By Liora Engel-Smith
Though he doesn’t see patients face-to-face these days, Dr. Charles Sawyer still carries his prescription pad. The 87-year-old doesn’t often write prescriptions by hand anymore, but there’s something about the familiar feel of the pad in his coat pocket, he said.
Sawyer, a primary care physician at Roanoke Chowan Community Health Center, is a traditionalist. He dictates, rather than types, patient notes to be transcribed into electronic charts. And though his notes are readily available to patients through an online portal, he still sends his patients letters after every visit.
In recent weeks, Sawyer’s practice has undergone a seismic change unlike anything else he’s seen in his 55-year career. Sawyer is seeing all of his patients online or via phone.
Gone are the exam room chats and the listening to hearts and lungs — those are left to younger staff who are less at risk for developing COVID-19 complications. Instead, Sawyer sits at his computer at the center in Ahoskie, and checks in with patients by phone or via video.
“I’m a hands-on type doctor, always have been. I do the best I can to adjust to it,” he said. “It’s not something I truly enjoy doing, but during this time of the virus, we just have to adjust and do the best we can.”
The move to telehealth appointments at Roanoke Chowan has been swift by necessity, but it was only possible because the center already had more than a decade of experience with caring for patients virtually, said CEO Kim Schwartz.
Like many rural areas across the state, Roanoke Chowan serves a population for whom internet access isn’t a given. Forget computers, some patients don’t even have a reliable phone connection — cell or landline. With libraries, schools and fast-food restaurants off-limits because of coronavirus, patients without internet at home may find themselves with few alternatives.
None of these challenges are new, but the need to address them has gained new urgency as coronavirus spreads through rural North Carolina.
“Certainly this situation highlights the inequities throughout the state,” said Jeff Sural, director of the Broadband Infrastructure Office at the North Carolina Department of Information Technology, in a Rural Center broadband webinar last week. “It really brought to bear the difference between the haves and the have nots.”
Deep within the broadband chasm that prevails within rural North Carolina, providers worry that a sizable group of digital “have nots” aren’t getting the care they need.
Broadband, telehealth triage
The first signs of change for telehealth in North Carolina began in March, as private insurers and state and federal payers such as Medicaid and Medicare amended billing rules for telemedicine appointments to promote social distancing. Before the change, some insurers paid less for telemedicine appointments, and even less for telephone conversations with patients, while others didn’t reliably cover such visits.
But coronavirus containment efforts pushed insurers — and the state — to pay more for video calls. And the increase in reimbursement rates has made virtual visits financially feasible for many providers, including those at Roanoke Chowan.
Telehealth caught on at other health centers too, said Brendan Riley, director of policy at the North Carolina Community Health Center Association. Before the rule change, roughly 10 of the state’s 42 health center providers offered some degree of telehealth, either through phone visits, remote patient monitoring or in-office computer consultations with specialists who are off-site. As of this month, at least 34 organizations have begun offering telehealth options, he added.
“It’s growing every day,” he said.
Within weeks of these telehealth financing changes, Roanoke Chowan staff moved 80 percent of all patient appointments to online or over the phone, Schwartz said. To get to that figure, staff took a multi-pronged approach, working with clients one-on-one. Clients who have an internet connection and a device get training on video conferencing. Staff invited those who don’t have a device or internet to the clinic parking lots, where WiFi hotspots and devices are available for appointments. Patients who can’t get to the parking lot receive a phone visit, and face-to-face appointments happen only when there’s no other option, such as in a medical emergency.
Schwartz knows that these workarounds aren’t long-term solutions. Patients may not have a car in which to sit during parking lot appointments, and conducting such appointments outside may not be feasible in a sweltering North Carolina summer. With no end in sight for the coronavirus crisis, the center has been exploring other alternatives, including scattering Wi-Fi hotspots in other spaces such as churches and community colleges, or even using Wi-Fi-enabled vans to bridge the digital divide.
The state Department of Information Technology recently took a similar approach in a related broadband access challenge: remote learning while schools and libraries are closed. The department is dispatching school buses with hotspots to dozens of locations in underserved areas to allow for remote learning. The department also compiled a statewide list of free hotspots, some of which are in rural areas.
But these solutions can only go so far, Sural said in last week’s webinar.
“To be honest, right now we’re in the triage phase. We’re simply trying to get connectivity to those that need it,” he said.
“It’s not the best solution. It’s not a permanent solution, but right now, we’re finding that that’s one way to at least give students access.”
Rural providers across North Carolina are performing a similar triage with telehealth initiatives in their respective communities.
In March and April, dozens of western North Carolina providers were suddenly thrust into the telehealth world. The largely rural region of the state had few telemedicine options outside of cities, said Bryan Hodge, director of rural initiatives at Mountain Area Health Education Center.
In a survey the agency conducted after COVID-19 became a reality in the state, 92 percent of 113 clinics in the western part of the state had adopted telemedicine and phone visits. Fewer than three-quarters of respondents, however, said they knew how to bill for these services.
MAHEC has been offering training and support on billing and technical issues to some of those providers, but rural areas in the western part of the state suffer from many of the same broadband availability challenges that providers at eastern North Carolina’s Roanoke Chowan clinics are up against.
Patricia Hall is all too familiar with these limitations. A primary care provider at Celo Health Center in Yancey County, Hall has been seeing patients virtually for several weeks now.
She’s seen her share of frozen screens during video calls, she said. Even when video works, the image may be too fuzzy to properly diagnose rashes and lesions.
Hall resorts to phone check-ins when videos appointments aren’t feasible. Audio calls alone can’t provide the level of detail she’s accustomed to because she can’t see the patient, she said, but the center has been exploring ways for patients to send pictures of rashes and other conditions securely. A similar approach is already being used successfully in other parts of the world where the rural broadband infrastructure is either weak or nonexistent.
When the internet and hardware cooperate, virtual visits can be a powerful tool, Hall said, especially because it can give her a glimpse into people’s living rooms and offices.
“I feel a real appreciation for patients,” she said. “We both get to see each other as more human, kind of literally having a window into each other’s lives.”
Phone visits are now the norm for Brittany Hipkins, a provider at Blue Ridge Community Health in Jackson County. On any given day, roughly a third to half of all the patients she works with need a phone visit because of internet access issues.
For patients who have an internet connection that’s fast enough for video calls, she added, virtual meetings can remove another common rural barrier to care: transportation.
That, in a nutshell is the promise of telehealth in rural areas. But for telehealth to fulfill that vision, rural broadband needs a significant boost, said Hodge, of MAHEC.
North Carolina’s investments in rural broadband have thus far been modest. In the most recent round of COVID-19 funding, lawmakers added $9 million to a matching grant program that helps internet providers connect rural homes to the internet.
The program, known as Growing Rural Economies with Access to Technology or GREAT, began in 2018 and had already awarded $15 million for rural broadband projects that wired roughly 450 businesses and more than 9,000 households as of last year.
By all estimates, the broadband needs of rural areas, however, are far greater.
“There’s not enough money in the world to touch every part of our country in the rural parts,” said Robert Hosford, North Carolina state director for USDA rural development at the Rural Center’s broadband webinar.
It’s difficult to put a dollar amount to that need because there are no reliable estimates of how many homes in rural North Carolina lack access to the internet. The cost of wiring homes also varies widely, depending on terrain, the type of fiber used and distance from the nearest wire. Laying a mile of cable can cost $18,000-$20,000, by some estimates. The total cost of such an undertaking in rural North Carolina is hard to calculate, but a recent estimate puts the cost of connecting every household in the United States to fiber broadband at $130-$150 billion over five to seven years.
With broadband improvements in North Carolina coming in small measures, the internet access conundrum, and by extension, the barriers to rural telemedicine in the age of coronavirus aren’t likely to resolve anytime soon.
For his part, Sawyer, the provider at Roanoke Chowan, has gotten used to the new reality of connecting with his patients online, and he hopes his patients have too.
“It’s a learning curve,” he said. “You start off, you don’t have a clue and then over a period of time, you get acclimated.”