Historically, “telemedicine” in Ontario was mostly focused on serving rural, northern Ontario regions where access to neurologists and other specialists was quite limited through programs such as the Ontario Telestroke Program. ^{Reference Holmes and Hart1} The use of virtual care (telephone or video visits) in Ontario increased dramatically during the pandemic but has since declined significantly to a new normal of about one in five visits. ^{Reference Stamenova, Chu, Fang, Bhattacharyya, Bhatia and Tadrous2}

Gros et al. ^{Reference Gros3} conducted a population-based, repeated cross-sectional study (March 2020–August 2023) comparing urban and rural access to virtual care among Ontario PD patients. As expected, virtual care use declined once pandemic restrictions eased, but this trend was seen across all Ontario patients and specialties, not just PD; unfortunately, the authors did not compare PD patients to a provincial average. ^{Reference Stamenova, Chu, Fang, Bhattacharyya, Bhatia and Tadrous2} This would have allowed us to see if the gap in PD patients is larger than average. Rural PD patients not only had lower access to virtual care but also had lower access to in-person specialist and primary care and lower rates of primary care attachment. The one exception was access to a neurologist, both in person and virtually, which tended to show fewer urban–rural differences (data in the Gros et al. Supplement).Reference Gros ³

This urban–rural gap is not unique to PD, Ontario, or Canada. When specialist practices cluster in cities, travel burdens alone limit access – more so for patients with mobility limitations. The consequences are familiar: poorer outcomes and inappropriate healthcare utilization, including the higher rural emergency department visit rates the authors report.

The premise of this article, and many like it, is that virtual care can somehow rescue access for rural patients. Outside pandemic-level crises, though, technology adoption in healthcare faces significant technological, individual, organizational and policy barriers. ^{Reference Cresswell, Williams and Sheikh4} For example, virtual visits are billable only within an existing in-person relationship. This policy locks out precisely those patients who need it the most, those without primary care attachment or specialist access. That restriction has merit; virtual-only relationships are rarely ideal, and virtual care works best alongside in-person care, but it leaves rural patients unable to access neurology, psychiatry or geriatrics solely via telehealth. Models like Baycrest’s Virtual Behavioural Medicine Program, ^{Reference Freedman, Binns and Serediuk5} which connects dementia patients with neurologists, psychiatrists and allied health remotely, or “hybrid teleneurology,” for Parkinson’s Disease patients where a specialist joins a family physician’s in-person visit remotely, ^{Reference Fereshtehnejad and Lökk6} could provide potential solutions.

Until care is redesigned around such models, rural gaps like those Gros et al.Reference Gros ³ describe will persist.