When a 10-year-old girl suffered a facial injury in a skiing accident, the physician staffing a small hospital ED in Maine sought a consult with Rafael Grossmann, MD, a trauma surgeon at Eastern Maine Medical Center in Bangor, one of the state's three trauma centers. An operator transferred the call to Dr. Grossmann's iPod Touch, putting the two physicians on a shared HIPAA-compliant WiFi system.
“Boom!” said Dr. Grossmann in a TED talk. (YouTube. http://bit.ly/2NcI0mY.) “Seconds later I connected to the local doctor, and was able to talk to and see the referring provider, the actual patient, the patient's mother, and was able to examine her remotely, and be able to look at her face, look at the swelling, examine her eye movements, and even look at how her pupils reacted, all from my mobile device.”
Broadband access—a key element in Dr. Grossman's anecdote—is called a social determinant of health by the World Health Organization, the Federal Communications Commission, and the American Public Health Association. It also enables other social determinants such as education, employment, and access to health care. Without broadband, telemedicine lacks the sharp video, the conversation between a patient and a physician, and the digital accessories that make it possible to assess a patient hundreds of miles away.
Such innovations are at the core of telemedicine and telehealth, particularly in rural areas. A letter in the Annals of Internal Medicine found that telemedicine will only address the barriers to isolated rural communities receiving care when the infrastructure improves and public and commercial payers reimburse telemedicine visits. (2019 May 21. doi: 10.7326/M19-0283.) “Broadband penetration rates decrease as counties become more rural, ranging from 96% in urban to 82.7% in rural to 59.9% in CEAC [counties with extreme access considerations] county types,” the authors wrote.
In fact, 58 percent of rural Americans said access to high-speed internet is a problem in their area, according to a survey by the Pew Research Center of 6251 respondents between Feb. 26 and March 11, 2018. (May 2018; https://pewrsr.ch/2lWrWK0.) An FCC comparison of U.S. states and territories with broadband access paints a dismal picture: At least 20 percent of the population in 18 states and territories had no broadband providers. (December 2017; http://bit.ly/2lX0dbO.) The problem is dire in territories such as Guam and Puerto Rico, where no residents had broadband access, and in Arkansas, where nearly 45 percent of the population had no broadband providers. (See table.)
Another letter in JAMA Internal Medicine associated broadband internet availability and telemedicine use in a variety of counties, including 869 metropolitan counties with at least some rural residents, 1317 nonmetropolitan counties of smaller towns and cities, and 599 fully rural counties. (2019 Jul 29. doi: 10.1001/jamainternmed.2019.2234.) In fully rural counties, greater broadband access was associated with greater telemedicine use: Counties with low broadband availability had 34 percent fewer visits per capita compared with those with high broadband availability.
The authors, led by Ateev Mehrotra, MD, MPH, of the department of health care policy at Harvard Medical School in Boston, noted that the Federal Communication Commission has awarded billions of dollars to expand broadband, but most of that money was not allocated to counties that need help. They suggested more targeted funding in fully rural counties.
Dr. Mehrotra said the availability of broadband in a residential situation may be very different from that in emergency departments, which may have more capacity to obtain broadband.
The ability to interact with patients is an important part of care in the ED. Telestroke consultations with physicians in a facility that is not a primary stroke center can guide care, for example, while teleradiology can provide diagnostic information in emergencies. Teletrauma can fill in the gaps for the 70 percent of the U.S. population that does not have access to designated trauma centers. As Dr. Grossmann's story illustrated, new technology can give trauma experts patient access even when they are not in the emergency department.
A Vehicle for Care
Viraj S. Lakdawala, MD, the director of telemedicine in the department of emergency medicine at NYU Langone Health, said his department has started online emergency care in the New York City region. His hospital set up virtual urgent care that allows patients to chat with one of their doctors. An integrated teleconsultation for stroke is part of emergency care. “There's a whole list of things we can treat well online,” he said.
Dr. Lakdawala said patients report that using telemedicine saves them three hours of their day and the cost of leaving work, getting a babysitter, and travel. Often patient visits are via cell service, he said. “They work pretty well on LTE networks and the newer generations of cell.” Telemedicine will play an important role as physician assistants and nurse practitioners take over care in rural areas, he said. “At least you have a physician to offer.”
Ed Sheehan, MD, the chairman of the American College of Emergency Physicians' telemedicine committee, said the push for broadband may compete with that for wireless. “I do still think there are people in 2019 who don't have internet access,” he said.
“The first thing to make clear is that telemedicine or telehealth is not some magical type of medicine,” he said. “It is just a vehicle in which we deliver care. Telemedicine is magic only in the sense that it allows one provider to be in an unlimited number of places at one time.”
Dr. Sheehan said the only drawback to telehealth is not being able to put a hand on the patient, but he called it a great opportunity for rural health. “There are not enough emergency physicians to staff all rural hospitals,” he said. “If we can provide backup via telehealth, doctors there can become better providers. We would not provide care but become an educational tool to make everyone better.”
The issue may be solved legislatively. The U.S. House of Representatives passed a broadband bill in May to advance critical connectivity and expand service (HR 1328). Meant to boost federal support for increased broadband in underserved areas, it establishes an office of internet connectivity and growth at the National Telecommunications and Information Administration, directs the office to simplify access for small businesses and local communities, streamlines federal assistance applications from small businesses and local communities. The Senate has yet to act.
Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.