‘Double-burdened counties’ have both poor health outcomes and low broadband penetration, making connectivity a priority. High-speed Internet creates access to telehealth services for preventive and critical care.
“Social determinants of health” is a hot topic among government and health system executives. The phrase usually refers to basic food, housing and transportation disparities that can lead adjoining ZIP codes to have drastically different life expectancies. But could lack of broadband Internet access also be considered a social determinant of health? Many rural health advocates say yes, and they are trying to do something about it by pushing for the infrastructure to enable telehealth programs and remote patient monitoring.
Broadband is defined as high-speed, reliable Internet with actual download speeds of at least 25 megabits per second (Mbps) and upload speeds of at least 3 Mbps. It can be delivered via fiber, wireless, satellite, digital subscriber line (DSL) or cable. According to a 2019 Pew Trust report, 60 percent of health-care facilities outside of metro areas lack broadband access.
Researchers have a name for areas that have both low rates of home broadband and higher-than-national-average mortality rates for cancer and other diseases: “double-burdened counties.”
The Federal Communications Commission’s Connect2HealthFCC Task Force has created a mapping platform that allows for the overlay of cancer mortality and other disease conditions with broadband access coverage. This allows them to pinpoint hot spots. In these areas, for example Appalachia, the task force found that more than 70 percent of counties with the highest lung cancer incidence and mortality have rural broadband access below 50 percent.
Telehealth efforts have made progress in connecting rural hospitals to academic medical centers to allow specialists to visit with patients and their care providers without arduous travel. But getting broadband access to smaller clinics and individual homes has proven more difficult, because telecom companies don’t find it financially viable to connect homes in rural areas at affordable rates. The FCC and U.S. Department of Agriculture have programs that subsidize the cost of broadband for some rural health providers, but those programs have traditionally been oversubscribed. Therefore, in-home virtual visits and remote patient monitoring for patients with conditions such as cancer, diabetes and chronic heart failure are not as widespread as they could be.
COVID-19: A Boon for Telehealth?
The COVID-19 crisis has led to an explosion in telehealth use in all settings, and the Centers for Medicare and Medicaid Services (CMS) has temporarily lifted longstanding barriers involving reimbursement requirements, HIPAA rules and licensure.
Some of these regulatory changes to address COVID-19 could become permanent. “We are seeing a lot of emergency rule changes to broaden the scope of the use of telehealth and allow for continuity of care during this time, which is so important,” said Danielle Louder with the Northeast Telehealth Resource Center. “Our organization doesn’t advocate or lobby, but we provide data and information that helps policymakers make decisions. We are encouraging people to think upstream. This really is an opportunity. While some pieces of the expanded policies may make sense to walk back, there will be some that absolutely should stay in place and we hope that they do.”
The sudden increase in telehealth use is straining broadband network capacity. If the telehealth surge persists, it may force government officials to consider prioritizing health care in the regulation and expansion of telecom networks.
Abby Sears, CEO of OCHIN, said that during the crisis, rural clinics are noticing service quality problems. “We are seeing degradation of networks. Providers seeking to use broadband to access services sometimes are not able to access them,” she told a March 26 committee meeting of the federal Office of the National Coordinator for Health Information Technology. At the same meeting, Denise Webb, a health IT consultant and former CIO of Marshfield Clinic Health System in Wisconsin, said health system CIOs are telling her that the sudden increase in video visits is putting a strain on their networks. She suggested that CMS offering payment parity for telephone visits and video visits, when appropriate, could ease physician demand for video connections.
The FCC is getting more funding to address some of these needs. As part of the CARES Act passed at the end of March, Congress appropriated $200 million to the FCC to support providers’ use of telehealth services in combating the COVID-19 pandemic. Plus, bipartisan legislation introduced in April would give the FCC an additional $2 billion to expand telehealth services during the crisis. These funds are expected to help eligible providers purchase telecommunications, broadband connectivity and devices necessary for providing telehealth services. This is in addition to the longer-term Connected Care Pilot Program that would study how connected care could be a permanent part of the Universal Service Fund by making available up to $100 million of universal service support over three years to help defray eligible health-care providers’ costs of providing telehealth services to patients at their homes or mobile locations, with an emphasis on providing those services to low-income Americans and veterans.
One multi-stakeholder effort, the LAUNCH initiative (Linking and Amplifying User-Centered Networks through Connected Health), is targeting rural Kentucky with a novel approach to participatory design of a potential solution. Created in 2017, LAUNCH’s goal is to demonstrate broadband-enabled connected health and community-based co-design, said David Ahern, a behavioral scientist researcher at Brigham and Women’s Hospital in Boston, who chairs the LAUNCH collaborative. The project brings together the FCC and the National Cancer Institute to coordinate improving broadband access and cancer outcomes in rural Appalachia. Other partners are a user-centered design team from the University of California, San Diego and the Markey Cancer Center in Lexington, Ky.
In some Appalachian counties, a trip to Markey might take two-and-a-half hours by car, but for many people with financial and transportation challenges, it might as well be on the other side of the moon, Ahern said. “People understand that if we could deliver some aspects of cancer care remotely, it would improve outcomes. Gaining connectivity into those counties is crucial.”
“One of the rationales for the collaborative is that we could take an informatics approach to identify targeted communities and work with the National Cancer Institute to try to deploy a user-centered design approach to create tools to improve cancer care in that region,” Ahern said. The co-creation concept is key, he explained. Rather than having experts coming into a rural area and saying, “We have a solution for you,” the idea is that to be successful, solutions that are meaningful and likely to be used in areas with particular cultures have to be built with lots of input from participants.
The first use case involves doing online distress screening for cancer patients. Research has shown that monitoring patient-reported outcomes through a Web portal actually lowers mortality rates among cancer patients, Ahern noted. Accrediting agencies of cancer centers require distress screenings, “but they have been done in a haphazard way in paper form,” he explained. LAUNCH is making the process electronic and building the workflows around responding quickly if patients rate their stress levels very high.
Ahern emphasizes that the project is not just about connecting doctors and patients. “We want to engage caregivers, family members, community health organizations and church leaders who can be part of a broader solution enabled by connectivity,” he said. “Fundamentally, it isn’t just putting in the broadband and walking away. We are looking at infrastructure as a core element to broaden the ecosystem.”
In its contribution to the project, the FCC is talking to companies and associations in the telecom industry to step up and assist wherever they can. And there’s been a lot of interest from companies wanting to be part of LAUNCH, according to Ahern. “Given the COVID-19 epidemic, there is a recognition that we need to have an all-hands-on-deck approach wherever there can be better connectivity that will save people’s lives, so the industry is poised to do that more rapidly than they might have otherwise done. We are working on that pretty diligently right now, particularly with satellite providers. We think there are some immediate opportunities there.”
During a summer 2019 LAUNCH project meeting, FCC Chairman Ajit Pai described a recent trip he had taken to Allen County, Ky., an economically challenged rural area near the Tennessee border. The school system there has more than 3,000 students — but not one pediatrician. The nearest one is a decent drive away in Bowling Green. “But now, thanks to broadband, local students can see a pediatrician simply by walking down to the school nurse’s office,” Pai said. “There, they can be seen virtually by a top-notch physician from Vanderbilt University’s Children’s Hospital, which has a partnership with the school district,” he said. “Think about what a difference all this makes: Students are healthier, parents worry less and don’t have to take time off work, and teachers can focus on teaching.”
Nic Powers, CEO of Winding Waters Community Health Centers in Enterprise, Ore., spoke last June at a congressional briefing about the value of the FCC’s Rural Health Care program, which provides broadband subsidies. He explained how this program makes affordable, reliable broadband to rural clinics possible. “This is an essential program for rural health-care providers, and it needs to work a lot better to continue making a positive impact,” he said. “Broadband connectivity underpins so much of the work we do every day and it’s so expensive in rural America.”
Winding Waters belongs to a collaborative operated by Portland-based nonprofit OCHIN, which provides hosted electronic health records as well as networking and telehealth support to 450 community health clinics with more than 10,000 clinicians across the nation.
Jennifer Stoll, OCHIN’s executive vice president of government relations and public affairs, describes Winding Waters as being in frontier country. “You leave Portland, drive east for five hours, bank a left and drive another hour north and you hit Enterprise,” she said. The town has very deep canyons surrounding it, so even though they have patients who are only seven miles away, it takes them hours to get to the clinic because they have to drive around the canyons to get there. “They have a health-care site that has a very difficult time with their broadband connectivity,” she added. When Powers told congressional leaders that the FCC program has to work better, he essentially meant it needs more funding. “The funds for the Rural Health Connect program need to be tripled,” Stoll said. “It is way oversubscribed right now. That slows down the applications and approval processes. We would like to see more consistency in how the program operates, because health centers need reliability in terms of broadband.”
Of course, the COVID-19 crisis has opened policymakers’ eyes to the value of telehealth (see sidebar, p. 14). “I think the COVID-19 crisis is elevating the conversation to a whole new level,” Stoll said. “We have to build capacity and there has to be redundancy. We support frontier areas in the West where there is one fiber line in, and on an almost regular basis, that line gets cut. It connects the one hospital in the county and they have to med-evac patients to the nearest local city. That is not the most efficient way to deliver health care. So where we have critical delivery systems of health care, we need redundancy.”
The Connect2HealthFCC program maps health outcomes with broadband access. This map, showing percent of each U.S. county with broadband-level Internet, can be viewed with rates of physician access, diabetes and other factors. / Credit: Federal Communications Commission
Because the federal grant money is disbursed from multiple agencies, some state governments have created broadband offices to manage state budgets and help coordinate how organizations in their state apply for federal funding. Among states with such offices are Oregon, Washington and Ohio. In March, the recently created Ohio Broadband Strategy announced a telehealth pilot project to connect K-12 students with mental health counselors in the rural Switzerland School District in Monroe County, located in southeast Ohio. The goal is to expand the project to other Ohio schools.
The Michigan affiliate of a national nonprofit organization called Connected Nation recently released a study that examines the use and perceptions of telehealth in five rural Michigan counties.
Eric Frederick, executive director of Connected Nation (CN) Michigan, said the study conducted random surveys of residents in the targeted counties to better understand whether they have Internet connections at home and how they interact with health-care providers. “Overall, we found about 60 percent had Internet connection at home, lower than state and national averages. So as we are considering telehealth virtual visits, 40 percent can’t participate right off the bat,” he said. “These are very rural places, so it is not surprising, but it sheds a light on the importance of getting everybody connected.”
In a survey of physicians, remote patient monitoring was the most commonly used online health service. “It is gaining in popularity,” Frederick said, “but again, if 40 percent don’t have an Internet connection to begin with, it is a nonstarter.”
CN Michigan is holding focus groups in the five counties to better understand the barriers to telehealth and to brainstorm some solutions. The organization is also recommending that the state follow through on the steps laid out in the 2018 Michigan Broadband Roadmap to improve broadband access, adoption and use. One of the road map’s key recommendations was to create a state broadband grant program. “That has now been done,” Frederick said. “A $20 million program was created and now it is in the process of final review of grant applications. For those grants, it helps to have a large anchor institution like a hospital because that helps make the financial case for expanding infrastructure further into the community.”
Amid the Wallowa Mountains in Enterprise, Ore., terrain can make an in-person doctor visit several miles away take hours. / Credit: Shutterstock
Danielle Louder, program director for the Northeast Telehealth Resource Center, leads efforts focused on implementing and growing telehealth programs in New England, New York and New Jersey. She says broadband issues continue to impact rural communities in her region, including islands off the Maine coast. “The Medicaid programs in several states in the Northeast allow for the home to be the telehealth originating site, rather than a clinic, and we see that there are lots of rural homes that have very poor or nonexistent Internet service.”
Some rural health-care provider organizations have decent broadband access, she adds, but there is often less competition, which can impact price. “Every time you add a new service line or consider different use cases like live video, that uses more bandwidth,” she said. Telehealth solution vendors are getting better, she added, at using less bandwidth for live videoconferencing applications, leading to fewer dropped calls. “Even a few years ago, dropped calls were a big issue. For both providers and patients, that is a good way to turn people off from telehealth — if the technology isn’t working.”
Louder said that the shift by the Centers for Medicare and Medicaid Services (CMS) and private insurers from fee-for-service payments to value-based care has meant that there is increasing interest in following patients discharged from the hospital more closely. “For accountable care organizations that want to stay in touch post-surgery, telehealth is how to do it.” Chronic heart failure is another use case for remote patient monitoring, she said. “Studies have shown a greater than 75 percent reduction in rehospitalization for those patients, so anytime we can keep folks out of the hospital or going back to the hospital, there are cost savings and patient satisfaction is much higher.”
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