No internet, no telehealth – NC Health News

By Shelby Harris

Carolina Public Press

Two summers ago, Lee Berger sat in her Macon County, N.C., home hunched over a laptop — pulling the small computer closer to her face. 

It was Berger’s first telehealth appointment, a routine check-up with her primary care physician, and she couldn’t hear what the doctor was saying. 

Berger thought about telling the doctor to speak up, but then she remembered her house, fastened at the end of a 17-house subdivision in the small town of Franklin, doesn’t often invite steady internet connection.

Berger isn’t hard of hearing, and she’s not unskilled when it comes to the internet. The 73-year-old retired school teacher frequently runs speed tests on her own Wi-Fi, which she gets through her cable provider, Optimum.

Macon County is a rural mountainous county ensconced in a large stretch of the Southern Appalachian Mountains.

The 18-county western part of North Carolina is also home to nearly 380,000 households, many of whom — like Berger’s — do not have solid internet connection due to a lack of access to fiber-optic broadband. 

Fewer than one in four mountain residents has access to fiber, according to a North Carolina Department of Information Technology (NCDIT) map that combines broadband data from the U.S. Census Bureau and the U.S. Federal Communications Commission (FCC).

This not only means that most of the region is unable to stream Netflix on a rainy night, but also that other facets of life becoming dominantly virtual, such as connecting to a doctor, are impossible for many. 

Across the entire state, an estimated 4 million North Carolinians don’t have access to reliable broadband service. This particularly affects rural residents, many of whom live in communities that tend to suffer most from a lower supply of health professionals. 

According to the University of North Carolina’s Cecil V. Sheps Center For Health Services Research, there’s an average of 6.8 primary care physicians, eight nurse practitioners and 1.8 physician assistants per 10,000 Western North Carolina residents.

Those figures are less than the state averages of 8.73 physicians, 9.7 nurse practitioners and 2.2 physician assistants per 10,000 North Carolinians.

Telehealth is often promoted as the solution to increasing access to health care. But what do we really know about the virtual resource, and how effective is it without a reliable internet connection?

The emerging prevalence of telehealth

Choosing to forego telehealth is not always an option, as doctors are starting to heavily rely on the resource. 

An American Medical Association survey showed that 85% of physician respondents used telemedicine services, and roughly 56% of those physicians said they were looking to increase telehealth use in their practices even after the COVID-19 pandemic ceases to prevent in-person appointments. 

Some medical services in Western North Carolina have switched solely to virtual platforms, such as Mission Health’s telehospitalist and telepsychiatry programs, Mission spokesperson Nancy Lindell said. 

Mission Health is the largest medical provider in the region with six hospitals, several specialty and walk-in clinics and 1,600 staff physicians, according to the hospital system’s  website. 

Mission’s owner, HCA Healthcare, the largest hospital system in the country, was sued earlier this year after several local governments alleged it had created a medical monopoly in the region. The lawsuit is pending. 

“Nearly all” providers employed by the health care system offer telehealth services, Lindell said. The fields with the highest telehealth uptake are primary care, weight management, children’s specialities, infectious diseases, neurology, genetics, behavioral health and cardiology. 

“Our providers have benefitted from the telehealth infrastructure we already had in place that was quickly rolled out during the pandemic,” Lindell said. “They have gained experience to understand where telehealth is clinically effective and beneficial for improved access.”

But for some, such as Berger and other rural North Carolina residents, telehealth may not mean “improved access.”

“I’ve been in this business for a while, and I do not believe that without a hybrid telehealth model — in-person and then also telehealth — that we will be able to do what we need to do for our rural citizens,” said Maggie Sauer, director of the state’s Office of Rural Health.

Inability to access telehealth can not only impede a person’s ability to receive basic health care, but it can also mean missing out on other benefits of virtual medicine, such as a doctor’s ability to observe a patient’s living conditions, Sauer said.

She described a recent conversation with a physician who said he couldn’t figure out why one of his patients would not take a prescribed medication.

The doctor sent a community health worker — a state-employee who connects community members to health and social services — to help the patient set up technology for an upcoming telehealth appointment.

The worker discovered the patient did not have electricity or running water and “the house was infested,” Sauer said.

“The community health worker helped kind of bring all these pieces together, and now this person is in a place that’s clean. They have food, they have water, they have access to medication,” she said.

Census data shows roughly a quarter of people in Western North Carolina’s rural counties are 65 and older, and one of the Office of Rural Health’s main goals is ensuring digital literacy and internet connectivity for this population.

The department has set up internet hotspots in rural areas and deployed community health workers to connect people in rural communities with telehealth providers, Sauer said. 

Vague data

It’s difficult to gauge how many rural North Carolina residents want to access telehealth, but can’t due to lack of internet, because little data exists on the subject. 

The U.S. Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) have released reports on telehealth use, but the information was collected via voluntary surveys that may not present the most complete picture. 

Further, the CDC’s data only reflected telemedicine uptake in 2020 at the peak of the COVID-19 pandemic.