Poor broadband access in rural areas limits telemedicine use: study

Telemedicine is frequently touted as a technology tool that can help improve healthcare access for rural populations, especially in areas with physician shortages. But telemedicine might not be the silver bullet to improve rural healthcare when those same areas have significant infrastructure challenges, according to researchers.

Rural counties where access to primary care physicians and psychiatrists is inadequate also have substantially lower broadband penetration rates, according to a recent research report published in Annals of Internal Medicine.

“This observation suggests that the inadequate broadband infrastructure in rural areas prevents telemedicine from mitigating the barriers to care associated with physician shortages and may explain the low rates of telemedicine use among rural Medicare enrollees,” the researchers said in the report.

Fewer than 10% of U.S. physicians practice in rural communities, where 25% of Americans live, according to the National Rural Health Association. There are several ongoing initiatives that use telemedicine to improve access to care for rural populations, such as Project ECHO (Extension for Community Health Outcomes) out of the University of New Mexico. Project ECHO is an initiative that uses telemedicine to help rural and remote providers learn from specialists to manage care for their complex patients.

While federal and state policymakers have enacted policies to expand telemedicine use among publicly and commercially insured beneficiaries, it's not clear whether Americans with the poorest access to care have the necessary broadband internet capability to fully benefit from telemedicine.

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To address this issue, researchers from the University of Pittsburgh, the University of Pennsylvania and Johns Hopkins University used a healthcare provider database and Google Maps to determine whether counties had adequate access to primary care physicians and psychiatrists based on driving time to those providers. The researchers then used Federal Communications Commission (FCC) data to measure whether counties had sufficient broadband internet access.

The researchers measured broadband internet access as the county-level fixed broadband penetration rate as defined by the FCC: the percentage of a county's population with internet access at a download speed of at least 25 megabits per second, which is sufficient to support video-based telehealth visits.

Broadband penetration rates decreased as counties became more rural, and counties with inadequate access to primary care physicians and/or psychiatrists generally had poorer broadband penetration rates, the researchers found. For example, the broadband penetration rate in the most rural counties was 62.4% if primary care physician access was adequate, compared with 38.6% if it was inadequate, according to the study. This relationship between access and broadband penetration was similar for psychiatrists.

As a comparison, the broadband penetration rate in urban counties was 96%.

The study did not address smartphone ownership, and the researchers acknowledged that telemedicine may be delivered via personal phones. However, some insurers, including Medicare, require most telemedicine appointments to originate from a rural healthcare facility; therefore, broadband access at those centers remains relevant.

Telemedicine has been proposed as a way to improve access to care in areas where physicians are in short supply, but it can only work if doctors and patients can access the internet, the researchers said.

“Although telemedicine has the potential to address geographic barriers that result from long drive times to receive care, its potential will not be realized until the telecommunications infrastructure improves and public and commercial insurers develop and expand policies to reimburse telemedicine visits from patients' homes, particularly in the most rural counties,” the researchers said.

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But broadband penetration may not be the only issue deterring the use of telemedicine in rural areas, according to physician leaders with Project ECHO.

In an editorial accompanying the study, Bruce Baird Struminger, M.D., associate director of Project ECHO, and Sanjeev Arora, M.D., director and founder of the project, wrote Project ECHO uses a cloud-based high-definition videoconference platform that functions fully on a modest bandwidth, and that substantially increases rural participants' access to programs either via land or wireless networks.

Effective high-definition video telemedicine is possible by using smartphones and laptops over land and wireless connections and over a range of bandwidths, Struminger and Arora wrote.

For 15 years, Project ECHO has supported videoconference telementoring across New Mexico, in which most counties are counties with extreme access consideration, the project leaders wrote. The initiative now has more than 275 partners across 35 countries using the model to build local healthcare workforce capacity in underserved areas.

The authors suggest that other issues may be barriers to telemedicine use, such as policy issues and reimbursement rules and incentives that inadvertently discourage the use of telemedicine in rural areas.

Struminger and Arora propose several recommendations for increasing adoption of telehealth in rural areas that include establishing incentives for academic medical centers to provide continuing tele-education and telemonitoring and creating incentives for rural providers to participate.

Reimbursement policies also need to change so patients can use telemedicine without the requirement that they participate from hospitals and clinics.

“Successful efforts to improve access to primary and specialty care in underserved geographic regions require a comprehensive approach combining more efficient use of telemedicine, alignment of incentives and policy to support upskilling of primary care clinicians, changes in policy and regulation to allow greater convenience for patients and easier interstate teleconsultation, and adaptation of proven solutions to meet patient needs in areas that lack medical providers,” Struminger and Arora said.