How Mobile Apps Could Transform Rural Health Care

Telemedicine is transforming health care for Americans. But the system still needs work.

National Journal
Clara Ritger
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Clara Ritger
Nov. 11, 2013, midnight

When it comes to rur­al health care, broad­band is a mat­ter of life or death.

Rur­al res­id­ents seek ser­vices from primary-care doc­tors and emer­gency rooms, which works if the pa­tient doesn’t have a chron­ic or life-threat­en­ing con­di­tion. But when they do, rur­al pa­tients don’t al­ways have ac­cess to the most com­pre­hens­ive care. Med­ic­al spe­cial­ists prac­tice in cit­ies, leav­ing rur­al doc­tors to weigh the choice between send­ing a pa­tient away for treat­ment — cost­ing both the pa­tient and prac­tice — or keep­ing them in house, where they risk pa­tient out­comes but keep the paycheck.

Ac­cess to health ser­vices was an obstacle in rur­al Col­or­ado un­til 2008, when the Col­or­ado Tele­health Net­work was formed. Rur­al fa­cil­it­ies could trans­mit X-ray res­ults and oth­er dia­gnost­ic tests to lar­ger pro­viders in a mat­ter of minutes, and treat­ment re­com­mend­a­tions from ex­perts in urb­an cen­ters could be car­ried out re­motely. Today, 201 fa­cil­it­ies are con­nec­ted to the broad­band net­work that ex­tends across Col­or­ado’s 104,000 square miles.

But ac­cess to care doesn’t im­prove pop­u­la­tion health overnight — es­pe­cially for rur­al areas where one in four people re­main un­in­sured. The next fron­ti­er for im­prov­ing rur­al pa­tients’ ac­cess to health ser­vices is mo­bile ap­plic­a­tions.

“There’s a cer­tain glam­our about this new tech­no­logy,” said Ed Bo­stick, CTN’s ex­ec­ut­ive dir­ect­or. “But there’s also push­back that it is just one more thing for people to di­gest.”

As smart­phones be­come a way of life, Amer­ica is on the cusp of turn­ing telemedi­cine and mo­bile tech­no­logy in­to daily health prac­tice.

“I think we could see tre­mend­ous growth in the next five years,” said Mur­ray Aitken, ex­ec­ut­ive dir­ect­or of the IMS In­sti­tute for Health­care In­form­at­ics, which provides policy makers with in­sight in­to the health care in­dustry.

There are chal­lenges, however, that keep tech­no­lo­gic­al ad­vances in health care from en­ter­ing main­stream prac­tice. Im­per­fect pay­ment sys­tems, lag­ging gov­ern­ment­al reg­u­la­tions, con­sumers’ pri­vacy and se­cur­ity con­cerns, sat­ur­a­tion of the app mar­ket, and a lack of re­search show­ing im­proved health out­comes rep­res­ent some of the hurdles telemedi­cine and mo­bile health apps have yet to over­come.

On iTunes, for ex­ample, there are more than 40,000 health apps, but that’s few­er than 10 per­cent of all apps in the store. Moreover, roughly 50 per­cent of health apps have been down­loaded few­er than 500 times, which Aitken says sig­nals a lack of aware­ness about which apps are the best to use.

“Apps can clearly be a very cost-ef­fect­ive means for pa­tients to en­gage in their health care,” Aitken said. “They’re help­ing keep pa­tients out of doc­tors’ of­fices.”

While apps are not a sub­sti­tute for doc­tors’ vis­its, pro­viders are con­fid­ent that in­teg­rat­ing apps in­to health care could re­duce doc­tors vis­its and help mit­ig­ate the doc­tor short­age that will be ex­acer­bated by the in­flux of newly in­sured con­sumers once the Af­ford­able Care Act takes full ef­fect next year.

“We can see that apps have the abil­ity to cap­ture in­form­a­tion about a pa­tient and trans­mit that data to a doc­tor re­motely,” Aitken said.

It’s not such an easy choice for doc­tors, be­cause few­er pa­tient vis­its mean lower pay. Al­though laws vary by state, in­sur­ance com­pan­ies are re­luct­ant to re­im­burse phys­i­cians for mo­bile apps and telemedi­cine.

“In­sur­ance com­pan­ies want to see evid­ence that this is an ef­fect­ive de­liv­ery meth­od of health care,” said Dar­rell West, found­ing dir­ect­or of the Cen­ter for Tech­no­logy In­nov­a­tion at the Brook­ings In­sti­tu­tion.

That means cre­at­ing more pi­lot pro­grams where in­surers can see pos­it­ive res­ults.

In Arkan­sas, for in­stance, rur­al pa­tients seek­ing gyneco­lo­gic­al and ob­stet­rics care have be­nefited from telemedi­cine, even though fixes to the pay­ment struc­ture have yet to be made, said Curtis Lowery, chair­man of the Uni­versity of Arkan­sas med­ic­al sci­ences de­part­ment of ob­stet­rics and gyneco­logy.

“If the pa­tients need to be seen by the uni­versity, then we’d have them come in,” Lowery said. “But few­er than 10 per­cent ever come to the uni­versity.”

About 48 per­cent of Arkansans live in rur­al areas, ac­cord­ing to the uni­versity’s data. At telemedi­cine hubs in re­mote parts of the state, ul­tra­sounds are streamed to UAMS for eval­u­ation.

“In­stead of send­ing a pa­tient away and nev­er com­ing back,” Lowery said, “it’s as if a vir­tu­al spe­cial­ist is prac­ti­cing with you.”

That has proven to be one way of re­mov­ing the pres­sure of a paycheck from de­term­in­ing a pa­tient’s course of treat­ment. Medi­care and Medi­caid re­im­burse for telemedi­cine, but some private in­surers are still hold­ing out.

State li­cens­ing boards also haven’t caught up with the tech­no­logy, which cre­ates ad­di­tion­al hurdles for doc­tors who are will­ing to look at pa­tient-sub­mit­ted pho­tos and video to make dia­gnoses.

“The li­cens­ing boards ex­ist to en­sure the phys­i­cians have met the cre­den­tials to be provid­ing care,” Lowery said. “But in Arkan­sas, a phys­i­cian de­veloped an app for people to send pho­tos of skin le­sions, and then he’d eval­u­ate and send his dia­gnos­is back to them. What if that’s not a qual­ity im­age? Should he be able to do that or not?”

But con­sumer de­mand for the ser­vices is there. Es­pe­cially for rur­al pop­u­la­tions, it is faster and cheap­er to dia­gnose re­motely.The un­answered ques­tion is wheth­er it im­proves health out­comes.

“We’re all hop­ing that apps change be­ha­vi­or,” Bo­stick said.

There isn’t enough re­search to lay the ground­work for a case that mo­bile apps and telemedi­cine im­prove health out­comes, which is one of the reas­ons in­surers and the app-de­vel­op­ing com­munity are re­luct­ant to jump in, Aitken said.

Re­gard­less of health out­comes, mo­bile apps and telemedi­cine do im­prove ac­cess to health ser­vices for rur­al Amer­ic­ans. And with one of every five un­in­sured Amer­ic­ans clas­si­fied as rur­al, mo­bile health tech­no­logy is the next battle­ground for open­ing path­ways to care.

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