Resource Use Patterns in US Telehealth Services: Machine Learning and Clustering Analysis Across 4 Specialties.

BACKGROUND

The expansion of telehealth services, particularly during the COVID-19 pandemic, has transformed health care delivery in the United States. Telehealth promises greater access and resource efficiency by reducing wait times and appointment lengths, especially in specialties like psychiatry, behavioral health, bariatrics, and sleep medicine. However, disparities exist in adoption based on demographics, geography, and socioeconomic status, raising concerns about equitable access and optimal resource use.

OBJECTIVE

This study aims to evaluate how telehealth impacts health care resource use across 4 specialties by examining 2 key metrics: patient-to-provider ratios and appointment durations. It seeks to understand how factors such as patient demographics, facility characteristics, and social determinants influence telehealth adoption and efficiency using a national dataset spanning from 2018 to 2023.

METHODS

We analyzed a deidentified dataset from Epic Cosmos, covering outpatient visits across 48 US states (2018-2023). After data preprocessing and feature engineering, we applied 3 machine learning (ML) models (random forest, extreme gradient boosting, and deep neural networks) to predict resource use. Using the model performing the best, feature importance was assessed using Shapley Additive Explanations values. We then used k-means clustering to group facilities into clusters per specialty. Comparative analyses were conducted to evaluate differences in use among clusters, during and after the pandemic.

RESULTS

Telehealth use peaked in 2020 and has remained above prepandemic levels since then. In 2018-2023, telehealth adoption reached 36.9% (4,543,021/12,311,710) in psychiatry, 23.9% (5,321,099/22,264,013) in behavioral health, 21.2% (924,333/4,360,061) in bariatrics, and 16.8% (851,803/5,070,256) in sleep medicine. Telehealth visits were consistently shorter than office visits (mean reduction 12.24 minutes; SD 3.33 minutes; P=.18), while patient-to-provider ratios varied significantly across specialties. Among ML models, extreme gradient boosting regression achieved the best performance (patient-to-provider ratios: R2=0.96-0.99; appointment durations: R2=0.61-0.69). Shapley Additive Explanations analysis identified visit type, telehealth use, facility size, rurality, and Social Vulnerability Index household vulnerability as the strongest predictors. Comparative analyses showed significant differences across clusters (all P<.05).

CONCLUSIONS

Telehealth has become a sustainable component of health care, enhancing access and efficiency across both rural and urban areas. However, its impact varies across specialties and regions, highlighting the need for targeted strategies such as staffing support for vulnerable populations, infrastructure investments in rural facilities, and reimbursement models that reflect telehealth's resource use. This study provides robust evidence from ML and clustering analyses, demonstrating how telehealth shapes resource use and offering actionable insights for equitable and sustainable integration.