ISSN 2472-1654 iMedPub Journals 2020 · connectivity challenges in which the issues of rural health provider connectivity was addressed. As C TN works with internet ser vice provider

Rural Northern California Telehealth CoverageCeleste A. Jones1, David Espinoza2*, Abigail R. Whittaker3 and Tyler J. Boyle4

1Professor, CSU Chico, School of Social Work, Distributed Learning Coordinator, USA2NECCC and UCCC Manager, CSU Chico, Geographical Information Center, USA3Project Analyst, CSU Chico, Center for Economic Development, USA4Senior GIS Analyst, CSU Chico, Geographical Information Center, USA*Corresponding author: David Espinoza, NECCC and UCCC Manager, CSU Chico, Geographical Information Center, USA, Tel: +5308983945; E-mail: [email protected]

Received date: March 17, 2020; Accepted date: April 08, 2020; Published date: April 12, 2020

Citation: Jones CA, Espinoza D, Whittaker AR (2020) Rural Northern California Telehealth Coverage. J Healthc Commun Vol.5 No.2:2.

Copyright: © 2020 Jones CA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License;which permits unrestricted use; distribution; and reproduction in any medium; provided the original author and source are credited.

Abstract

The North State Development and Planning Collective(NSDPC) at the California State University (CSU), Chico,and the California Telehealth Network (CTN) havecollaborated for around ten years addressing issues ofrural broadband connectivity in rural Northern Californiathrough identifying geographic areas that lack broadbandservices and supporting expansion of these services torural health care providers (i.e., rural hospitals and healthclinics). As part of these efforts, and in response to thelack of health care options, limited access tospecializations, and the number of uninsured in ruralNorthern California, the NSDPC ’ Northeastern andUpstate California Connect Consortia (NECCC & UCCC) andthe CSU, Chico, School of Social Work partnered to createa survey to assess the status of telehealth services andchallenges that prevent rural healthcare facilities fromadopting and implementing these services.

The NSDPC’s Geographical Information Center (GIC) andCenter for Economic Development (CED) partnered toidentify and map rural health care facilities in ten countiesin rural Northern California and reached out to them toconduct the survey. The sample size consisted of 40respondents representing 76 health care facilities.Although the sample size did not provide an adequatenumber for any statistical significance, or generalizations,the data do create an initial assessment of potentialissues and barriers associated with delivering broadbandand telehealth services to rural and isolated communities.This survey is the first step in a larger investigation oftelehealth service delivery in Northern California.

Survey respondents indicate that a majority of on-siteproviders have ‘presenting site video conferencing’, utilizepsychiatric, mental/behavioral services for diagnosing andtreatment or as follow-up care. Off-site providers use theirtelehealth for clinical labs, experience connectivity

barriers, and purchase their equipment through publicgrants or through general operating funds. The on-siteonly facilities identified ‘inability to connect at the neededbandwidth’ as one of the largest barriers; while off-siteproviders stated major barriers were ‘inability to connectat the needed bandwidth’ and ‘lack of community/patientacceptance of telehealth’.

A number of challenges are presented when usingtelehealth and technology; however, there is anopportunity to address the promise of telehealthimproving access and increasing quality of care. Increasedawareness of California Telehealth Resource Center(CTRC) can be provided through public serviceannouncements, workshops, trainings, and education onthe telehealth services designed specifically for each ruralarea. Along with education, technical support is critical forrural providers to become comfortable implementing anew form of health care delivery. With CTRC involvement,there can be support with technical concerns, fundingresources, grants, private funding, and political advocacy.Additionally, legislation can be implemented to supporttelehealth usage, for example Assembly Bill 1264, Petrie-Norris. Medical Practice Act: dangerous drugs:appropriate prior examination (2019) can reinforce theuse of a telehealth delivery system. This bill specificallyindicates telehealth as a means for receiving approval forthis type of medication. The political support and policydevelopment regarding key issues of telehealth is anessential element needed for telehealth to evolve.

Finally, telehealth is at a critical juncture as it advancesfrom a tool used intermittently to an integrated tool on aroutine basis. The overall findings of this inventoryconfirm that more research is needed on telehealthservices and implementation models. Furtherinvestigation into the effectiveness, cost savings, andquality of telehealth is needed.

Research Article

iMedPub Journalswww.imedpub.com

DOI: 10.4172/2472-1654.100007

Journal of Healthcare Communications

ISSN 2472-1654Vol.5 No.2:2

2020

© Copyright iMedPub | This article is available from: https://healthcare-communications.imedpub.com/ 1

http://www.imedpub.com/

https://healthcare-communications.imedpub.com/

Keywords: Update to Telehealth; California; RuralHealthcare; Broadband

AbbreviationsNorth State Planning and Development Collective: The

North State Planning and Development Collective (NSPDC) isthe umbrella organization of the California State University,Chico ’ s Center for Economic Development (CED) andGeographical Information Center (GIC). The two centersfunction to expand the services and resources offered to theregion’s businesses, governments, and residents by pairing GISmapping services and broadband infrastructure support witheconomic development research, surveying, analysis, planningand implementation throughout the state of California. TheNSPDC is also the lead agency supporting the Northeasternand Upstate California Connect Consortia providing resourcesto Northern California broadband infrastructure projects. Thegoal is to facilitate resources and technical assistance toimprove broadband in rural communities throughout theNorth State. For more information visit: https://www.nspdc.csuchico.edu/; Northeastern and UpstateCalifornia Connect Consortia: The Northeastern and UpstateCalifornia Connect Consortia consist of counties, cities, towns,Internet service providers, and community anchor institutions,among other partners, and support the counties of Colusa,Glenn, Lake, Butte, Tehama, Plumas, Shasta, Lassen, Siskiyou,and Modoc. The consortia are funded by the CPUC under theCalifornia Advanced Services Fund program. For moreinformation visit: www.necalbroadband.org/www.upcalbroadband.org/; Center for EconomicDevelopment: The Center for Economic Development is adivision of the North State Planning and DevelopmentCollective at California State University, Chico. The Centerprovides regional leaders with accurate and timely informationto address the socioeconomic challenges and opportunitiesfacing the region. For more information visit: http://cedcal.com/; Medical Practice Act: https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200AB1264; California Telehealth Network: TheCalifornia Telehealth Network (CTN) had the mission topromote advanced information technologies and services toimprove access to high quality healthcare focusing onmedically underserved and rural Californians. For moreinformation visit https://www.caltelehealth.org/; HealthcareConnect Fund: Universal Service Administrative Company –Rural Health Care: https://www.usac.org/rural-health-care/;California Teleconnect Fund: https://www.cpuc.ca.gov/ctf/;CPUC Broadband Availability Data: The California PublicUtilities Commission (CPUC)’s broadband availability data (asof December 2017 and released on December 2018) oradvertised service availability data are collectedby the CPUCfrom a majority of broadband service providers in California.Most of the broadband availability is provided by last-milebroadband service providers. Coverage data for wireline andfixed wireless providers are reported at the census block level.The data are mapped and validated for accuracy using CPUC’sbroadband validation methods. For more information on these

date visit: https://www.cpuc.ca.gov/Broadband_Availability/;Health Care Broadband in America – Early Analysis and a PathForward: OBI Technical Paper(August 2010) No. 5. https://transition.fcc.gov/national-broadband-plan/health-care-broadband-in-america-paper.pdf. AB-1264 Medical PracticeAct: Dangerous drugs: appropriate prior examination(2019-2020) https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200AB1264

IntroductionThe North State Development and Planning Collective

(NSDPC) (https://www.nspdc.csuchico.edu/) at the CaliforniaState University (CSU), Chico, has a long history of working inbroadband connectivity issues in rural Northern California,beginning with work on broadband mapping in 2009 andexpanding to mobile broadband performance testing in 2012.The NSDPC is the parent organization for the GeographicalInformation Center (GIC) (established in 1988) and the Centerfor Economic Development (CED) (established in 1986), and isthe leading agency for the Northeastern and Upstate CaliforniaConnect Consortia (NECCC & UCCC) (https://upcalbroadband.org/ and https://necalbroadband.org/). TheNSDPC provides services and resources to the region ’ sbusinesses, governments, and residents by pairing GIS(geographical information system) mapping services andbroadband infrastructure support with economic developmentresearch, surveying, analysis, planning and implementationthroughout the state of California. This leading agency seeksfunding from various federal, state and private sources tosupport rural broadband connectivity throughout NorthernCalifornia. Through these broadband-related projects, theNECCC & UCCC has the opportunity to explore data collectionand analysis leading to the focus of specific topics liketelehealth services utilizing a team of researchers and subject-matter experts.

The NSDPC and the California Telehealth Network (CTN)have collaborated for around ten years addressing issues ofrural broadband connectivity in rural Northern California. TheNSDPC’s work identified geographic areas that lack broadbandconnectivity, which provided a broader framework ofconnectivity challenges in which the issues of rural healthprovider connectivity was addressed. As CTN works withinternet service provider partners to connect rural hospitals,health clinics and other facilities, this infrastructure expansioncould be leveraged to provide improved household access.Then these organizations worked in collaboration throughidentifying geographic areas that lack broadband services, andsupporting expansion of broadband services to rural healthcare providers. As part of these efforts, and in response to thelack of health care options, limited access to specializations,and the number of uninsured in rural Northern California, theNSDPC’s NECCC & UCCC and the CSU, Chico, School of SocialWork partnered to create a survey to assess the status oftelehealth services and challenges that prevent ruralhealthcare facilities from adopting and implementing theseservices. The NSPDC and School of Social Work recognized thechallenges rural students and health providers face with


ISSN 2472-1654 Vol.5 No.2:2

2020

2 This article is available from: https://healthcare-communications.imedpub.com/


broadband connectivity. As the NSPDC developed its workplan for the NECCC & UCCC, faculty in social work werebrought on to help develop linkages between the broadbandefforts and their distributed learning program and rural healthconnections. The faculty’s expertise in survey methods helpedthe NECCC & UCCC understand barriers to telehealth in theregion. This study reports on developing and conducting thesurvey to assess the status of telehealth services and theresults and findings.

There have been substantial enhancements in the deliveryof health care, but many rural communities have not benefitedfrom these developments. Health care systems in rural areashave been disproportionally impacted by a lack of medical carefor years. Rural areas experience long-standing barriers inproviding adequate health care. Singh, Matthiessen, Stachura,and Astapova [1] report that less than 11% of health carespecialists and physicians are located in rural areas. Finding thenecessary professional expertise in a rural area is afundamental problem [2].

In the 1950’s and 1960’s, telecommunication began to gainpopularity using two-way communication to resolve manymedical issues [3]. As technology progressed, hospitals andclinics adopted telehealth (telemedicine and telehealth usedinterchangeably) to increase access and quality to health care[4]. As telemedicine improvements in digital data transmissionand storage continued to evolve, the expense grew; however,during the 1976 surge of technology advancements, theindustry was forced to create small and manageable datastorage [5]. Having data transmitted in a manageable waystimulated the cost of telehealth to lower significantly andtrigger more interest from health care providers. This allowedtelehealth and distance communication technology to providemore affordable medical care from one site to another.

Although first created to serve the needs of geographicallyremote areas with limited access to health care, telehealth hasprogressed to addressing various aspects of health care.Bashshur, Shannon, Krupinski, and Grigsby [3] report thattelehealth cannot only meet the feasibility of remote andisolated places, but could also aid in the cost of health care,balance the quality of care among segments of the population,and increase access to specialists.

Merrell [4] indicates that the 2009 United States (US)Recovery and Reinvestment Act included provisions forbroadband and electronic medical record program initiatives.These initiatives expanded broadband to many rural areas andschools. In addition, the improvement in the electronicmedical record system expanded the communication betweenhealth care providers.

Krupinski and Weinstein [6] report there are over 60subspecialties of telehealth. Several examples of the variety oftelehealth services include telestroke, which is considered animportant aspect of emergency care [7]; teleradiology, whichhas become a standard in many rural and urban health caresystems; and telepsychiatry, which is common in many healthcare systems [6]. Moreover, Johnson [8] reports that thedemand for mental health counseling has allowed tele-mental

health services to be available to schools, jails, and NativeAmerican Tribal Health and Human Services.

One in five United States residents living in rural areas viewtelehealth as a solution to the lack of local health careservices; however, despite these recent medicaladvancements, telehealth has not populated many rural areas.There remains apprehension in rural clinics and health carefacilities regarding the use of telehealth [8]. Rural areasexperience challenges in service delivery, an uneasiness withthe technology, and burdensome costs. Medical devices usedto make telehealth possible can be costly. According to a 2015study, (de la Torre-Diez et al) the largest total of medical costsin many clinics are attributed to medical devices. The start-upcosts can be overwhelming to a rural community clinic, not tomention digital medicine education for staff and a medicaltech staff to manage these devices [9]. Although technologycan be manageable, feasible, and accessible, many ruralpatients, providers, and practitioners must also accept andtrust the use of technology [10]. There are privacy and securityconcerns for all involved. Voran [11] argues that regulatoryconstraints and lack of reimbursement discourage rural areaproviders from using the technology.

Voran [11] divides telehealth into categories. By using astratified method of examination, Voran separates telehealthinto three categories, “Big telemedicine” (multimedia room,high resolution equipment, high-speed and closed network,scheduled appointments, synchronous), “ Intermediatetelemedicine” (cart-based mobile services, patient to provider,can be installed on a home computer, synchronous), and“ Small telemedicine ” (inexpensive personal computer ortablet, asynchronous, no video component, public Internet).Regulatory and reimbursement policies intentionally focus onthe “ Big telemedicine ” and “ Intermediate telemedicine ”categories leaving the “Small telemedicine” programs to beignored. Less expensive options are avenues to consider. Witheach new generation of smart phones, tablets, watches, andcomputers could offer a promising trend toward telemedicine.

Understandably, uninsured individuals directly impact thecost of telehealth. Northern California (the Counties of Alpine,Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt,Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta,Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, and Yuba)has 73,000 uninsured individuals (California Health CareFoundation, [12]; Dietz et al. [13]; UCLA Center for HealthPolicy Research & UC Berkeley Labor Center [14]). Althougheligible for Covered California (both with and without federalACA subsidies), Northern California has a higher percentage ofuninsured residents when compared to the state average [14].In addition to the uninsured population, there is a need forincreased specialized care due to the growing population ofolder adults in rural areas. According to the CA Department ofAging, in rural Northern California, approximately 15.6% of thepopulation is 65 years or older. This is proportionally higherthan the rest of California at 11.8% or the U.S. at 14.1% [15].Mitchell [16] indicates that the need for primary care doctorswill not only increase, but California will experience a primarymedical care shortage within the next 15 years.


ISSN 2472-1654 Vol.5 No.2:2

2020

© Copyright iMedPub 3

With the lack of health care options, limited access tospecializations, and the number of uninsured, anunderstanding of current status of telehealth in rural NorthernCalifornia can help identify the potential role of telehealth as asolution to these problems. This study will provide informationon telehealth needs, current practices, barriers, and regionalconnections. This information can be used to make significantchanges that will enhance the health care and telehealthoptions for Northern California.

Research MethodologySurvey Research was designated as the research design,

using both quantitative and qualitative questions [17].Although most of the questions had a limited number ofresponses, a category of Other was included in severalquestions to obtain more contextual information.

SampleA list of participants who are involved in the California

Telehealth Network (CTN) [18] with broadband access wasobtained. The Geographic Information Center (GIC)/ Center forEconomic Development (CED) Team prepared a list of contactslocated in the northernmost counties of California. Anonprobability convenience sample was used to determinewhich participants were health care professionals oradministrative personnel working at the facilities or medicalgroups in the Northern California [19].

SurveyA survey was created using an adapted version of the Klink,

Coffman, Jetty, Peterson, and Bazemore ’ s [20] survey ontelehealth. The survey included 26 questions using thefollowing definition of Telehealth: telehealth is the use ofmedical information exchanged from one location to anothervia electronic communications (i.e. broadband or high-speedInternet service) to improve a patient ’ s health [21].Telemedicine and telehealth are used interchangeably. Skiplogic was used on several questions to create a path basedupon the responses each participant [19]. The surveyquestions contained a variety of responses: 8 “Yes or No”closed-ended questions, 18 multiple choice questions, and oneopen-ended question at the end. Except for five questionsregarding percentages, age, and time, all multiple-choicequestions included an “other” option.

The Center for Economic Development (CED) constructedthe survey instrument in Constant Contact, making minoramendments to question or answer text only where necessaryto increase participant clarity about the information sought,when questions were delivered in a different order than theoriginal script, or to increase cross-group comparability. Theskip logic feature in Constant Contact was used to bypasssurvey questions that would have been inapplicable to therespondent based on their answers to several key questionsabout their facility and the services offered. The ten countiessurveyed were Siskiyou, Modoc, Shasta, Lassen, Tehama,Plumas, Butte, Glen, Colusa, and Lake.

Data collectionBefore making an initial contact attempt, CED survey

facilitators searched each health facility’s online presence toidentify an appropriate contact person within the facility.When the call was initiated, the survey facilitator asked tospeak to this person by name or title. If no online staffdirectory or similar resource existed, the CED survey facilitatorwould instead ask to speak with an office administrator orsupervisor. When connected to an appropriate person byreception staff, the facilitator would explain the purpose of thecall and assess the contact’s willingness to participate in thesurvey on behalf of the facility. Respondents generally held arole similar to office administrator or health service manager;few respondents were specialists in telehealth technology orrelated program deployment. Each of the respondents weredetermined by CED staff to have appropriate knowledge andauthority to represent the facility prior to commencement ofthe survey delivery.

Respondents were offered the choice to participate in thesurvey over the phone or online, at their convenience. Thosewho opted to participate online were sent a unique access linkvia email through Constant Contact. This allowed theirresponse to be associated with their email address and loggedon the contact list to ensure that survey facilitators would notcontinue to follow up with them. Contact names weredocumented on every call, along with the outcome of the call(i.e. a survey was completed, a callback time was scheduled,an online survey link was sent, a voicemail was left). Thesurvey facilitator recorded any insights gathered on facilityaffiliations- such as when one administrative office served amedical group with multiple office locations-to avoid solicitingduplicate surveys where possible.

Before taking part in the survey, CED survey facilitatorsinformed respondents that their participation was voluntary,confidential, and that their responses could help theNortheastern and Upstate California Connects Consortia(NECCC & UCCC) to support expansion of the CaliforniaTelehealth Network and to connect rural health care facilitiesto potential funding opportunities for telehealth such as theFederal Rural Health Care (RHC) Program-Healthcare ConnectFund (HCF), which provides subsidies of 65% on broadbandexpenses and network equipment, and the CaliforniaTeleconnect Fund (CTF), which provides an additional 50%subsidy on the remaining 35%. Surveys administered over thephone were completed in a single call with a single surveyrespondent. If the respondent was unsure of the best answerto a question, the survey facilitator would clarify or reword thequestion, and then prompt the respondent for their bestestimate. Surveys were completed within a range of 3 to 10minutes, depending on the number of questions that wereapplicable to the respondent and the extent of their answers.Respondents’ answers to each survey question were recordedin Constant Contact during the call. Phone calls were notrecorded.

After an initial unsuccessful contact with a facility (i.e. callsent to voicemail, or the reception staff asked CED to call backat a later time), CED would make two follow-up calls at least 5


ISSN 2472-1654 Vol.5 No.2:2

2020



business days apart before removing the facility from thecontact list. If the respondent requested that they be providedwith a link to access the survey by email, CED staff wouldfollow-up once by email and once by phone if the survey hadnot been completed within 2-3 weeks of delivery, with eachcontact attempt at least 5 business days apart. Wheneverfollow-up contacts were made, CED would reach out to theinitial contact target to ensure effective communication.

The only exception to the three-attempt contact limit is thatCED made additional follow-up calls to facilities in countiesthat were grossly underrepresented in the survey results asthe end of the study period was approaching. Two counties fell

into this category, and given the importance of ensuring thatthe needs of each county were reflected in the data toaccurately identify funding priorities, CED staff used existingprofessional relationships to connect with personnel in countygovernment or economic development roles in both counties.These personnel were encouraged to use their influence as atrusted local leader to broker successful contacts with healthcare facilities in their county. CED survey facilitators wouldfollow up on those brokered connections one or twoadditional times, with each contact attempt being at least 5business days apart.

Figure 1 Telehealth delivery system type (n=25). The most frequent response was “Live, interactive video conferencing” with14 individual responses, followed by “Direct-to-patient videoconferencing,” “Live, interactive video conferencing” and “Other”with 9, 5, and 5 responses, respectively. Note that respondents were allowed to provide multiple answers for this question;therefore, the total number of responses may exceed the total number of respondents (n=25).

ResultsFacilities and medical groups from all ten counties

participated in the survey. Between March 1, 2019 and May31, 2019, CED survey facilitators contacted each of the 285facilities on the list by phone and determined 28 facilities to beclosed or disconnected and 145 facilities to be duplicates oraffiliates of previously contacted facilities. Of the 28 closed ordisconnected facilities, 13 were closed due to the recent CampFire in Butte County. Of the remaining 112 unique contacts, 40consented to participate in this voluntary study, representing76 total facilities in the study region, as some facilitiesadministratively oversee others in the region. From the 40

participants, 65% offered Telehealth Services (26) and 35% didnot (14).

On-Site telehealthOf the 26 participants who identified as using telehealth

services, 96% of those offering telehealth services (n=25) hadthese services On-Site with 14 participants indicating that theydo not offer telehealth services. When asked about the type oftelehealth delivery system, 14 participants (56%) indicated thetelehealth service at their facility or medical group was Live,Videoconferencing ‘Presenting Site’ Services and five named‘Receiving Site’ services. There were 3 participants (12%) thatreported the facility had technology that would ‘Store and


ISSN 2472-1654 Vol.5 No.2:2

2020


Forward ’ items such as images, vital signs, video clips,diagnostic results, or other records to a Specialist orConsultant. One participant (4%) reported being able toMonitor Patients Remotely. There were nine participants(36%) who had Direct-to-Patient Videoconferencing and threeparticipants (12%) had the ability to conduct Direct-to-PatientPhone Conferencing.

Five participants (20%) offered services that were identifiedas belonging to the Other category. (Telemedicine carts;

Telehealth carts that use Zoom [videoconferencingtechnology] and Pollycom ‘Patient in the building and theDoctor is at a remote location’; and Skype (Figure 1).

When asked the estimated time frame a facility or medicalgroup (n=25) had offered telehealth services, four participants(16%) reported less than a year, six reported (24%) between1-2 years, nine (36%) reported 3-5 years, three (12%) reported6-10 years, and three participants (12%) reported more than10 years (Figure 2).

Figure 2 Provided telehealth services (n=25). The most frequent response was “3-5 years” with 9 individual responses,followed by “1-2 years,” and “Less than 1 year” with 6 and 4 responses, respectively.

Figure 3 Telehealth patient utilization (n=25). The most frequent response was “Psychiatry, Mental Health, and/or RemotePatient Monitoring” with 20 individual responses, followed by “Other” and “Neurology” with 15 and 7 responses, respectively.Note that respondents were allowed to provide multiple answers for this question; therefore, the total number of responsesmay exceed the total number of respondents.


ISSN 2472-1654 Vol.5 No.2:2

2020



Figure 4 Facility telehealth usage (n=25). The most frequent response was “Diagnosis and/or Treatment” with 22 individualresponses, followed by “Follow-up” and “Second Opinion” with 16 and 11 responses, respectively. Note that respondentswere allowed to provide multiple answers for this question; therefore, the total number of responses may exceed the totalnumber of respondents.

Figure 5 Telehealth services obtainment (n=25). The most frequent response was “Purchased with public grant funding” with12 individual responses, followed by “Purchased with general operating funds” and “Purchased with private grant funding”with 9 and 7 responses, respectively. Note that respondents were allowed to provide multiple answers for this question;therefore, the total number of responses may exceed the total number of respondents.

The telehealth service selected as the highest serviceutilized was Psychiatry, Mental Health and/or BehavioralHealth (20 participants) with the second highest being theOther category (15 participants). The Other categorycontained responses that were not listed such as Cardiology,Rheumatology, Pulmonary, Pain Management, Endocrinology,Nutrition Therapy, Infectious Diseases, Dietician, Cardiac

Rhythmology, Addiction Medication, Emergency PediatricCare, and Diseases with Intermittent Symptoms.

The third highest was Neurology (7 participants) followed byPediatric Care and/or Pediatric Specialty Care, then Radiology.Primary Care and Dermatology were a second to last tie withone participant each for Tele-pharmaceutical, Tele-prescribing


ISSN 2472-1654 Vol.5 No.2:2

2020


and/or Medication Compliance; Emergency Trauma Care;Extended Care, Post-Discharge, Home Health and/or RemotePatient Monitoring; and Intensive Care and/or Critical Care(Figure 3).

The 25 participants polled indicated that they use telehealthin their facility or medical group for Diagnosis and/ortreatment (22), Follow-up (16), Second Opinions (11), ChronicDisease Management (9), Other (3), and Emergency Care (2).The Other category yielded further utilizations such asConsultation, Psychiatric Counseling, Psychology Counseling,and Establishing Care (Figure 4).

Twelve participants (48%) responded that they had obtainedtheir telehealth equipment through Public Grant Funding andseven (28%) reported Private Grant Funding; five (20%)responded Other; three (12%) reported their equipment was

Provided by a Hospital or other Health Care Facility; two (8%)stated they used Existing Equipment; one (4%) indicated theequipment was Donated by a Charitable Foundation; and one(4%) has Leased the Equipment. The Other category elicitedthese responses: Obtained Two Telemedicine Care via Grantsand Then Allowed to Keep the Equipment; through LicensedSoftware from Contract Company; from a Telehealth Company;from the “Northern Sierra” Grant and the Company Boughtthe New Equipment; and finally, Unknown (Figure 5).

Compensation for the cost of telehealth was covered by29% (7 participants) of health plans at more than 75% of costs,29% (7 participants) of covered Less than 25%, 25% (6participants) of health plans covered Less than 50%, 13% (3participants) of plans covered No Costs, with only 4% (1participant) covering Less than 75% (Figure 6).

Figure 6 Telehealth reimbursement (n=24). The most frequent responses were “Less than 25% and “More than 75% ” with 7responses each, followed by “Less than 50% ” with 6 responses.


ISSN 2472-1654 Vol.5 No.2:2

2020



Figure 7 Other telehealth funding services (n=24). The most frequent response was “None” with 9 individual responses,followed by “Cash payment directly from patient,” “Public grant funding” and “Other” with 7, 5, and 5 responses, respectively.Note that respondents were allowed to provide multiple answers for this question; therefore, the total number of responsesmay exceed the total number of respondents.

Outside of insurance health plan reimbursements, nine(n=24) participants (36%) reported None of the cost wasreimbursed, seven participants (29%) stated the cost wasreimbursed by Cash Payments Directly from the Patient; 5(21%) reported Public Grant Funding; 5 (21%) stated Other(Unknown, Medicare Part B and Patient Co-Payment, MOU

Grant through a Partnership, Indian Health Service, andHospital Funding); four (17%) said Private Grant Funding; one(4%) participant indicated Donations by a CharitableFoundation; and one (4%) said Off-Set Costs in Other Areas ofthe Facility Budget (Figure 7).

Figure 8 Telehealth attributed cost-savings (n=24). The most frequent response was “None” with 12 individual responses,followed by “1-25%” and “25-50%” with 5 and 4 responses, respectively.


ISSN 2472-1654 Vol.5 No.2:2

2020


Figure 9 Telehealth usage by age (n=24). The most frequent response was “Ages 41-60” with 13 individual responses, followedby “0-20” and “21-40” with 5 and 4 responses, respectively.

Figure 10 Future telehealth usage projections (n=23). The most frequent response was “10-30%” with 9 individual responses,followed by “Less than 10%” and “31-50%” with 5 responses each.

When asked about the percentage of cost savings to afacility, out of 24 participants, 12 (50%) participants reportedNone; Five (21%) had 1-25%, four (17%) had 26-50%; 3 (13%)had 51-75%; and none had 75-100% (Figure 8) (In a series of2018 reports by the Center for Economic Development at CSU,Chico, residents of many communities within the consortiaregions were shown to have inadequate medical care near totheir homes. Residents of 11 of the 25 communities covered in

these reports (Susanville, Berry Creek, Stonyford, Lodoga, ElkCreek, Westwood, Alturas, Cedarville, Likely, Bieber, Nubieber,Adin, Chester, Greenville, Quincy, Burney, Fall River Mills,Dorris, Happy Camp, McCloud, Mt Shasta, Weed, Etna, FortJones, Yreka) must travel over 20 miles to reach the nearesthospital. For more information on these reports visit: https://forestcommunityresilience.org/) . In this point, cost savings fortelehealth might also come from the patient side by providing


ISSN 2472-1654 Vol.5 No.2:2

2020



access to health care professionals, and reducing travel time tohealth care facilities and associated costs (i.e., off work hours,fuel, lodging, etc.).

The age group that used the facilities telehealth services themost was the ages of 41-60 group (13 participants), with ages0-20 (5 participants) next, followed by ages 21-40 (4participants), ages 61-80 (2 participants), and none at age 81+(Figure 9).

When asked the percentage of patients that would needtelehealth services three years from now (n=23), ninerespondents (39%) projected 10-30%; five (22%) predicted31-50%, another five (22%) expected Less than 10%, three(13%) indicated 71-90%, one (4) answered 51-70%, and noneof the facilities or medical groups reported 91-100% (Figure10).

When asked whether they would be expanding telehealthservices and what specific services would be provided throughthis expansion, thirteen (57%) participants predictedexpansion of services within the Other category (primary care,workers compensation care, dermatology, nutrition, expandingthe rooms for telemedicine and pain management,nephrology, psychology, infectious disease services with plansto expand those further, eye packs, diabetic screening, seeother patients than those strictly through Partnership,neurology, ED in patients/groups, family planning, adolescentpsychiatry, addiction, and the goal is to have clinics with

everything). Five (22%) participants chose Geriatrics, four(17%) reported No Plans to Expand, three (13%) statedRehabilitation, two (9%) cited Developmental Disabilities, one(4%) indicated School Health and one (4%) said Prison Health(Figure 11).

Sixty-five percent (15) of the participants stated they hadexperienced barriers in Using, Implementing, or AccessingServices via Telehealth. Of those who experienced thesebarriers (n=15), nine (60%) stated Other (Patients areApprehensive, Getting Patients to Buy-In, Getting the WordOut There and Providing More Education, Reimbursement,Finding Reliable Specialty Providers, Lack of Providers, PayerReimbursement Plan, and Connectivity Issues); eight (53%)reported Inability to Connect at Needed Internet BandwidthSpeeds; four (27%) indicated Lack of Community/PatientAcceptance of Telehealth Services; three (20%) noted Lack ofFunding, Lack of Health Insurance Reimbursements forTelehealth Services, and Inability to Secure Support FromPhysicians in using the Technology; two (13%) revealedInability to Determine the Return on the Investment andConcerns Related to Privacy and Security, and one (6%) statedLimitations to Online Prescribing, Inability to DevelopPartnerships with Originating Sites, Inability to DevelopPartnerships with Presenting Sites, and Inability toElectronically Exchange Patient Medical Records orInformation (Figure 12).

Figure 11 Future telehealth expansion (n=23). The most frequent response was “Other” with 13 individual responses, followedby “Geriatrics” and “No plans to expand” with 5 and 4 responses, respectively. Note that respondents were allowed to providemultiple answers for this question; therefore, the total number of responses may exceed the total number of respondents.


ISSN 2472-1654 Vol.5 No.2:2

2020


Figure 12 Facility encountered telehealth barriers (n=15). The most frequent response was “Other” with 9 individualresponses, followed by “ Inability to connect at needed Internet bandwidth speeds” and “Lack of community/patientacceptance of telehealth services” with 8 and 4 responses, respectively. Note that respondents were allowed to providemultiple answers for this question; therefore, the total number of responses may exceed the total number of respondents.

Off-siteOff-site telehealth services were offered by 67% of the

respondents (n=24). The types of facilities (n=8) included fiveparticipants (63%) reporting Other (Clinics, Rural Areas, County

Mental Health, Emergency Evacuee Camp, and Inmate Camp),three participants (38%) stated Clinical Laboratory, withPrescribed Pediatric Care Center, Nursing Home, Hospital, andAssisted Living Facility tied with one participant (13%) each(Figure 13).


ISSN 2472-1654 Vol.5 No.2:2

2020



Figure 13 Facilities that offer telehealth services (n=8). The most frequent response was “Other” with 5 individual responses,followed by “Clinical Laboratory” with 3 responses. Note that respondents were allowed to provide multiple answers for thisquestion; therefore, the total number of responses may exceed the total number of respondents.

Figure 14 Encountered off-site telehealth barriers (n=5). The most frequent responses were “Other” and “Inability to connectat needed Internet bandwidth speeds” with 2 responses each. Note that respondents were allowed to provide multipleanswers for this question; therefore, the total number of responses may exceed the total number of respondents.


ISSN 2472-1654 Vol.5 No.2:2

2020


When using off-site telehealth services (n=8), 62% of theparticipants stated they Experienced Barriers. Two (40%)participants indicated that the barriers were Inability toConnect at Needed Internet Bandwidth Speeds and Other(Scheduling and Connectivity). The remaining participantsnoted that Lack of Community/Patient Acceptance ofTelehealth Services, Lack of Funding, Lack of Health InsuranceReimbursements for Telehealth Services, Inability to Secure

Support From Physicians in using the Technology, Inability toDevelop Partnerships with Originating Sites, Inability toDevelop Partnerships with Presenting Sites, Inability toDetermine return on the Investment, and Inability toElectronically Exchange Patient Medical Records orInformation with each category being identified by oneparticipant (Figure 14).

Figure 15 Off-site telehealth equipment obtainment (n=8). The most frequent responses were “Other,” “Purchased with publicgrant funding,” and “Purchased with general operating funds” with 3 responses each, followed by “Provided by a hospital orother health care facility” with 2 responses. Note that respondents were allowed to provide multiple answers for thisquestion; therefore, the total number of responses may exceed the total number of respondents.

When asked how off-site telehealth equipment wasobtained (n=8) three participants (38%) stated either Other(Unknown, County Jail Purchased It, and Corporate Office),Purchased through Public Grant Funding, and/or Purchasedthrough General Operating Expenses; 2 (25%) participantsindicated Provided by Hospital or Other Health Care Facility;and one (13%) participant each stated Able to use ExistingEquipment, Shared/Group Purchase, Donated by CharitableFoundation, and Purchased by a Private Grant (Figure 15).

Past provisional telehealth servicesWhen asked about past provisional telehealth services, 57%

of participants reported they had Never Attempted TelehealthServices (n=14). Of those who have attempted telehealth (6

participants), three participants (50%) indicated the means bywhich their facility or medical group obtained their equipmentas Other (No Idea, Partnership, Possibly Grant Funded), one(17%) participant stated Leased Equipment, one (17%)reported Private Grant Funding, and one (17%) stated GeneralOperating Funds (Figure 16).

Of the six participants who had attempted to providetelehealth services, 4 (67%) of the respondents experiencedbarriers accessing telehealth services. The barriers identifiedwere Lack of Funding, Lack of Community/Patient Acceptanceof Telehealth Services, and Other (No Telephone Lines atHomes, Problematic Cell Service, the Length of Time to Get theProject Up and Running, and the Staff was Unsure of How toInitiate Service) (Figure 17).


ISSN 2472-1654 Vol.5 No.2:2

2020



Figure 16 Telehealth equipment obtainment (n=6). The most frequent response was “Other” with 3 individual responses,followed by “Leased Equipment,” “Purchased with private grant funding,” and “Purchased with general operating funds” with1 response each.

Figure 17 Telehealth usage, implementation, and obtainment barriers (n=4). The most frequent response was “Other” with 3individual responses, followed by “Lack of funding” and “Lack of community/patient acceptance of telehealth services” with 1response, each. Note that respondents were allowed to provide multiple answers for this question; therefore, the totalnumber of responses may exceed the total number of respondents.


ISSN 2472-1654 Vol.5 No.2:2

2020


Resistance to telehealth provisionsOf the facilities and medical groups who have no past or

present telehealth provisions (n=8), four participants (50%)reported the lack of telehealth services was due to Other (NoKnowledge of Telehealth Medicine, Adult Day Center had NoNeed Due to Physician On-Site, and See Patients Daily with No

Need for Telehealth Services) and Lack of Funding, twoparticipants (25%) reported Lack of Health InsuranceReimbursement for Telehealth Services Provided, and oneparticipant (13%) each reported both Inability to DevelopPartnerships with Originating Sites, and Inability to DevelopPartnerships with Presenting Sites (Figure 18).

Figure 18 Reasons for not attempting to implement telehealth services. (n=8). The most frequent responses were “Other” and“Lack of funding” with 4 responses each, followed by “Lack of health insurance reimbursement for telehealth serviceprovided” with 2 responses. Note that respondents were allowed to provide multiple answers for this question; therefore, thetotal number of responses may exceed the total number of respondents.

Closing questions to all participantsThe last section of survey focused on whether and how

participants (n=37) were aware of the resources availablethrough California Telehealth Resource Center (CTRC). Fifty-one percent (19) of the participants had not heard about CTRCand 49% (18) had heard of CTRC. Several respondentsindicated what would be helpful in implementing, sustaining,and/or expanding telehealth services. The following responseswere recorded by the participants:

“Pass CA State Bill AB 1264”

“[B]eing able to know where to find the resources for whatwe need and where to find answers, for what can be billed”

“[R]eimbursement and more resources for critical accesshospitals”

“[P]ublic knowledge of the service so they would be morewilling to use it”

“[R]esources for the purchase of equipment, resources forset up and ongoing support for electronic issues”

“Telehealth coordinator” “Time and resources”

In summary, a majority of on-site providers utilize‘presenting site video conferencing’ , in psychiatric, mental/behavioral services for diagnosis and treatment or as follow-upcare. They have been using telehealth services for 3-5 years,receive some reimbursement through health plans and/orcash payment, and have yet to experience any cost savings.On-site providers see mostly 41-60-year-old patients,experience inability to connect with the appropriatebandwidth, and project only a 10-30% increase in telehealth


ISSN 2472-1654 Vol.5 No.2:2

2020



services in the next 3 years. Off-site providers use theirtelehealth for clinical labs, experience connectivity barriers,and purchase their equipment through public grants orthrough general operating funds.

Discussion

Broadband AvailabilityThere was a total of 76 facilities within the 10 counties that

represented the responses. From those facilities, only 40

respondents provided information for the broadbandassessment survey. The majority of high-speed Internetavailability resides mostly in the valley. Figure 19 below showsthe location of the rural health care facilities that responded tothe telehealth survey across the 10 counties of theNorteastern and Upstate California Connect Consortia.

Figure 19 Rural medical facilities that responded to the telehealth survey located across 10 counties in rural NorthernCalifornia.


ISSN 2472-1654 Vol.5 No.2:2

2020


Figure 20 (Top left) Fixed wireless broadband coverage. (Top right) DSL broadband coverage. (Bottom left) Cable broadbandcoverage. (Bottom right) Fiber optics broadband coverage. Source: CPUC Broadband availability data 2018.

Based on 2018 broadband availability data from theCalifornia Public Utilities Commission (CPUC), Figure 20 belowshows the coverage and speeds available in the 10 counties. Asexpected, fixed wireless coverage has the largest footprint,

however, it only offers speeds comparable to DSL service (tensof Mbps) and below cable modem (tens to hundreds Mbps) orfiber optics (hundred Mbps to Gigabit). Higher speeds are


ISSN 2472-1654 Vol.5 No.2:2

2020



offered mostly in the valley and along state highways (Figure20).

Table 1 below shows recommended speeds for differenthealth IT use cases including different sizes of health care

providers. Based on more recent telehealth applications anduses, which might use heavy data transfer protocols,recommended speeds might be higher to provide up to datemedical services. This table can be used as an initial reference.

Table 1 Health IT use cases and associated actual broadband requirements.

Health Care Provider Recommended Speed

Single Physician Practice ≥ 4 Mbps

Small Physician Practice (2-4 physicians) ≥ 10 Mbps

Nursing home ≥ 10 Mbps

Rural Health Clinic (approximately 5 physicians) ≥ 10 Mbps

Clinic/Large Physician Practice (5-25 physicians) ≥ 25 Mbps

Hospital ≥ 100 Mbps

Academic/Large Medical Center ≥ 1 Gbps

Based on 2018 broadband availability data from theCalifornia Public Utilities Commission (CPUC), and locations ofthe 76 rural health care facilities represented by the 40 surveyrespondents, Figure 21 below shows the broadband speedsavailable at these facilities. Eight (11%) facilities do not havebroadband service available. From the 68 facilities that havebroadband service available, 5 (7%) facilities have downloadspeeds from 1.5 Mbps to 12 Mbps, 18 (24%) facilities have

download speeds from 20 Mbps to 50 Mbps, 13 (17%) facilitieshave speeds from 100 Mbps to 300 Mbps, and 32 (43%)facilities have speeds available from 986.5 Mbps to 1000Mbps. A more detailed analysis based on the size and numberof physicians at each health care facility will help to assess theappropriate broadband speed available to provide telehealthservices.

Figure 21 Broadband speed (download and upload) available at the 76 represented rural health care facilities, based on CPUCbroadband availability data.

There are several aspects of rural telehealth that werehighlighted when reviewing maps of the 10 counties. One sucharea is the technology used to provide the regions withInternet access. Some of these areas have wirelinetechnologies and others have wireless. The overarching term,broadband pertains to any type of high-speed connection thatcan connect people to the Internet and it can be wireless orwired (WI Public Service Commission, UW-Extension Madison,

& the Center for Community Technology Solutions, 2014 [20]).Wireline refers to digital subscriber line (DSL), cable modem,or fiber optics and uses a physical connection to provideaccess to the Internet; while wireless is connected throughradio waves or satellites with no direct physical connection (WIPublic Service Commission, UW-Extension Madison, & theCenter for Community Technology Solutions, 2014 [20]). Thesustainability of telehealth requires Internet access with high-


ISSN 2472-1654 Vol.5 No.2:2

2020


speed connections especially for live video conferencing andremote monitoring of patients. In rural areas, usually theconnection is with satellite broadband services that can bedisrupted by weather conditions, can be more expensive, andcan have substantial lag time between sending and receiving(WI Public Service Commission, UW-Extension Madison, & theCenter for Community Technology Solutions, 2014) [20]. Thecounty maps for cable, wireless, DSL, and fiber optics depictsthe limited broadband services and their concentration in thevalley and limited availability in the hill, forest and mountainregions.

Telehealth surveyAs an initial survey/assessment of the telehealth services in

Northern California, it is understandable that a small numberresponded. A total sample size of 40 respondents is limitedand does not provide an adequate number for valid statisticalevaluation or for generalizations; however, the data do suggestpotential issues and barriers associated with deliveringbroadband and telehealth services to rural and isolatedcommunities. This survey is the first step in a largerinvestigation of telehealth service delivery in NorthernCalifornia.

On-site servicesIt is interesting that from the 40 respondents, 65% (26

participants) offer telehealth services and most of thosefacilities provided On-Site (25) services. Primarily, participantsreported having Live, Videoconferencing with ‘Presenting Site’Services. The second highest service was Direct to-PatientVideoconference technology (9). A majority of these on-siteparticipants established their telehealth services within thepast 1-5 years. There were four (16%) on-site respondents wholaunched their telehealth services less than a year ago and six(24%) reported more than 6 years of service delivery. Knowingthat telehealth and telemedicine have been a part of themedical community since the 1976 surge in technologicaladvancements [4], it appears that Northern California ruralcommunity medical facilities have mainly incorporatedtelehealth services only within the past 5 years.

The predominant telehealth services used were Psychiatry,Mental Health and/or Behavioral Health with the secondhighest being the Other (Cardiology, Rheumatology,Pulmonary, Pain Management, Endocrinology, NutritionTherapy, Infectious Diseases, Dietician, Cardiac Rhythmology,Addiction Medication, Emergency Pediatric Care, and Diseaseswith Intermittent Symptoms). The specific type of servicesprovided by telehealth focused on Diagnosis/Treatment,Follow-up, Second Opinion, and Chronic Disease Management.This inventory identified a limited number of NorthernCalifornia providers who offer a variety of telehealth servicesthat fall into either “ big telemedicine, ” “ intermediatetelemedicine,” and/or “small telemedicine” [10], highlightingthe need for more access to medical services and specialists inthese rural areas.

Cost of telehealth services and reimbursement dilemmasare significant challenges that need further assessment. Mostrespondents received their telehealth equipment throughPublic Grant Funding or Private Grant funding and werereimbursed either less than 25-50% or more than 75% for thetelehealth services. The highest number of respondents hadno other funding reimbursement other than the health plan.Some respondents received additional supplement funds tothe health plan through patient payment, public grant funding,or private grant assistance. While many of the respondentshave yet to experience any cost-saving, a minority indicated upto 75% cost savings. For on-site facilities, the largest age rangefor those who needed telehealth serves was the 41-60 agegroup. This age group will only increase in the future alongwith the need for gerontologic services.

Finally, when asked about expansion of services for thefuture, a majority responded that they expected less than a30% expansion of telehealth services in the following areas:Primary Care, Workers Compensation Care, Dermatology,Nutrition, Expanding Rooms For Telemedicine and PainManagement, Nephrology, Psychology, Infectious DiseaseServices, Eye Packs, Diabetic Screening, See Other Patients NotAssociated with the Partnership, Neurology, ED In Patients/Groups, Family Planning, Adolescent Psychiatry, Addiction, andClinics with Everything. Geriatrics was the next highest serviceexpansion prediction.

Most respondents have experienced barriers to telehealth,noting Other (Patients are Apprehensive, Getting Patients toBuy-In, Getting the Word Out There and Providing MoreEducation, Reimbursement, Finding Reliable SpecialtyProviders, Lack of Providers, Payer Reimbursement Plan, andConnectivity Issues) and Inability to Connect at NeededInternet Bandwidth Speeds as the largest barriers. Additionalbarriers mentioned were funding issues, community/patientacceptance, and lacking support from physicians.

Off-site servicesAlthough most of the respondents do not offer off-site

services, 33% (8) of respondents did. Those facilities ormedical groups used off-site locations for Clinics, Rural Areas,County Mental Health, Emergency Evacuee Camp, InmateCamp, or Clinical Laboratories. The barriers most off-siteproviders experienced centered around Inability to Connect atNeeded Internet Bandwidth Speeds and connectivity. Finally,those medical facilities or groups with off-site equipmentobtained this equipment through a variety of ways such asPublic Grant Funding, General Operating Expenses, and Countyor Corporate Funding.

Provision to Telehealth. Whereas most respondents did notattempt to offer telehealth services (8), there were 6 (43%)respondents who had attempted telehealth and obtained theirequipment from a Partnership or Grant Funded. There is aslight majority of facilities or medical practice settings whohave not attempted telehealth due to barriers such as Notelephone lines at homes, cell service as an issue,implementation too lengthy, the staff was unsure of how toinitiate service, funding, and no community or patient


ISSN 2472-1654 Vol.5 No.2:2

2020



acceptance. Respondents commented that the lack ofknowledge of telehealth, funding issues, no partnerships, andlack of reimbursements were the reasons for not attemptingtelehealth.

Approximately half of all the respondents (19) had notheard of CTRC as a resource for telehealth service delivery.When asked what assistance is needed to implement, sustain,or expand telehealth, the respondents reported they neededassistance in funding equipment, training employees, supportpersonnel on site, more public knowledge of the technology,and receiving reimbursements.

Comparing those with both On-site and Off-site Services.When comparing those facilities with both on- and off-siteservices (n=7), respondents stated they received their on-siteequipment mainly using Public Grant Funding (36%) or GeneralOperating Expenses (29%) as the means for purchasing theequipment. The off-site equipment was obtained throughGeneral Operating Expenses (22%), or Public Grant Funding(22%), or Other (21%). In addition, those with both on-site andoff-site services rated the greatest barriers as Inability toConnect at the Needed Bandwidth, Lack of Funding, and Other(not identified). On this question, the respondents did nothave the opportunity to identify what Other meant.

Comparing those with either On-site or Off-site Services.Those facilities with on-site only services indicated PublicGrant Funding (27%), Private Grant Funding (23%), andGeneral Operating funds (19%) as the largest three categoriesfor obtaining telehealth equipment. Those facilities with onlyoff-site telehealth services reported that 100% were providedby a hospital or other health care facility. Additionally, the on-site only facilities identified Other (not identified) and Inabilityto Connect at the Needed Bandwidth as the largest barriers;while off-site providers stated the only barrier was the Lack ofCommunity/Patient Acceptance of Telehealth (100%).

Past Provider information: Past Providers indicated Other(not identified) as the most significant means by which theyacquired equipment, followed almost equally by GeneralOperating Expenses, Private Grant Funding, and Leased TheirEquipment. In addition, these past providers indicated themajor barriers were Other (not identified; 29%), then Inabilityto Connect with Internet Bandwidth (24%), and Lack ofCommunity/Patient Acceptance of Telehealth (14%).

RecommendationsA number of challenges are presented when using

telehealth and technology; however, there is an opportunity toaddress the promise of telehealth improving access andincreasing quality of care. Increased awareness of CTRC can beprovided through public service announcements, workshops,trainings, and education on the telehealth services designedspecifically for each rural area. Along with education, technicalsupport is critical for rural providers to become comfortableimplementing a new form of health care delivery. With CTRCinvolvement, there can be support with technical concerns,funding resources, grants, private funding, and political

advocacy. In turn, these issues can be communicated andcirculated to the local, state, and federal health care initiatives.

Legislation can be implemented to support telehealthusage. As mentioned by one of the respondents, AB 1264 canreinforce the use of a telehealth delivery system (AB 1264,Petrie-Norris. Medical Practice Act: dangerous drugs:appropriate prior examination) [22]. California recently passedlegislation that regulates medical examinations for thoseseeking dangerous prescription drugs. State Bill AB 1264:Petris-Norris. Medical Practice Act: Dangerous Drugs:Appropriate Prior Examination passed on September 11, 2019and signed by the Governor October 11, 2019, filed by theSecretary of State on the same day. This bill mandatedimmediate regulation on prescribing medications. Health careprofessionals licensed to prescribe, dispense, or providedangerous medications must provide an appropriate medicalexamination and indication before approval of dangerousmedications. This bill specifically indicates telehealth as ameans for receiving approval for this medication. The politicalsupport and policy development regarding key issues oftelehealth is an essential element needed for telehealth toevolve [21].

Finally, telehealth is at a critical juncture as it advances froma tool used intermittently to an integrated tool on a routinebasis [21]. The overall findings of this inventory confirm thatmore research is needed on telehealth services andimplementation models. Further investigation into theeffectiveness, cost savings, and quality of telehealth is needed.

ConclusionTelehealth has yet to integrate into the mainstream of rural

health care. This broadband assessment inventory is the firstphase in establishing the status of telehealth and the barriersof implementing telehealth in Northern California ruralcommunities. Much of the data align with the literatureregarding barriers and complications in administeringtelehealth services. Klink, et al. found that both users and non-users of telehealth identified the obstacles as the cost ofequipment, lack of knowledge and training, and lack ofreimbursement by insurers. With a majority of users beingfrom rural areas, adequate broadband connections andefficient technology platforms remain problematic.Acceptance by providers and patients were a shared concern.While the literature and providers concurred, telehealthimproves access and provides a continuum of care to isolatedregions, the medical culture and standards of care prefer face-to-face interaction. The next stages of telehealth growth anddevelopment need further investigation and research to gainthe confidence of the medical community as it addresses theinequitable access to health care.

AcknowledgementThis work was carried out under scope of work and activities

of the Northeastern and Upstate California Connect Consortia(NECCC&UCCC) funded by the California Public UtilitiesCommission (CPUC) under the California Advances Services


ISSN 2472-1654 Vol.5 No.2:2

2020


Fund (CASF) program and the North State Planning andDevelopment Collective (NSPDC) to expand broadbandinfrastructure and services in rural Northern California. NECCC& UCCC activities included telehealth collaboration tocoordinate with the California Telehealth Network (CTN) toprovide outreach on expansion of network and documentationof benefits.Wealso thank our colleagues Susan Strachan,Courtney Farrell, Jessica Beckley, Melissa Kovacs, Paul Fortuneand Luke Scholl from the North state Planning andDevelopment Collective for their assistance on this project.

References1. Singh R, Mathiassen L, Stachura M, Astapova E (2010)

Sustainable rural telehealth innovation: A public health casestudy. Health Serv Res 45: 985-1004.

2. Rickets TC (2005) Workforce issues in rural areas: A focus onpolicy equity. Am J Public Health 95: 42–48.

3. Bashshur RL, Shannon G, Krupinski EA, Grigby J (2013)Sustaining and realizing the promise of telemedicine. Telemed JE Health 19: 339-345.

4. https://www.hrsa.gov/rural-health/telehealth/index.html

5. Merrell R (2015) Geriatric telemedicine: Background andevidence for telemedicine as a way to address the challenges ofgeriatrics. Healthc Inform Res 21: 223-229.

6. Krupinski EA, Weinstein RS (2014) Telemedicine, telehealth andm-health: New Frontiers in Medical Practice. Healthcare 2:250-252.

7. Wechsler LR, Tsao JW, Levine SR, Swain-Eng RJ, Adams RJ, et al.(2013). Teleneurology applications: Report for the AmericanAcademy of Neurology Telemedicine Work Group. Neurology 80:670-676.

8. Johnson SR (2017) Minnesota deploys telehealth to expandmental health across to rural areas. Modern Healthcare 47:13-14.

9. De la Torre-Diez I, Lopez-Coronado M, Vaca C, Aguado JS, DeCastro C (2015) Cost-utility and cost-effectiveness studies oftelemedicine, electronic, and mobile health systems in theliterature: A systematic review. Telemed J E Health 21: 81-85.

10. Fong B, Fong ACM., Li C, Li K (2011) Telemedicine technologies:informationctechnologies in medicine and telehealth. UnitedKingdom: John Wiley & Sons, Ltd.

11. Voran D (2015) Telemedicine and beyond. Missouri Medicine: JMissouri State Med Assoc 112: 129-135.

12. California Health Care Foundation. (2017) How many in yourarea are uninsured—and why?

13. Dietz M, Graham-Squire D, Becker T, Chen X, Lucia P, et al.(2014). Preliminary CalSIM v 2.0 Regional Remaining UninsuredProjections.

14. http://laborcenter.berkeley.edu/pdf/2016/Preliminary-CalSIM-20-Regional-Remaining-Uninsured-2017.pdf

15. U.S. Census Bureau, 2017. Data: Table H-8. Median HouseholdIncome by State.

16. https://www.calhealthreport.org/2017/10/23/californias-rural-communities-primary-care-remains-hard-find/

17. Rubin A, Babbie ER (2014). Empowerment series: Researchmethods for social work. Boston, MA: Cengage Learning. 43

18. http://www.caltelehealth.org/participating-sites.

19. Faulkner SS, Faulkner CA (2014) Research methods for socialworkers: A Practice-based approach. Chicago, IL: Lyceum Books,Inc.

20. https://broadbandmatters.com/broadband101#n18

21. https://www.graham-center.org/content/dam/rgc/documents/publications reports/reports/RGC%202015%20Telehealth%20Report.pdf


ISSN 2472-1654 Vol.5 No.2:2

2020



Documents

ISSN 2472-1654 iMedPub Journals 2020 · connectivity challenges in which the issues of rural health provider connectivity was addressed. As C TN works with internet ser vice provider