When this rancher was gored by a bison, ambulance telehealth helped save his life

Video systems on ambulances let medics get help from more
advanced providers. (Photo by Arielle Zionts, KFF HN)

When severe ranch injuries happen, having experienced medical care on hand can mean the difference between life and death. But in many cases, rural medics don't often treat life-threatening wounds. Some ingenious South Dakotans figured out how to overcome that dangerous knowledge gap.

"Rural medics who rescued rancher Jim Lutter after he was gored by a bison didn't have much experience handling such severe wounds," reports Arielle Zionts of KFF Health News. "But the medics did have a doctor looking over their shoulders inside the ambulance as they rushed Lutter to a hospital. The emergency medicine physician sat 140 miles away in a Sioux Falls, South Dakota, office building. She participated in the treatment via a video system recently installed in the ambulance."

Ed Konechne, a volunteer emergency medical technician with the Kimball Ambulance District, told Zionts, "I firmly believe that Jim had the best care anyone has ever received in the back of a basic life support ambulance." Zionts adds, "The ambulance service received its video system through an initiative from the South Dakota Department of Health. The project, Telemedicine in Motion, helps medics across the state, especially in rural areas."

The pandemic years helped Telehealth become more accepted, and the "technology is starting to spread to ambulances. Similar programs recently launched in regions of Texas and Minnesota, but South Dakota officials say their partnership with Avel eCare — a Sioux Falls-based telehealth company — appears to be the nation's only statewide effort," Zionts reports. "Rural medics often have less training and experience than their urban counterparts, Konechne said. Speaking with a more experienced provider via video gives him peace of mind, especially in uncommon situations. Konechne said the Kimball ambulance service sees only about three patients a year with injuries as bad as Jim Lutter's."

Katie DeJong was the emergency medicine physician at Avel eCare's telehealth center "who took the ambulance crew's video call," Zionts writes. "After speaking with the medics and viewing Lutter's injuries, she realized the rancher had life-threatening injuries, especially to his airway. . . . . DeJong called the emergency department at the hospital in Wessington Springs — 25 miles from Gann Valley — to let its staff know how to prepare. DeJong also arranged for a helicopter to fly Lutter from the rural hospital to a Sioux Falls medical center, where trauma specialists could treat his wounds."

To read more about Lutter's rescue or how South Dakota is funding its program, click here.

As rural communities lose physicians, a creative "patchwork" of care can emerge

An OnMed health kiosk uses high tech, remote care.
(Photo by Arielle Zionts, KFF Health News)

Rural patients are more likely to face medical provider shortages, and these communities have to find new ways to provide care. In LaFayette, Alabama, "Terry Vester and her husband, Al, are the only primary care doctors in the town of 2,700 residents, surrounded by farms and other small communities," reports Arielle Zionts of KFF Health News. "The Vesters are in their late 60s and would like to retire soon. Terry Vester wants to spend more time with her grandson and aging parents. But she can't imagine abandoning her patients, some of whom she has cared for since they were born."

Attracting new physicians is challenging for LaFayette, which is not a wealthy town with the amenities many doctors seek. Residents have a median income of $39,077, compared to the state's $59,910. "Black residents — who make up 70% of the population — are much more likely to live in poverty than white residents," Zionts writes. "The Vesters have worked in LaFayette since the early 1980s and saw the local hospital close in 1988. The nearest emergency room is now in another town 20 minutes away along a rolling road. So are the nearest urgent care clinic and pediatrician's office."

With those barriers in mind, town residents who need medical advice have turned to "the city fire department, staffed with full-time firefighters and emergency medics," Zionts reports. "People from LaFayette regularly walk or drive themselves to the fire station to ask for help, said Fire Chief Jim Doody. He added that the station has a makeshift exam area within its small entryway, containing a bench, defibrillator machine, and cabinet filled with medical supplies. . . .This de facto walk-in clinic option isn't available in most other rural areas, where emergency medical services are often run by volunteers who aren't posted at a station all day, Doody said. But he's noticed fewer LaFayette residents relying on the fire department since a new telehealth service arrived in town."

OnMed telehealth kiosk service opened in LaFayette to meet basic medical needs. Patients can head into a computerized booth, press a button and see "a nurse practitioner appear on a large vertical video screen positioned at eye level," Zionts explains. "OnMed patients use an automated blood pressure cuff and other devices to collect their vital signs, and the data is sent to the provider treating them from a distance. Patients can also hold a stethoscope to their chest to transmit the sounds of their heart and lungs. A special camera captures internal temperatures, which can be used to diagnose infections. A hand-held camera lets providers examine problems such as rashes, irritated eyes, and swollen throats. In some states, the stations can dispense medications."

While Vester spoke positively about OnMed services, she feels "It's still important to have doctors in town," Zionts reports. "Vester plans to reach out to Alabama medical schools to let them know she's looking for doctors to take over for her and her husband."

DEA looks to curb telehealth prescriptions, which advocates say will complicate rural care and addiction treatment

Photo by Ted S. Warren, The Associated Press

The opioid epidemic has become a persistent, brutal feature of American life. "Its despair and suffering echo through cities large and small, from pitched tents . . . to the hamlets and hollows reeling from the opioid epidemic across Appalachia . . . a nation seemingly inured to the startling toll of addiction," wrote Kevin Deutsch of The Rio Grande Sun in Española, New Mexico, long plagued by drugs.

The stories of suffering, death and a medical communities stretched to their limits explain recent push-back against a new Drug Enforcement Administration "plan to resume tighter limits on the prescribing of controlled substances through telehealth," report Stephanie Armour and Liz Essley Whyte of The Wall Street Journal. "Under the proposed rules, other drugs, including Adderall, Ritalin and OxyContin, would require patients to meet in person with prescribers first or be referred by a doctor they met in person. . . . Patient-advocacy groups say the requirements would create barriers to care. . . . The in-person requirement will make it harder for certain patient populations who live in rural areas where there are few doctors or in areas where there are long waits to see a provider, according to organizations opposed to the proposal."

Dr. Bobby Mukkamala, chair of the American Medical Association's Substance Use and Pain Care Task Force, told the Journal, "The DEA proposal requiring an in-person visit within 30 days to get a prescription refill is far too short and unrealistic. For patients being treated for opioid-use disorder, this proposal could result in more overdose deaths. For those who rely on controlled substances, it could result in avoidable emergency visits and hospitalizations." The Journal reports, "Dr. Brian Hurley, new president of the American Society of Addiction Medicine, said adding the requirement risks undermining public safety because the country is in the throes of an overdose crisis."

Why now? "The proposal comes as the Justice Department has been increasing its focus on telehealth companies that prescribe controlled substances [citing] possible violations of the Controlled Substances Act. . . . The Department of Health and Human Services  issued a special alert warning about telehealth fraud and its potential to harm patients . . . . Still, a number of medical groups say the in-person mandate isn't the solution to possible fraud. They say the DEA has rushed through the proposal, which got about 35,000 comments during a 30-day public comment period."

"A Biden official said the in-person requirement is meant to make sure that patients struggling with addiction are also screened for other health problems, such as heart conditions or diabetes," the Journal reports. "Telehealth with medication-assisted treatment for opioid-use disorder was linked with greater patient satisfaction, an overall reduction in healthcare costs, and an increase in the use of buprenorphine, according to a June 2022 study in the journal Telemedicine and e-Health.

Sexual assault victims in some rural areas are now able to get examinations through telemedicine services

Nurse Lindee Miller stands with the cart used for teleSANE exams at
Avera St. Mary’s Hospital in Pierre, S.D. (Photo by Arielle Zionts, KHN)

Until recently, rural sexual assault victims who sought medical care faced multiple hurdles to simply get to a hospital. Through advances in telehealth exams, that reality is changing, reports Arielle Zionts of Kaiser Health News.

Zionts presents the example of a nurse in Eagle County, Colorado: "Amanda Shelley was sitting in her dentist’s waiting room when she received a call from the police. A local teenage girl had been sexually assaulted and needed an exam. . . . She went to her car and called a telehealth company to arrange an appointment with a sexual assault nurse examiner, or SANE. The nurse examiners have extensive training in how to care for assault survivors and collect evidence for possible criminal prosecution. . . . About an hour later, Shelley met the patient at the Colorado Mountain Medical urgent care clinic in the small town of Avon. She used a tablet to connect by video with a SANE about 2,000 miles away, in New Hampshire."

The exam process involves "the remote nurse using the video technology to speak with the patient and guide Shelley through each step of a two-hour exam. One of those steps was a colposcopy," Zionts reports. "The remote nurse saw, in real-time, what Shelley could see, with the help of a video camera attached to the machine."

Zionts writes, "The service, known as 'teleSANE,' is new at Shelley’s hospital. Before, sexual assault patients faced mountains of obstacles — literally — when they had to travel to a hospital in another county for care." Shelley told Zionts, "We’re asking them to drive maybe over snowy passes and then [be there] three to four hours for this exam and then drive back home — it’s disheartening for them. They want to start the healing process and go home and shower.”

TeleSANE services are "expanding across the country in rural, sparsely populated areas," Zionts reports. "Research shows SANE programs encourage psychological healing, provide comprehensive health care, allow for professional evidence collection, and improve the chance of a successful prosecution."

Big bill's rural-health items touch Medicaid money, telehealth rules, mental-health hotline, drug treatment, Native care

Senate Majority Leader Chuck Schumer speaks with reporters as he
walks to a vote at the U.S. Capitol. (Photo by Francis Chung, Politico)

The whopping 4,155-page omnibus spending bill is whipping its way through Congress. The $1.7 trillion measure is crammed with public-policy changes and funding provisions.

Here are some items with rural resonance that made it in, starting with several health-related provisions:

• An earlier end to Covid-era state Medicaid funding and rules. Additional funding will end on April 1, 2023, instead of June 30. The change will end rules that effectively barred any state from dropping people from the rolls if the state wanted to get the 6.2% bonus.
  
• An extension of rules that supported telehealth options through 2024, which "falls far short of a push from some lawmakers who wanted to make that flexibility permanent," Politico notes. The pandemic ushered in telehealth as accepted medical care.
• Almost $502 million, a nearly $400 million increase, for the new 988 national hotline for mental-health services. "The ultimate goal is to be able to dispatch mobile crisis teams immediately to anyone in need, no matter where they live," The Washington Post reports.
• Easier access for health-care providers to prescribe buprenorphine to treat opioid addiction. They would no longer have to get a separate waiver from the Drug Enforcement Administration.
• More stable funding for the Indian Health Service, a result of perhaps the largest effort by Native American groups "to provide more funding certainty to the federal health agency that helps serve roughly 2.6 million American Indians and Alaska Natives," the Post reports.
• A limit for tax breaks on land-conservation purchases: "The provision would automatically disallow any deduction that is 2.5 times more than what investors put into a partnership that is making the deals — an indication that easement organizers artificially inflated the value of conserved land to get more tax savings," reports Benjamin Guggenheim of PoliticoPro.
• "Maine lawmakers successfully included a pause on new regulations they warned would cripple their state’s lobster industry," Politico reports. "The provision delays new rules by six years, which critics argue will allow fisheries to put off actions that would prevent fishing gear from harming and even killing endangered whales."
  
• UPDATE: The bill funds a program that gives poor families $40 per month per child for summer groceries, and "allows schools and nonprofits in rural areas to deliver meals or offer pick-up options to families during those months," The New York Times reports.

The bill would also amend the Electoral Count Act of 1887 to make clear that the vice president, as presiding officer of the Senate, plays only a ministerial or ceremonial role in the counting of electoral votes from the states. The law's vagueness contributed to the violence at the Capitol on Jan. 6, 2021. The bill would also raise the threshold for challenging electoral votes to one-fifth of both the House and Senate, from the current one member of each chamber.

Amid shaky finances in rural health care, Heartland Forward report suggests ways to improve access and services

By Worth Sparkman
Axios NW Arkansas

Affordability, telehealth and a trained, motivated workforce are the keys to keeping the engine of rural health care running smoothly. A Heartland Forward report outlines strategies policymakers and community leaders in rural America can use to improve health care access and services.

Many rural hospitals in the U.S. face a funding crisis. Many small, independent hospitals face possible closure or consolidation through acquisition as they struggle with finances. One in 10 hospitals in Texas and more than half of Mississippi's rural hospitals are at risk of shuttering.

The report analyzes data from Arkansas, Kansas, Kentucky, Missouri, Oklahoma and Tennessee, where Heartland Forward convened focus groups and expert interviews, but researchers see potential applications for its concepts nationwide. Authors found three areas with the most possible impact:

• Increasing price transparency and working to reduce complexity in understanding the health care system can lead to residents using it more often for preventive care rather than acute care.
• Expanding access to telehealth by lowering policy barriers for providers and normalizing the tools for patients.
• Boosting the health care workforce through training, streamlining licensing regulations and providing advancement opportunities for practitioners.

True to its nature as a "think and do tank," Heartland developed three tools for communities in the six-state region to use to guide care-related planning and decision making:

• A policy recommendations document that provides a detailed map of barriers and opportunities to address affordability, telehealth and workforce issues.
• An interactive accessibility dashboard that provides detailed county, congressional district and state-level data on various health and wellness topics.
• An interactive labor market tool with detailed geographic data on 31 health care professions.

The bottom line: Researchers write that as access to health care declines in rural areas, the workforce becomes less productive and slows economic performance, so a focus on health and wellness will also rev up an area's economic vitality.

New FCC broadband map faulted by telehealth advocates; it's easier to challenge, but the deadline is Jan. 13

The Federal Communications Commission's new maps of high-speed internet service in the U.S. may be "a step in the right direction" but it leaves much to be desired, telehealth advocates say.

They told senators Thursday that the maps. which will guide Infrastructure Investment and Jobs Act funding for internet expansion, "need to be significantly revamped -- as some communities are entirely missing from the maps -- to ensure the unserved and underserved are accurately represented," Cara Smith reports for Inside Telehealth. They want the FCC to extend the Jan. 13 deadline for comments.

"A government official told Inside TeleHealth that navigating the FCC maps also were confusing, so individual community members may have significant challenges navigating the data," Smith reports. "Even if the maps are corrected in time, lawmakers and stakeholders still worry about instances of fraud, waste and abuse from contractors receiving funding to construct broadband in unserved or underserved areas."

Smith notes that the Government Accountability Office, the bipartisan auditing arm of Congress, has "called for the White House to synchronize the over 100 federal programs that aim to expand broadband access to rural areas and other locations with limited or no access to internet, and to ask for congressional help if necessary. Without a national plan, GAO said, the federal government could miss the chance to expand internet access and increase access to essential services, like telehealth."

The new map is still based on reports from telecommunications companies, but at a more granular level, Robert Gallardo, director at the Purdue Center for Regional Development, told Kristi Easton of The Daily Yonder. "That’s the same glitch that we had before, which is providers reporting on their own,” he added. “Now you can go in and challenge that availability, but it does require a little bit of prep time, meaning you can see the options you have to challenge the availability piece.”

To challenge the map, "One has to include either a bill from the provider or include a screenshot from the website that shows the package is not available for that address," Eaton reports. "The worry, according to Gallardo, is that challenging the map takes some technology know-how that not everyone may have. And the deadline to challenge for this map is Jan. 13."

Feds plan to allow addiction-treatment drug to be prescribed via telehealth, since Congress seems unlikely to do so

Congress seems unlikely to relax the rules for prescribing Suboxone (buprenorphine), a drug that helps addicts kick opioids, so the Biden administration plans to do it at least temporarily: by regulation, under the powers it has under the public-health emergency for the Covid-19 pandemic. 

A White House official told Inside Telehealth that the administration will seek public comment “hopefully very soon” on its plan to allow Suboxone to be prescribed via telemedicine, "as stakeholders appear to face an uphill battle in getting Congress to extend a COVID-19 pandemic waiver of . . . in-person prescribing requirements for controlled substances," Cara Smith reports. 

"Beth Connolly, assistant director of public health at the Office of National Drug Control Policy, said . . . Wednesday evening that the administration is making the move to prevent people from losing access to the drug used to treat opioid use disorder."

The administration has suggested congressional action might be needed "to allow controlled substances to be prescribed via telehealth, lobbyists and research organizations have said it is within the Drug Enforcement Administration’s regulatory power," Smith reports. "A temporary waiver of the in-person prescribing requirements for controlled substances that was put in place during the Covid-19 pandemic expires when the public health emergency ends, expected to be in mid-April," though the Centers for Medicare and Medicaid Services "will reimburse for audio-only initiation of buprenorphine through the end of 2023."

The administration may face internal resistance from the DEA. Last year, the Department of Health and Human Services began allowing most medical providers to prescribe buprenorphine for opioid-use disorder without having to obtain special training, but the DEA's aggressive tactics against pharmacies suspected of improperly dispensing the drug may dissuade stores from carrying it, making prescription filling more difficult.

Telehealth potential unrealized in places with poor internet; that becomes a bigger issue when telehealth is mandated

Homes in wealthy communities like the Blue Ridge Mountain Club near Boone, North Carolina, have access to high-speed internet. But most parts of the mountainous western region of the state, which has many poor people, have little broadband infrastructure. (Photo by Mark Darrough, Carolina Public Press, via The Daily Yonder)

The pandemic proved the great potential of telehealth for rural Americans, advancing its use years beyond what its advocates had expected. But it remains hamstrung by the lack of reliable, high-speed internet in many rural areas. That problem is explored in a four-part series by The Daily Yonder, the Institute for Nonprofit News, Carolina Public Press, Honolulu Civil Beat and Shasta Scout. with support from the National Institute for Health Care Management Foundation.

"Chronic health conditions and distance to medical services mean rural residents need more health-care specialists and better telehealth. But they are less likely than urban areas to get it," the Yonder says in introducing the first installment, in which Kristi Eaton cites examples from upstate New York, the Hawaiian island of Lanai, northern California and western North Carolina.

From the latter region, Eaton writes: "Lee Berger sat hunched over her laptop trying to complete a routine appointment with her primary-care doctor. But the 73-year-old, who has good hearing, couldn’t fully hear what the doctor was saying. It came down to unreliable internet access, she told Carolina Public Press. In North Carolina, an estimated 4 million residents don’t have access to reliable broadband service. This tends to have a greater effect on rural residents, many of whom live in communities that suffer most from a smaller supply of health professionals."

Fiber-optic service is provides the best broadband. but fewer than one in four households in western North Carolina even has access to fiber, Shelby Harris of CPP reports in the second installment, which reveals another problem: health-care providers who mandate telehealth, "such as Mission Health’s tele-hospitalist and tele-psychiatry programs. . . . Mission Health is the largest medical provider in the region" and is owned by HCA Healthcare, "the largest hospital system in the country."

Maggie Sauer, director of the North Carolina Office of Rural Health, told Eaton, “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.”

Health-care roundup: Providers in N.D. discuss challenges; regulations boosting telehealth expansion will expire soon

Here's a trio of stories about rural health care:

At a roundtable discussion Monday, rural health-care providers in North Dakota spoke to state and federal officials about the difficulties they face. Participants "cited workforce issues, regulations and rising costs as three challenges to provide services in rural areas," Masaki Ova reports for The Jamestown Sun. Officials in attendance included Sen. John Hoeven, R-N.D.; Xochitl Torres Small, the Agriculture Department’s undersecretary for Rural Development; and Erin Oban, her North Dakota director.

Rural hospitals had to adapt to survive during the pandemic, aided by federal funding. Some hospitals hope to keep some of those new capabilities, but may not be able to when the federal public-health emergency order expires—drying up funding with it.

Donald Lloyd, CEO of St. Claire Regional HealthCare system in Morehead, Ky., said the shift to telehealth is likely here to stay. "Before the pandemic, telehealth visits weren’t common at his hospital. Now telehealth visits account for nearly 20% of hospital visits," Liz Carey reports for The Daily Yonder. That goes especially for behavioral health, he said, since more than 80% of such visits to the hospital are via telehealth these days.

Speaking of telehealth: Relaxed regulations during the pandemic allowed health-care providers to more easily prescribe buprenorphine for opioid-abuse disorder. Studies have shown that telehealth prescription visits are at least as effective as in-person visits in keeping patients on their medication, but those regulations will expire along with the federal public-health emergency order. "That could come as soon as October, and the Drug Enforcement Agency, which has sought to clamp down on buprenorphine’s misuse, has already missed deadlines to facilitate virtual access," Krista Mahr and Ben Leonard report for Politico. "The expansion across sectors has been critical in rural areas, where access to licensed clinicians is scarce and social stigma runs high."

Doctors worry that telehealth makes it more difficult for them to detect drug abuse by patients or the patients' risk for it

Telemedicine, or telehealth, has proven its value in the pandemic, but physicians are concerned that it leaves them less able to detect patients' misuse of drugs, a national poll of doctors found.

Quest Diagnostics found that two-thirds of physicians it surveyed "fear they missed signs of drug misuse during the pandemic, and, given how the global health crisis disrupted medical care, anticipate rising overdose deaths – especially those involving prescribed and non-prescribed (illicit) fentanyl – even as the pandemic subsides," the company said in a news release. For the full report, click here.

Quest noted an increase in drug-overdose deaths in the first year of the pandemic, and big increases in non-prescribed fentanyl and heroin among people whose test results it ran early in the pandemic. The poll found that 94% of primary-care doctors "reported seeing more patients experiencing stress, anxiety or other mental-health issues because of the pandemic and fear a correlation between rising mental health issues and prescription drug misuse."

Three-fourths of the 505 physicians surveyed said they believe telehealth limits their ability to determine if patients are misusing prescription drugs, or are at risk for it. The release said "91% of physicians feel confident they can recognize the signs of prescription drug misuse during in-office interactions with patients, but only 50% report the same confidence via telehealth visits."

Quest said nearly half of tested patients showed signs of drug misuse, and a fourth "engaged in drug combining, a particularly dangerous form of misuse," the release said. But about half of physicians "do not follow up with definitive tests when presumptive tests are positive."

The poll also found that only a third of physicians are "very confident" in their ability to properly prescribe naloxone, which blocks opioid overdose, to patients who may be at risk of overdose.

Quick hits: Libraries lining up 'digital navigators' for telehealth; FactCheck delves into origin of the coronavirus

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email heather.chapman@uky.edu.

"Digital navigators" may soon be available at rural libraries to help residents access telehealth services. Read more here.

Many rural communities are celebrating Pride day/week/month for the first time. Read more here.

FactCheck.org says it has "a detailed and authoritative piece" from its science editor, who has a Ph.D. in immunology from Yale University, about the origins of the coronavirus in China.

Rise in covid-19 cases worries rural hospitals; overall health may have declined as people delayed care for other issues

A rise in covid-19 cases in rural areas is causing concern among rural hospitals and their staffs, amid worries about overall health, Todd Neeley reports for DTN/The Progressive Farmer.

"Cash-strapped and under-equipped since even before the pandemic hit, the new coronavirus forced them earlier this year to adjust their plans and resources to get through the past few months and survive in their communities -- as well as save and serve their patients," Neeley writes in the first of a two-part series. "As states and communities emerge from various restrictions and regulations that may have helped slow or contain the spread of covid-19 for the past few months, the number of cases is growing."

And cases of other diseases and disorders are more serious because many people delayed treatment in the first three months of the pandemic, so overall health may have worsened, Kyle Ulveling, cardiologist and chief medical officer at St. Anthony Memorial Hospital in Carroll, Iowa, told Neeley: "I can easily say the patients I'm seeing in clinic are sicker than they were six months ago."

In the second part of his package, Neeley uses St. Anthony as an example of how rural hospitals have dealt with the pandemic from the start, including increased use of telehealth, financial pressures from shutdown of elective procedures and dealing with coronavirus hotspots at meatpacking plants.

Telehealth expansion for pandemic has made mental health care more accessible in some rural areas

Aggressive efforts to expand telehealth care in rural areas during the pandemic are bringing the unexpected side benefit of making mental health care more accessible in some areas, Raga Justin reports for the San Angelo Standard Times. Though Justin's story centers around Texas, the same thing is likely happening in other states.

"In April, Gov. Greg Abbott temporarily waived restrictions on telehealth, allowing mental health care providers and local mental health authorities to broadly expand services and collect reimbursement for online appointments more easily," Justin reports. "The state also implemented a mental health hotline in March that offers free over-the-phone support and provides resources and information to callers who need help."

Andy Keller, president and CEO of Texas-based Meadows Mental Health Policy Institute, told Justin that "in some ways, people in rural Texas have better access to health care than they’d ever had before" and noted that expanded telehealth access has lifted barriers to accessing physicians in other parts of the state.

Telemedicine appointments at Texas Tech University's Psychiatry Department—a telemedicine pioneer—have been skyrocketing since the pandemic began, according to department chair Sarah Wakefield.

But lack of broadband access in rural areas has stymied further expansion of telemedicine. About 500,000 Texas households lack broadband access in Texas, and about 440,000 of them are in rural areas, Justin reports.

Study cites benefits of telehealth; commentary says mental telehealth is 'clinically equivalent to in-person care'

As people across the nation have been asked to shelter in place because of the novel coronavirus, never before has the importance of telehealth, especially for mental-health care, become more evident, says a commentary in The Journal of Rural Health. 

The authors assert that mental-health therapy over video platforms "has been demonstrated as clinically equivalent to in-person care."

Before the pandemic, they write, video-to-home telehealth services for mental-health care was not uniformly offered, but has since gained some traction, especially in rural areas where mental-health provider shortages are great.

The authors note that telehealth visits have ensured continuity of care during stay-at-home orders, all while minimizing physical contact to keep both patients and providers safe.

But they also recognize that this type of care also comes with many challenges, including overburdened networks, poor internet bandwidth, inconsistent internet service, a lack of equipment,  billing and scheduling challenges, and usability issues for both providers and patients. These challenges have resulted in some providers conducting phone-only visits, especially after federal rules were relaxed to allow reimbursement for such visits.

But the authors say that in this time where "the loss of in-person contacts has never been more pronounced," phone-call appointments, while efficient, don't offer the same connection that video-based meetings do.

"During this pandemic, we believe that visual contact remains crucial; thus institutions that work to facilitate the availability of [video-to-home] visits will significantly benefit both patients and providers,"  they write. "Robust telehealth programs require a significant commitment of time and resources, and large health care organizations with the foresight to invest in telehealth are poised to transition [mental health] care from in-person to virtual visits."

The authors say they regularly collect patient input through interviews about virtual appointments, and have found that many patients say the video connection makes it more personal and that seeing their provider during the therapy session is "very important." Further, patients have told them that they are more comfortable getting their mental-health care at home.

"We believe that prioritizing video over phone-only calls will help maintain the integrity of [mental health] care by maintaining important social rhythms, supporting rapport, and offering a more patient-centered care approach," they write.

They add that such visits allow for the re-establishment of "social rhythms" that many patients prefer, and let the patient and the provider see nonverbal communication cues that would otherwise be missed. It also allows the provider a window into their patient's physical space, the authors write.

Video-to-home "may help patients share more with their provider within the context of therapy by enhancing the therapeutic relationship and allowing providers to establish connections that could never be achieved over the phone," they write.

The authors conclude that video-to-home "will become part of the new normal in the post-pandemic period" and say that now is the time to build competency and capacity for it.

In particular, they note that video-to-home care has been quite successful in rural Veterans Health Administration treatment centers.

A study, also published in The Journal of Rural Health and named article of the year, found that over  a six-year period, 2009 to 2015, use of clinical video telemedicine grew from 30 to 124 encounters per 1,000 veterans, with faster growth among rural veterans than urban ones.  It also found that more than 50 percent of the telehealth visits were for mental-health care.

The study adds that in fiscal year 2015, the last year of the study, 3.2% of urban and 7.2% of rural veterans used telemedicine for nearly 725,000 clinical encounters.

The authors said vets were more likely to use telemedicine if they had a "younger age, longer driving distance to VHA facilities," or multiple medical conditions.

The study concludes that the availability of telemedicine "has likely increased access to care for rural veterans, especially for mental-health care."

The challenge of broadband access that is needed to facilitate telemedicine is not just a problem for rural America, but also in tribal nations.

A letter to the editor in the same journal speaks of barriers to health care among tribal nations in the Southwest: "It is likely that the covid-19 pandemic will exacerbate disparities among American Indian tribes, particularly when coupled with existing barriers to access health services."

The authors point to commentary that provides a history of the many challenges Native Americans have had with infectious diseases, as well as those that currently exist amidst the covid-19 pandemic, and points to telemedicine as a way to address this.

But they note the ongoing challenges that exist around broadband internet services, and summarize the Census Bureau's American Community Survey 2018 estimates for census tracts with the largest tribe in the U.S.: "58.1% to 87.7% of households in Navajo Nation census tracts reported not having broadband internet services, compared to 19.6% nationally." Even if Native Americans have internet access, these locations are not ideal for telehealth visits, especially if related to mental health, they write.

Pandemic made telehealth necessary and easier to get, and 'We are never going back' to the way it was, surgeon says

Rural Health Information Hub graphic

The coronavirus pandemic made telehealth necessary, and much easier to get, and its uptick will continue long after the crisis is over, federal officials predicted in a Rural Health Information Hub webinar Tuesday, covered by Melissa Patrick of Kentucky Health News.

"I can tell you from personal experience that we are never going back," said Dr. Jeff Colyer, a surgeon who chairs the National Advisory Committee on Rural Health and Human Services. "I've seen the majority of my patients via telehealth, and they like the convenience and the access that it gives them. And so we are going to see those changes continue on in the future."

Bette Brand, deputy undersecretary for Rural Development in the Department of Agriculture, said, "The coronavirus has made the need for telehealth even more urgent. Its life-saving convenience is now underscored by its lifesaving ability to limit travel and unnecessary exposure."

Deputy USDA Secretary Stephen Censky pointed to a USDA summary of recent changes in telehealth policy by the Department of Health and Human Services. Deputy HHS Secretary Eric Hargan called the changes "historic" and said they include, among other things, eliminating some barriers to Medicare reimbursement, enabling waivers or reductions of cost sharing, and allowing the use of everyday technologies, like FaceTime and Skype, in health care.

"In just about a month and a half, I think we've seen about seven or eight years worth of progress on telehealth," Hargan said. "Really, it's a revolution provoked by necessity. I'm excited to see what the future looks like based on getting patients and providers acclimated to the idea of telehealth in this way," he said. "What sounds to many like dry, obscure flexibilities in regulations and reimbursement is translating into millions of Americans getting access to healthcare more safely."

Tom Morris, associate HHS administrator for rural health, said the use of telehealth resource centers is "well more than 1,000 percent of this time a year ago."

Two analysts and a fellow at the Brookings Institution came to many of the same conclusions after taking a detailed look at telehealth regulations and recent changes. They write:

Telehealth has proven itself a viable supplement to an already strained health-care system, where both medical providers and patients are seeking timely, effective, and robust tools for early detection, primary care, and long-term evaluation. While progress was being made before the coronavirus outbreak to adopt telehealth in states, the pandemic not only demonstrated its worth but also proved it necessary to avert larger meltdowns in hospital systems and among medical professionals—even those whose work was stopped due to social distancing.
The world will probably not return to the normalcy it once experienced before covid-19—and neither should health care. As Congress is charged with re-evaluating the leniencies permitted to health-care providers during this crisis, federal lawmakers should also see the benefits. The same holds true for states that will need to reconsider lifting boundaries on telehealth services to accelerate its transformational capabilities for patients and doctors.

Coronavirus pandemic prompts postponements of deadlines for Real ID, ReConnect loans and grants and more

The pandemic has prompted the federal government to move back compliance or application deadlines for many programs. Here are a few with rural resonance:

President Trump announced Monday that he will push back the Oct. 1 deadline that would have required Americans to have a Real ID-compliant identification in order to board a plane or enter military bases and federal buildings, Andrea Noble reports for Route Fifty. After the deadline, people without a Real ID would have to have a passport in order to fly or enter those buildings.

No new deadline has been set, but the National Governors' Association asked the Department of Homeland Security to extend the deadline by one year, Noble reports. An extension will help rural residents especially, who have been having a harder time acquiring Real IDs.

The Department of Agriculture has extended the application deadline for the ReConnect rural broadband program to April 15, according to a press release. The deadline has already been extended once for the program, which will provide up to $600 million in loans, grants, and loan/grant combos for rural broadband buildout.

The Federal Communications Commission announced last week that it will extend the application window for the Rural Health Care Program until June 30. The program provides funding to qualified health care providers for telecommunications and broadband services for telehealth services. Annual funding is called at $571 million.

VA puts telehealth sites at Walmarts and VFW posts

In an effort to reach more rural veterans, the Department of Veterans Affairs is adding telehealth diagnostic facilities at selected Walmarts and Veterans of Foreign Wars posts.

The VA announced in August a partnership with health technology company Philips to implement the Accessing Telehealth through Local Area Stations (ATLAS) pilot program at rural VFW posts in Linesville, Penn.; Los Banos, Calif.; and Eureka, Mont., Liz Carey reports for The Daily Yonder.

Walmart donated space and equipment in five stores across the country for similar telehealth locations. In December, the first Walmart ATLAS site opened in Asheboro, North Carolina. Four more ATLAS sites are slated to open in Boone, N.C.; Fond du Lac, Wisc.; Howell, Michigan; and Keokuk, Iowa, Carey reports.

"The Veterans Administration has faced harsh congressional criticism for wait times for veterans to get in to see VA healthcare providers," Carey reports. "The VA estimates that nearly 5.2 million veterans, or about a third, live in rural areas and have to travel long distances to access care at a VA hospital. That’s up from 5 million veterans living in rural areas in 2017, according to the U. S. Census Bureau."

ER telemedicine defines growing rural-urban health gap

Dr. Kelly Rhone with a map of hospitals using Avera eCare. (Photo by Michael S. Williamson, The Washington Post)

"If anything defines the growing health gap between rural and urban America, it’s the rise of emergency telemedicine in the poorest, sickest, and most remote parts of the country, where the choice is increasingly to have a doctor on screen or no doctor at all," Eli Saslow reports for The Washington Post.

Avera eCare Services is a major telemedicine provider; the Sioux Falls, S.D., office "provides remote emergency care for 179 hospitals across 30 states. Physicians for Avera eCare work out of high-tech cubicles instead of exam rooms," Saslow reports. "They wear scrubs to look the part of traditional doctors on camera, even though they never directly see or touch their patients. They respond to more than 15,000 emergencies each year by using remote-controlled cameras and computer screens at what has become rural America’s busiest emergency room, which is in fact a virtual ER located in a suburban industrial park."

Telemedicine is one answer to a growing problem. The number of rural ER patients has increased by 60 percent in the past decade, but rural doctors and hospitals have declined by up to 15%, and many hospitals and standalone ERs are on the brink of bankruptcy, Saslow reports. Access to telemedicine actually helps retain rural doctors, too, since it gives them more support and time off to recharge.

Hooking up to telemedicine can be expensive, though. The standard subscription rate for Avera is about $70,000 a year, and the hospital must be outfitted with fiber-optic cables, cameras, and microphones. Beyond that, the hospital must have (and pay for) broadband access, Saslow reports.

FCC adjusts rural health program to boost telehealth; Democratic members say changes could hurt rural providers

"The Federal Communications Commission is making changes to the Universal Service Fund’s Rural Health Care Program in a bid to boost support for telehealth expansion," Eric Wicklund reports for mHealth Intelligence.

The FCC voted last year to add more money to the program and adjust its allocation formula, citing a need for more efficiency and less fraud and abuse. "Launched in 1997, the fund was designed to finance broadband expansion in rural regions and other parts of the country where online connectivity is weak," Wicklund reports. "The fund included a $400 million annual cap, but the agency voted last year to change that cap and add $171 million to match a surge in requests for support."

The decision wasn't unanimous; all three Republican commissioners voted for the changes, but the two Democrats voted against it. "Commissioners Jessica Rosenworcel and Geoffrey Starks, while both approving the plan, also offered dissenting comments. Both said the agency’s plan to create new methods for determining and prioritizing funding requests could end up doing more harm than good for rural health-care providers," Wicklund reports.