Graduation Date

Spring 5-4-2024

Document Type


Degree Name

Doctor of Philosophy (PhD)


Biomedical Informatics

First Advisor

James Campbell, MD

Second Advisor

W. Scott Campbell, PhD, MBA


The examination of healthcare disparities, which the COVID-19 pandemic exacerbated, revealed a pronounced divide between rural and urban settings. This divide particularly underscored the challenges of integrating rural healthcare into the Learning Health System (LHS) and utilizing real-world data (RWD) in response to a public health emergency. Our investigation expanded the growing body of literature on the rural mortality penalty, encompassing the period following the COVID-19 pandemic. By employing an LHS-enabled centralized platform of RWD, we assessed the impact of rurality on adverse COVID-19 outcomes (Aim 1), focusing on inpatient adverse events and the effectiveness of treatments and vaccinations across demographics. Our efforts also included exploring associations with adverse post-COVID-19 events, post-vaccination breakthrough infections, variations in treatment effectiveness, and temporal trends in adverse events following the vaccine rollout. We investigated the informatics challenges and methodological approaches necessary for studying rural populations using RWD (Aim 2). This task involved strategies for managing data harmonized from various sources, optimizing data quality and usability, and navigating the complexities of integrating and analyzing diverse datasets from different contributing centers across the US. We assessed the current state of rural healthcare's integration within the LHS (Aim 3), identifying steps toward advancing a rural-inclusive model. This assessment thoroughly evaluated achievements and gaps in data standardization, system adaptation, and rural engagement, aiming to develop targeted recommendations for enhancing rural health integration. Despite the barriers, using the LHS enabled the demonstration of higher hospitalization and mortality rates, alongside increased rates of breakthrough infections post-vaccination, in rural compared to urban areas. Better incorporation of rural communities into the LHS will offer clearer insights into these growing disparities, equipping providers, public health officials, and policymakers with enhanced tools and resources to address ongoing and future public health crises.


2024 Copyright, the authors

Available for download on Monday, April 13, 2026