By Taylor Knopf

These days, no one discusses rural health without talking about telemedicine.

It’s a technology that digitally connects patients with health providers located elsewhere. Telemedicine is seen as one of the top solutions for improving access to medical care to the most remote areas of the state.

Last year, state lawmakers directed the N.C. Department Health and Human Services to draft a report with recommendations to improve telemedicine. DHHS staff submitted its report in October. And later this month, legislators are expected to take up the issue.

There are lots of pieces at play when it comes to telemedicine and many still need to be worked out.

Every state has different definitions, standards, limitations, safeguards and payment methods for telemedicine. Provider reimbursement has been a big question for a while. However, many of the big insurance payers are getting on board with telemedicine, including Medicare, Medicaid and Blue Cross Blue Shield of NC.

The DHHS study addressed all of these areas in its report to the General Assembly.

“Technology is evolving quickly and our ability to assist our most vulnerable citizens through creative uses of this tool has vastly increased,” DHHS staff wrote in their report.

“DHHS firmly believes that telemedicine can improve the health of our population if we respond effectively to two opportunities: 1115 Medicaid Waiver and Broadband Infrastructure.”

Crossing state borders

Technology knows no state geographic borders. In theory, a physician could treat a patient anywhere as long as there is an Internet connection.

Dr. Tegeler shows how he would examine a patient via the robotic telestroke program.
Physicians examine western N.C. patients remotely via a robotic telestroke program based at Wake Forest Baptist Hospital. Photo credit Jill Braden Balderas/ NCHN

According to the DHHS report, the state’s Medicaid Waiver says telemedicine is a way to reach the state’s most vulnerable residents.

“As the State moves to a managed care environment, Medicaid Managed Care Organizations (MCOs) should be required to ensure access to high quality, patient-centered care by incorporating telemedicine into their payment models,” the report said.

But right now, North Carolina lacks a Interstate Medical Licensure Contract with any other state. For example, a provider in North Carolina currently cannot see a patient via telemedicine who is located in, say, Tennessee.

To provide the best care, North Carolinians need access to a robust workforce of physicians and other providers, the report stated. DHHS staff recommended creating access to more providers by participating in an Interstate Medical Licensure Compact.

This is a contract that would allow physicians in participating states to see patients within any of those states.

DHHS staff also recommend providing incentives to providers to use telemedicine to help patients in underserved areas.

Broadband connection

As for broadband, the report advises the legislature to adopt the North Carolina Office of Broadband Infrastructure 2017 Broadband Report recommendations as soon as possible.

“[This would] enable individuals to connect in their homes by computer, smart device, or home monitoring systems,” DHHS staff wrote. “Though broadband is in every county, residents and businesses struggle to access adequate service for some telemedicine modalities.”

There are still many parts of North Carolina where it’s difficult to find a cell phone signal, much less broadband.

According to the Federal Communications Commission (FCC), 93 percent of North Carolinians have access to the Internet.  Of those without, only 1 percent live in urban areas. Meanwhile, 89 percent of those without access — about  640,000 people — live in rural areas.


North Carolina actually ranks 9th in the U.S. in broadband deployment, better than many of its neighbors.

According to the  N.C. Office of Broadband Infrastructure (BIO), cost of construction and population density are two major barriers to installing broadband to those remaining 640,000 people in the state.

Broadband runs through cables either underground or by above-ground poles. The cost of burying the lines depends on the soil.

“Boring through granite, prevalent in the western part of the state, is costlier than boring through clay, prevalent in the Piedmont, and substantially costlier than digging or boring through sand prevalent in eastern NC,” BIO staff wrote in their report.

Burying these lines is estimated to cost between $20,000 to $50,000 per mile or higher, according to BIO. Attaching lines to poles owned by telephone or electric companies costs between $1,500 to $10,000 per mile, BIO staff wrote.

shows urban areas in green, to signify broadband availability, and large white expanses, to signify lack of broadband - and therefore telemedicine - access
North Carolina’s rural areas still have wide expanses of so-called white spaces, areas where there’s little or no connectivity. Map courtesy NC BIO

This past September, the U.S. Senate unanimously passed The CHRONIC (Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care) Care Act, a bill that would expand telemedicine for stroke and dialysis patients, and for use in certain accountable care organizations.

Legislative response

Rep. Donny Lambeth (R- Winston Salem), co-sponsor of the bill that ordered the DHHS telemedicine report, is also co-chairing the Joint Legislative Oversight Committee on Health and Human Services, Graduate Medical Education Subcommittee, which will meet Feb. 12.

headshot of older white man with mustache and glasses
Rep. Donny Lambeth (R-Winston-Salem) Image courtesy of the NC General Assembly website

“I believe we will explore options for telemedicine as part of that committee work,” he wrote in response to questions.

“What I expect into the future is in part expansion and new definitions of this technology to allow patients convenience to care givers for both simply office visits and more complex medical evaluations from sites such as our states(sic) emergency rooms,” he wrote.

Lambeth added that the DHHS study was a “good first step” that will help frame the discussion moving forward.

“I continue to work with advocates across the state to look at funding issues and methods to encourage expansion of this technology to better meet the access needs of patients,” Lambeth said. “Healthcare is in transition and telehealth has a role to expand specialist and even primary care into areas where we have shortages.”

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Taylor Knopf writes about mental health, including addiction and harm reduction. She lives in Raleigh and previously wrote for The News & Observer. Knopf has a bachelor's degree in sociology with a...