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This reporting is part of a collaboration with Carolina Public Press, the Institute for Nonprofit News, The Daily Yonder, Honolulu Civil Beat and Shasta Scout. Support from The National Institute for Health Care Management (NIHCM) Foundation made the project possible.
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.
This story is one in a four-part national series on health equity produced by The Daily Yonder, the Institute for Nonprofit News, Carolina Public Press, Honolulu Civil Beat and Shasta Scout. Illustration by Phillip Clark
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.
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.
According to the HHS survey, one in four Americans reported accessing telehealth services four weeks prior to taking the survey, which ran from April to October 2021.
The survey showed that video telehealth participation was lowest among people without a high school diploma, those aged 65 and older, and Asian, Latino and Black populations. Only about half of respondents falling in each of these populations reported using video telemedicine.
Other sources, such as the COVID-19 Healthcare Coalition, a private-sector collaboration of medical organizations, nonprofits, academic researchers and business leaders, have conducted similar research to shine a light on telehealth’s prevalence.
Roughly 2,000 people responded to the coalition’s 2021 survey, managed by the Mayo Clinic Health System research team.
The results show little variation in responses among those who self-reported living in rural areas and those who self-reported living in urban areas. For example, 72% of rural respondents indicated they’d use telehealth again, compared to 76% for urban respondents.
The survey, however, was conducted online — effectively omitting the perspectives of the 19 million people the FCC reports lack access to a solid internet connection.
As with the shortage of concrete telehealth data, information about internet accessibility is equally vague.
The FCC tracks broadband fiber access by census tract. Tim Love, director of economic development for Buncombe County, Western North Carolina’s most populous county, explained that if an internet provider claims to provide connection to one home in a census tract, all other homes in that tract are considered to have access.
“Our argument is that that makes no sense,” Love said. “So our approach is that we’re going to make our own map that looks to see who can get online.”
Census data shows 59% of mountain households have internet through fiber-optic, cable or DSL sources. The data does not, however, specify which source the household uses — leaving the total number of people connected to fiber-optic broadband, considered the most stable form of internet connection, up in the air.
According to Love, fiber is the likeliest of all internet sources to provide at least 100 megabits per second for download and 20 Mbps for upload.
That’s enough to connect multiple devices to the internet at the same time, and that level of connectivity is the goal speed for internet connection throughout the state, said NCDIT’s Nate Denny.
“If you’ve got a couple of kids learning from home, a couple of parents working from home, and you’re trying to see your kid’s pediatrician on a telemedicine app, you need much higher speeds,” Denny said.
Despite the state’s acknowledgement that fiber-optic access is the only way to ensure stable internet connectivity, moves to put the infrastructure in places like the rural mountainous areas of North Carolina have been slow-coming.
Though data regarding broadband, telehealth and the relationship between the two has yet to be solidified, its magnitude can be seen through experiences like Berger’s — a 73-year-old cupping her ear to hear a doctor through a computer screen.
“I remember sitting there at one point, moving closer to my laptop thinking, ‘I really would like to hear him better,’” she said.
Two years later, Berger still struggles with her internet, and she has little faith that much will be done to fix the issue.
“I will be shocked if I am in this house when they put a fiber-optic line up this road,” she said.
While I agree that Internet availability and speed is still a big problem in rural areas, Telehealth problems exist at a number of levels:
1. Availability of Internet with reasonable speed.
2. Having Internet service working in the home. (Even a cellphone with Internet access might suffice.)
3. A user interface that is VERY easy to understand.
4. A user with sufficient skills to user the technology.
You are correct with all the issues related to items 1 and 2, but I have been helping seniors with technology since retiring about 15 years ago and issues 3 and 4 are also huge. I have relatives who have written published books with Microsoft Word but still can‘t comfortably start a Zoom meeting because of the number of things that can go wrong. I have friends in their 80s that I have helped a number of times with the same problem getting into their email, bank account or something else.
Last but not least, having lived in European countries where everyone has health insurance and can go to a doctor at any time, one huge problem is the waiting rooms full of elderly people who often sit there for hours and don‘t mind doing that. If Telehealth does really take off, meeting demand will be another huge problem.
Many new technologies remain in an embryonic stage for years before finally taking off, and predicting the duration of that embryonic stage is very difficult. I think Telehealth, while important and growing, still has numerous obstacles to rapid and successful growth, and they are not just Internet access.