of Sciences, Engineering, and Medicine). 2015. Improving diagnosis in health care. Edited by E. P. Balogh, B. T. Miller and J. R. Ball. Washington, DC: The National Academies Press.

NIH (National Institutes of Health). 2023. Pathways to prevention program: Improving rural health through telehealth-guided provider-to-provider communication. https://prevention.nih.gov/research-priorities/research-needs-and-gaps/pathways-prevention/improving-rural-health-through-telehealth-guided-provider-provider-communication (accessed December 19, 2025).

Oklahoma State Department of Health. 2022. Health professional shortage areas primary care (scores). Oklahoma City, OK: Oklahoma State Department of Health, Office of Primary Care.

Probst, J., J. M. Eberth, and E. Crouch. 2019. Structural urbanism contributes to poorer health outcomes for rural America. Health Affairs 38(12):1976-1984.

RHI Hub (Rural Health Information Hub). 2025. Rural health disparities. https://www.ruralhealthinfo.org/topics/rural-health-disparities (accessed October 29, 2025).

DISCLAIMER This Proceedings of a Workshop—in Brief was prepared by Jennifer Lalitha Flaubert and Adrienne Formentos as a factual summary of what occurred at the workshop. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

PLANNING COMMITTEE Kathryn McDonald (Cochair), Johns Hopkins University; Saul Weingart (Cochair), Tufts Medical Center; Joseph Benitez, University of Kentucky; Helen Burstin, Council of Medical Specialty Societies; Meggan Grant-Nierman, Heart of the Rockies Medical Center; Peiyin Hung, University of South Carolina; Pari Pandharipande, University of Pennsylvania; Kia Parsi, Texas A&M. The National Academies’ planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Akshar Abbott, U.S. Department of Veterans Affairs; Lyn Behnke, University of Michigan—Flint, Saginaw Valley State University; and Jennifer Bacani McKenney, Fredonia Family Care. Leslie Sim, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS This workshop was supported by the American Association of Nurse Practitioners; American Board of Internal Medicine; American College of Radiology; Centers for Disease Control and Prevention; College of American Pathologists; Danaher Corporation; The Doctors Company; The Gordon and Betty Moore Foundation; The John A. Hartford Foundation; The Mont Fund; and Radiological Society of North America. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

STAFF Jennifer Flaubert, Adrienne Formentos, Eliana Pierotti, and Sharyl Nass, Health Care and Public Health Program Area, Center for Health, People, and Places, National Academies of Sciences, Engineering, and Medicine.

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2026. Advancing Diagnostic Excellence in Rural Areas: Proceedings of a Workshop—in Brief. Washington, DC: National Academies Press. https://doi.org/10.17226/29360.

For additional information regarding the workshop, visit https://www.nationalacademies.org/our-work/advancing-diagnostic-excellence-in-rural-areas-a-workshop.

Copyright 2026 by the National Academy of Sciences. All rights reserved.