Telehealth in Rural America: Q and A

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A recent report from the Department of Health and Human Services (HHS) shows the impact the COVID-19 public health emergency has had on the expansion and increased utilization of telehealth. Medicare fee-for-service primary care visits provided through telehealth in April 2020 jumped to 43.5%, compared to far less than 1% in February 2020, before the public health emergency (1).

Kidney News invited Scott Bieber, DO, ASN Quality Committee chair, and Terrence Jay O’Neil, MD, FASN, ASN Quality Committee member, two nephrologists practicing in rural communities, to discuss how their practices are providing kidney care via telehealth and the particular challenges that rural Americans face. Dr. Bieber’s practice covers the entire panhandle of northern Idaho, from the border of Canada to the lake regions of Coeur d’ Alene and Sandpoint all the way south to farming regions of the Palouse in Moscow and east to the mining towns around Kellogg and the mountainous border between Idaho and Montana. Dr. O’Neil’s practice area runs from Marion, Virginia, in the east to Sevierville, Tennessee, in the west, and from Harlan, Kentucky, south to near Asheville, North Carolina.

We have seen exponential growth in use of telehealth during the COVID-19 pandemic. How has that worked in your areas?

Beiber: In Coeur d’ Alene, where our main practice site is located, telehealth has for the most part gone very well with some rare exceptions for patients who live outside the city in areas where cell access is spotty in their homes and they maybe do not have Internet or WiFi. In the outreach clinics of Kellogg and Moscow, it has been worse. The entire city of Kellogg lacks access to high speed Internet, and there are some real gaps in cell phone coverage inside the city (my cell does not get signal from our outreach clinic there). Most of the people who live out there are in the mountains and their coverage is zero. Similar problems exist over in the Palouse. Some patients do not have cell phone coverage at their farms or homes and have no Internet access. This means the telephone is the only way we can reach them.

O'Neil: In East Tennessee, I have been working with the James Quillen Veterans Affairs Medical Center (VAMC) to create a tele-video preventive renal care education program for veterans with identified chronic kidney disease at risk for progressive kidney insufficiency. This tele-video program is intended to replace a program created 6 years ago that used a model of group meetings of veterans and their families at the VAMC main campus and each of the six community-based outpatient clinics. The James Quillen VAMC has been very involved in creating a telehealth infrastructure to provide face-to-face voice or (where possible) voice-and-video telehealth to East Tennessee veterans. There have been problems, however, that have tended to deny access to such programs to those most in need—the rural less-well-off Appalachian region veterans.

Are you experiencing what is called the digital divide, or constraints due to broadband access? What have been your experiences? Have you had to change approaches due to broadband challenges?

Beiber: Yes. When it comes to telehealth, of course a telephone call is better than nothing, but a video connection is better than a telephone call alone. Being able to visually see the patient makes a big difference in my ability to recognize and troubleshoot potential problems. In general, due to poor connectivity, we have not been able to provide reliable telehealth services to those patients in the outreach clinics. We leave the choice for a phone call or in-person visit up to the patient and nearly all patients have decided it is better to come to see us in the clinic.

O'Neil: Yes. According to, the average download speed in Tennessee is 12 MBPS and only 82% of Tennesseans have access to a bandwidth of 25 MBPS or more. Keep in mind that download speeds are considerably greater than upload speeds, and secure adequate video at the provider end requires a symmetrical upload for good audio and video. The bandwidth considered best for a business-grade tele-video connection is 50 MBPS. DSL connections are generally inadequate and found mostly in the urban regions around Memphis and Nashville.

If cable broadband access is not available, cellular can substitute, but only when there is adequate signal strength. A review of the (generally overly generous) commercial accessibility maps such as the Multi-Providers Cellular Coverage Maps shows that there are significant pockets of north-central and eastern Tennessee where coverage is sparse or nonexistent. Many veterans live in exactly those areas. Also, cellular data charges escalate rapidly beyond the ability of rural veterans of reduced means who own cell phones to support tele-video connections as they use up gigabytes of data rapidly. And there are many still using landline dial-ups.

There is currently no mechanism in place to pay veterans for the cost of enhanced data/bandwidth plans, even where such plans are available. The current ISP business model is effectively a regional monopoly, and in many areas of rural Tennessee Internet providers have no economic incentive to put expensive cable installations in areas where population density and income would not return a good profit on investment.

What technology do your patients own or have access to (computers, tablets, phones)? How well do they use them?

Beiber: Most people here have a cell phone, but many do not have a smart phone or Internet-capable phone. I continue to be surprised at the number of people who live here who simply do not want to have a smart phone and prefer a standard old school flip phone. Most have a computer or tablet at home but that is hit-and-miss as well. Many do not have one and if they do it is sort of irrelevant to what we can do for them with telehealth because their Internet provider can’t deliver a reliable real time video connection.

O'Neil: Veterans living in the more urban and suburban regions of Tennessee have cable access of some sort. Fairly quickly as one gets into the mountains adjacent to North Carolina, Kentucky, and Virginia, however, the population may have a landline phone or a burner cell phone. Many do not have any computers of any kind. Where there is available Internet access, the VAMC has been loaning Internet-capable iPads. However, many of the same families who lack any form of computer also lack Internet connectivity. The VAMC provides automated blood pressure (BP) cuffs and weighing scales with memory, and if the connection is adequate, those can telemeter the BP and daily weights back to the telehealth office for transmittal to the primary care provider.

How about cell phone coverage? What are the least-served areas? What do you do in those cases?

Beiber: There are many areas in Idaho that do not get cell phone coverage. The least served areas are the mountainous areas and rural farming areas, particularly the farther away you get from major highways or interstates, but even some of the highways I travel have cell phone coverage gaps. Those patients usually elect to come and see us in person, or we do a telephone encounter over a landline.

O'Neil: Much like the situation Dr. Bieber described in Idaho, veterans living in several east and northeast Tennessee regions lack adequate cell phone coverage. Where landlines exist (and some do not have even that), audio-only telehealth is practiced, but with the caveat that face-to-face medical encounters are still required for basic physical parameter documentation (BP, pulse, weight) and physical examination of organs at risk (eyes, ears) as well as crucial laboratory monitoring.

What other thoughts and observations would you like to share?

Beiber: This is a complicated problem. On the one hand, it seems there are certain people who are being left behind due to lack of cell phone and Internet services in the area in which they reside. On the other hand, part of what draws many of these patients to live in areas that are underserved is their desire to be “off the grid,” so to speak. Many of them are perfectly happy not having Internet or cell phones. From a healthcare provider's perspective, what I feel is most important is that we meet patients where they are with regard to technical abilities and continue to have the flexibility to decide what type of encounter is going to work best for that particular patient and clinical situation. I hope that rules and regulations continue to work to facilitate more options for patients to choose how they receive their care.

O'Neil: I agree with Dr. Bieber’s comments regarding Idaho. Additionally, whereas it is true that many of those who live in digitally underserved areas of Tennessee choose to do so, many are in health and demographic groups most at risk for progressive disease and premature death or disability. Their particular reason for living in those areas may indeed be due to a desire to be less digitally accessible, but many are there because the communities they reside in have suffered collapsed mining economies and they lack either the means or the motivation to move.

In the 1930s and 1940s, large stretches of the Appalachian and Blue Ridge Mountain regions had no access to electricity, and the people living in those areas adapted. However, farm productivity was low, and it became a recognized national priority through the Tennessee Valley Authority program to ensure that electricity was accessible by every American, however rural. Today, digital connectivity correlates strongly with educational attainment and prosperity. A program to alter or supplement the private for-profit ISP business model would be justified to ensure that the minimum Internet connectivity judged technically necessary to support distance learning and medical telehealth is available to every American.