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Lack of Broadband Limits Telemedicine in Rural Areas

Fixing connectivity holes could improve health for many older people


Part of the Strengthening Rural Health Care for Older Adults Special Report

(Editor’s note: This story is part of a special report for The John A. Hartford Foundation.)

With a computer tablet from the Center for Telehealth at the University of Mississippi, health care providers regularly monitored a rural diabetes patient’s condition. But when the patient needed to transmit data to the doctors at the center, things got complicated.

“He had to get in his car and drive to the top of the hill so he could make sure he had clear communication,” said Michael Adcock, the center’s executive director. “That’s not something he should have to do. He was passionate about the program and wanted to improve his health. There’s got to be a better way.”

Broadband Connections Often Difficult

It’s not an uncommon dilemma in rural America.

In aging communities there where rates of diabetes, obesity, heart disease and cancer tend to be above average and doctors are in short supply, the alternative of telehealth — connecting patients and health care clinicians remotely through digital technology — is often stymied by spotty or nonexistent broadband connections.

To appreciate the scope of the dilemma, consider that the prevalence of diabetes is 41 percent higher than the national average in in the country’s least-connected rural communities.

In fact, almost a third of Americans in rural areas don’t have Internet connections that meet the Federal Communications Commission’s (FCC) minimum definition of broadband service. The figure is even higher in some states, including Mississippi. That significantly limits how well doctors can track the progress of patients who lives hours away, especially older ones who no longer drive.

“The big thing we like to be able to do in a home is monitor how people are managing chronic disease,” Adcock explained. “That service could be expanded pretty dramatically if we had better broadband that could increase the speed and capacity so we could do video visits. Right now, that would be an extreme challenge.”

Adcock points out that the ability to do remote monitoring not only can help people with chronic conditions get healthier, but it also reduces their hospital admissions and visits to emergency rooms for treatment.

“This is the first situation I’ve seen in health care where it’s truly an all-around win — for the patient, for the health care provider and for the payer,” he said. “You never see that.”

‘Double-Burdened’ Communities

The reality, unfortunately, is that many sick people who could most benefit from digital health care don’t have access to it.

That’s illustrated through a project undertaken by an FCC task force called Connect2Health. Last year, in conjunction with the Robert Wood Johnson Foundation, it launched an interactive tool that enables users to see the level of broadband availability in individual counties, along with rates of obesity, diabetes and access to physicians.

It’s not a pretty picture. It’s more of a worst-case scenario.

“One thing the task force maps show is that there are too many counties in this nation that we call double-burdened,” said FCC Commissioner Mignon Clyburn. “These are counties with the worst access to primary care physicians, and also the least connected when it comes to broadband.”

A Focus on Appalachia and Cancer

The task force is now taking a closer look at a region where the situation is particularly grim — Appalachia. It’s the only area in the country where both cancer cases and mortality have continued to rise over the past four decades. In the hardest-hit counties, the rate of cancer deaths is 120 for every 100,000 residents, almost three times the national average.

Connect2Health recently joined the National Cancer Institute and the Markey Cancer Center at the University of Kentucky in a research project called L.A.U.N.C.H. (Linking and Amplifying User-Centered Networks through Connected Health). The goal is to determine how much broadband connectivity can improve the ability of rural cancer patients to manage their symptoms.

It will be a real test of long-distance monitoring because cancer treatment is more complex and individualized than what’s prescribed for a condition like diabetes. The drug regimen can be demanding, the side effects brutal.

“What we want to figure out is what does it take to stay connected with our patients once we send them home,” said Robin Vanderpool, associate professor in the University of Kentucky College of Public Health and director of Community Outreach and Engagement at Markey. “How do we help them take care of their symptoms — everything from fatigue to nausea and vomiting to depression? Do we send them home with a tablet that transmits their personal data to a care team at a hospital or cancer center? That way the doctors and nursing staff can see what’s going on with them in real time versus having them go see a doctor four weeks later and trying to remember what’s happened the past month.”

What Monitoring Can Do

She provided an example of how that kind of monitoring could make a difference. Said Vanderpool: “Say a patient’s pain started as a two (on a scale of one to 10) in the morning, but got to be an eight or nine by the end of the day. They’ll probably end up in the ER. But what if you could monitor this on more of a real-time basis and come up with an immediate care plan?”

Bradford Hesse, who heads the National Cancer Institute’s Health Communication and Informatics Research Branch, agrees that a key to improving the dismal cancer statistics is maintaining connections with faraway patients.

“The high mortality rate tells us there’s an implementation problem,” he said. “We’re just not getting this knowledge to people. That’s why the L.A.U.N.C.H. project became a very interesting idea for us.”

Another potential benefit of good broadband service, Hesse noted, is that access to telemedicine tools could make it easier for residents of rural areas to participate in clinical trials, something that doesn’t happen very often due to the distances they would otherwise need to travel to hospitals or clinics.

Who Will Pay?

Broadband access remains scarce in so many rural communities because big telecom companies have little financial motivation to build out infrastructure in areas with so few potential customers. So more places are beginning to create public-private partnerships as a way to move things forward. It’s an approach FCC Commissioner Clyburn believes has much potential.

“Government can’t afford the investment by itself,” she acknowledged. “Private industry is not going to go where it’s not going to get a certain return on investment. And, foundations cannot address all the challenges we have in society. But if we get all three together, we can take on this challenge.”

That’s where a project such as L.A.U.N.C.H. comes in. If it can show a transformative impact of telemedicine on the health of cancer patients, that helps build the case for broadband investments in more remote locations.

“We are looking for this demonstration project to become a model for how we can sustainably implement connected health using broadband-enabled technology anywhere in the country,” said David Ahern, a member of the Connect2Health task force and the FCC’s lead on the L.A.U.N.C.H project. “We hope to learn more and more about the benefits when people are connected, how their health can improve and how it can also help clinicians deliver care more efficiently and more proactively.”

Not Just About Netflix

There is still much to learn about how patients will respond. Will they become engaged with the technology? Or will they eventually lose interest or become intimidated by it, as is sometimes the case with older adults?

“We can sit in our ivory towers and dream up all kinds of things to send home with patients, but are they actually going to use them?” Vanderpool conceded. “How much do you need to train them? Or do you need to train the caregiver, too? Or do we get health workers who are already in the community to help?”

To Adcock, it’s critical to sharpen public perception that broadband access can help keep people healthy and reduce health care costs.

“We need to keep making the point that we need high-speed broadband not just to use Netflix, that it’s not just to stream YouTube videos or be able to order more on Amazon,” he said. “If we can show that we can save a lot of money using telehealth, maybe we can push more broadband expansion that makes it even more prevalent.”

By Randy Rieland
Randy Rieland often writes about aging and technology for the Innovations blog on Smithsonian.com. Previously, he was in charge of digital media for the Discovery Channel.  He is based in Washington, D.C.

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