Rural Health: Connecting Doctors and Patients

Oct 25, 2017

Dr. Eric Wallace reviews Mary Epp's chart during a telemedicine appointment.
Credit UAB

All year long on Alabama Public Radio, we’ve been looking at rural health care. Advocates of rural health in Alabama say one of the biggest issues is access to health care in rural areas. The state is facing a massive shortage of physicians, and the doctors we do have are largely concentrated in metropolitan areas.

The situation gets worse when it comes to specialty and subspecialty care. The vast majority of the state’s specialists are in Birmingham, Huntsville or Mobile. But doctors are now starting to use technology to bring specialty care into rural Alabama.

“So how is everything today?”

“It’s good. Everything’s good.”

Mary Epp is 84 years old and a home dialysis patient. She’s at a routine followup appointment with her endocrinologist Dr. Eric Wallace at the University of Alabama at Birmingham School of Medicine. But Mrs. Epp isn’t in Birmingham. She’s at the Dallas County Health Department, about 75 miles to the south.

“They can not only see each other face-to-face, but they can use enhancements to listen to the heart rate, to monitor the EKG, to look into the ears, the eyes, the nose, the throat...”

Dr. Walter Geary is the Medical Director for the Alabama Department of Public Health. Thanks to telemedicine equipment at dozens of county health departments across the state, Dr. Wallace is able to provide Mrs. Epp and many other patients a full-fledged checkup hundreds of miles apart.

I caught up with Dr. Wallace at a statewide conference on telehealth.

Jessica Hardy shows off a specialized camera used to examine patients in telemedicine appointments.
Credit Alex AuBuchon / APR

“Probably 80 percent of what physicians need to do can be done by listening to the patient. But we also need a physical exam. So what happens is I use a telestethoscope to listen to the patient's heart and lungs and abdomen. I use specialized cameras to look at lesions -- in dialysis patients, the exit site...”

Dr. Wallace says providing care remotely is more than a convenience for these patients. He says it’s quickly becoming a necessity, given the state of health care in Alabama.

“If we had 500 doctors to land in Alabama today, we still wouldn't have enough.”

Ron Sparks is a rural health care and telehealth advocate.

“If we had 250 dentists land in Alabama today, we wouldn't have enough. So access to health care is definitely a problem in the state of Alabama. Using technology and using telemedicine is a way to reach folks who don't have access to health care.”

Sparks previously headed the state’s Office of Rural Development under Governor Robert Bentley. He says the expansion of telemedicine is inevitable.

“You've either used telemedicine, or you will use telemedicine. It's gonna happen.”

There are currently a collection of different small, regional telehealth networks offering various telemedicine services. Dr. Wallace says he wants to see those providers work together.

“My real vision for Alabama is that you have one overriding way of linking all of those networks together to create, really, a comprehensive network that is far-reaching and able to link any provider with any patient across the state.”

The Alabama Department of Public Health is taking the lead on developing that network. Jessica Hardy is the director of the Office of Women’s Health at ADPH.

“We have a very new telehealth program within the Department of Public Health, so we are growing, and we are being charged to try to go into eleven different areas of subspecialty at this time.”

Public health medical director Dr. Walter Geary says the possibilities for specialty care delivered remotely are nearly endless.

“That could be done for just the entire state of Alabama, if we had the bandwidth to do that, for a huge variety of problems and complications. All kinds of chronic illnesses, from diabetes to Chron's disease, to ulcerative colitis, to diabetic ulcers of the feet... All those kinds of things require daily treatment management, but intermittent physician oversight.”

Bandwidth is one potential hurdle to a widespread adoption of telehealth. Many rural areas in the state don’t have consistent cell service, much less broadband internet. And supporting high-resolution video conferencing along with medical data in a telehealth visit requires a lot of bandwidth.

Ron Sparks says it’s hard to understate the importance of quality internet.

“If you live in rural Alabama in today's world and you don't have access to broadband, that's like cutting off one of your main arteries to your heart. You're just not going to function very well. Big industry is not going to look at you. You're not going to have the health care that you deserve. You possibly could not have the emergency care, the public safety care...”

But the Alabama Department of Public Health has an unusual leg up. Thanks to a state mandate, county health departments have special broadband infrastructure and 60 of Alabama’s 66 county health departments currently have the bandwidth for telehealth, even if other areas of those counties fall short.

Coffee Middle School Nurse Charlene Smith conducts a telemedicine examination with a student in Douglas, Ga.
Credit Coffee County Schools

Another telehealth model is gaining lots of steam across the border in Georgia – telemedicine systems in school.

“The child's there at school all the time. That school nurse probably knows that child pretty well.”

Sherrie Williams works with the Global Partnership for Telehealth, based in Georgia.

“What if she is able to take that child to the next level by providing these care services into the mix? So it really becomes a whole lot bigger than just that primary care model. It truly can create a system of care.”

Williams says school-based telehealth can fill major gaps in community health care, especially after rural clinics or hospitals in those areas close.

“When a hospital closes, usually those primary care doctors leave also, so you're left with a huge void. Not only for the children, but you're talking about entire populations at this point in time. So I think being able to put telehealth inside the schools is a huge step in the right direction in figuring out how to fill that health disparity in our rural communities.”

Unfortunately, the model in Georgia isn’t possible in Alabama, at least not yet, because of Medicaid regulations. State Medicaid rules don’t consider schools an acceptable place to receive healthcare.

That’s not the only way Medicaid regulations are posing a bigger problem to telehealth. Alabama doesn’t have what’s called a “parity law” in place. That assures doctors get paid the same rate whether they see a patient remotely or in person. Georgia does, as well as Mississippi.

“Just across the border in Mississippi, their telehealth program has been going on 15, 16 years now.

Michael Smith is the director of telehealth for the Alabama Department of Public Health.

“They have about 6,000 telehealth encounters each and every month. We can benefit from the successes that they have made, but still have a lot of work to do in terms of development of our program.”

Alabama is starting on the back foot in terms of telemedicine. But Dr. Wallace is optimistic about the near future.  

“What I foresee, with all the progress we’ve made thus far in the state, I foresee that this time next year, you will have multiple subspecialties at UAB providing care across the state. Important care, care that we need to actually improve the outcomes of patients in our state.”

Meaning patients like Mary Epp, dealing with a variety of complicated medical issues, can get quality health care a lot closer to home.