Transcript: Community Broadband Bits NC Bonus Episode 7

This is the transcript for episode 7 of the Why NC Broadband Matters series on the Community Broadband Bits podcast. In this episode, Christopher speaks with Dave Kirby, President of the North Carolina Telehealth Network Association. The pair discuss the importance of telehealth services and broadband to achieve health equity. Listen to the episode, or read the transcript below.


Dave Kirby: Convenient means for most people who are also working or taking care of children are taking care of elders, not having to arrange for those things to be managed in their absence, while they go off for a nurse and doctor visit that could have been done with a telehealth modality, with just a few minutes out of both a doctor's day and the patient's day.

Jess Del Fiacco: We're bringing you another episode in our special community Broadband Bits Podcast series, Why NC Broadband Matters. I'm Jess Del Fiacco, with The Institute for Local Self-Reliance, in Minneapolis, Minnesota. NC Broadband Matters is a North Carolina nonprofit. Their mission is to attract, support and champion the universal availability of affordable, reliable, high capacity Internet access necessary for thriving local communities, including local businesses and a local workforce so each can compete in the global economy. The group has created the North Carolina chapter of CLIC, The Coalition for Local Internet Choice. The Institute is working with NC Broadband Matters to produce this series, focusing on issues affecting people in North Carolina that also impact folks in other regions. Today we're joined by Dave Kirby, President of the North Carolina Telehealth Network Association.

Jess Del Fiacco: In this episode, Christopher and Dave talk about the role of broadband in telehealth in 2020. They discuss the differences between rural and urban healthcare and how telehealth in rural areas could reduce costs. Dave also points out all of the issues that health technicians can face without broadband access, and why telehealth has become even more important during the COVID-19 pandemic. Now, here's Christopher talking with Dave Kirby of the North Carolina Telehealth Network Association.

Christopher Mitchell: Welcome to another episode of the Community Broadband Bits Podcast, a special edition on North Carolina, as part of our long running series that started from about a hundred years ago before this pandemic began. Well, we are going to be addressing it today, talking about telehealth, but this is part of a series sponsored by NC Hearts Gigabit, NC Broadband Matters, organizations that care a lot about broadband in North Carolina. So let me introduce you to my guest. Dave Kirby is the President of the North Carolina Telehealth Network Association and he's actually its founder from back in 2006. When that's not keeping him too busy, he provides consulting and information security and privacy for emerging information technology type stuff. Welcome to the show.


Dave Kirby: Thank you. Good to be here, Chris.

Christopher Mitchell: I really appreciate you taking some time to come in, I guess we're all staying in right now, but to do this interview. Tell us a little bit about what the North Carolina Telehealth Network Association does, please.

Dave Kirby: It's an association of, whose members are subscribers to the North Carolina Telehealth Network, and its mission is to advocate for and support broadband services for public and nonprofit healthcare providers here in North Carolina.

Christopher Mitchell: Wonderful. So we've decided to switch to a different microphone over the phone line rather than doing the interview because I was afraid of the quality. So I don't want to work my producers too hard.

Dave Kirby: Right.

Christopher Mitchell: I guess one of the things that I wanted to ask you about is what does broadband have to do with healthcare now, in the year 2020?

Dave Kirby: Well, you can pick up almost anywhere with this, but I would pick up maybe 15 years or so ago. The public policy around healthcare gravitated towards the idea that the use of information systems in healthcare needed to be broader and deeper in order to improve the efficientness, effectiveness and all around quality of healthcare. And a number of programs and pushes later, what we have is most healthcare providers in the country have adopted information services mostly that are remotely serve. So these are like electronic health record system, is a big piece of this. Connections to places like imaging centers and other diagnostics, labs, that sort of thing. And so if you just turn on today and look at it, what you'll find is that most healthcare providers are very dependent minute-to-minute on the availability and quality of their broadband connection, nowadays. The result is a much higher interest, much higher profusion of high quality and highly reliable broadband connections throughout the healthcare system.


Christopher Mitchell: I think it maybe worth taking a step back to describe what the healthcare system is, in part because so many of us I think try to spend as much time as we can not dealing with the healthcare system. But when you say the healthcare system, is this a few big hospitals or how far down does it get?

Dave Kirby: No, in North Carolina, we clock it at something in the neighborhood of a couple of thousand sites, those being hospitals, clinics, things called federally qualified health centers, which serve mostly the low income people, free clinic behavioral health sites in the State, the kind of outlying clinics that you see around the typical hospital. All of our big hospital systems here in this State, as maybe the public thinks of them, are not just hospitals. There are hospitals plus a large number of clinics for every one of them. So, oh, I can pick a number, UNC Health Systems seems to have something like 250 odd sites, at which care are provided throughout the region. I believe Novant is another good example. They have something like 400, 500 sites here in North Carolina. And so virtually anywhere today that you meet somebody who's providing you a medical service, that's part of the health system.

Christopher Mitchell: And that location is going to need broadband just as part of how they do on a regular day. They're going to need a high quality Internet connection that is not going to break the bank and is going to make sure they have the reliability they need. Because I'm assuming if they're down for 15 minutes, it can be really a problem.


Dave Kirby: It's a problem being down for 15 minutes. Although if the outage is caused by, say a typical one is a fiber cut, where somebody has unfortunately cut a piece of fiber somewhere and taken down a whole bunch of people usually, it usually takes on the order of hours to repair those things and maybe a day or more depending on weather conditions. And most healthcare providers are now in a situation where what happens immediately when the network connection goes down is that they no longer have access to patient records. They no longer have access to functions that allow them to even make appointment and carry out ordinary clinical activities in the course of seeing a patient. They can't record information that will be relevant, either for getting paid or for subsequent clinical care. So those are all really important consequences for the typical site today.

Dave Kirby: Now of course, it's true also that the people who are doing what I think the public imagination sees as telehealth services, most people iconically think of talking to a clinician over a video link, and surely that's a major form of this kind of activity. But those things also require connections, and when they're down or not working adequately, then the experience that both the clinicians need and that the patients value is interrupted. And you can imagine what a disturbance it is. So it's at least as important as power and water and any other utility in the typical healthcare site today.

Christopher Mitchell: I like the way you phrase that in terms of the popular imagination. And just briefly, I mean I think we do want to spend most of our time talking about that, the part of imagining using the video system to do it either from your home or from a local location with some distance specialists. But I mean just from a perspective of telehealth writ large, is that the most important thing that we're working on right now? Or are there other aspects of telehealth that often get ignored but are crucial to understand for improving healthcare?


Dave Kirby: Well, I think that aside from the direct video call kind of centric care model that we just talked about, the second sort of large category of applications are probably generally better described as connected care. They look like places where patients usually have devices that they keep with them at home or as they move around. And devices might be say, an Internet connected watch or an Internet connected monitoring system at home that monitors things like glucose level or weight for people with COPD, and communicates that information back to a healthcare provider. Sometimes automatically and sometimes at the patient's direct request in each case, and that becomes part of the care process. It either, it may become a notification to the care provider that something needs to be done, that the patient needs to be engaged or it may just be the accumulation of information like a longterm glucose readings from a diabetic to help determine what to do to help them, whether their A1C is working well or whether their glucose levels are working well on a more acute basis. So there's all this communications of stuff that's going on with us in our daily lives, and that kind of field is getting to be called connected care.

Christopher Mitchell: One of the things that rural America is dealing with all over the nation is these rural hospital closures. And that seems like it's really hit North Carolina hard, particularly over the last 15 years when you've been working on these issues. And I'm curious if you can give us a sense of what care is like in rural areas of North Carolina, without the telehealth and then we can go into how that is hopefully changing both now and in coming years.


Dave Kirby: Well, I think the historical problem in the rural areas that telehealth applications have been focused on is extending viable access to care to the rural population, especially in places where that viable access is just totally missing. And by viable access, I mean let's suppose you have to see a psychologist and you live in a rural area and you've decided to enter into a therapeutic kind of relationship with them where you go once a week. Well, if you're in a rural area and the psychologist is 50, 100 miles away, which would be pretty difficult, it's just not practical for you to do that unless it's just hyper critical for you to see this person and you're willing to somehow manage a 50, 100 mile trip, times two, once a week in order to do this. Well that cuts off a lot of people from practical access to a service like that. And so at least for the last decade or so, the telehealth applications have been emerging, have been ones for address to rural populations, have been to cut the travel problem.

Dave Kirby: Of course, the travel problem exists in the other direction too. You have limited opportunities to bring the psychologist to the patient's community once a week, for example. Same thing with medical providers. It's not great use of an expensive resource like a doctor for example, to have them have to show up and spend a lot of their lives traveling around the State in order to get to a number of very thinly populated pockets of people. That's a real hard problem to solve, in terms of making good sense out of spending healthcare time and even attracting people to do it. But the remote doctor, the remote nurse, the remote therapist and psychiatrist, those things are things that you can practically do with a lot of care scenarios. Of course eventually, you're going to hit a bump where a patient has to really see a doctor. But what's happening here, is telehealth is reducing those occasions and making access to medical services a lot broader and better and easier and more viable for people in rural populations.


Christopher Mitchell: Do we have any sense of the difference, whether it's in dollars or some other measurement of how people living in rural areas are missing out or having worse outcomes because they don't have the same access that people do in more urban areas?

Dave Kirby: Well, you can certainly find any number of projects over the last decade or so who've been put up as pilot projects that were meant to evaluate this. And those pilot projects of course have produced the first round of data that helps us see what the difference is between a population with and without telehealth based activities with it and access to medical services through telehealth modalities. I don't think I've seen one rolled up into one big package because it's usually studied one issue at a time. So here's therapy for depression over here, and here's program to support diabetics in the rural community that's telehealth based. And here's another one that's about managing strokes in rural locations. And so it's a little hard, at least I don't have access to a kind of an overarching thing.

Dave Kirby: But you can tell by the number of projects, and at least my sense of how broadly it is that the payers who, especially Medicare, Medicaid and private payers, have agreed that this is an effective modality for addressing these populations, is the rate at which payers and the ways in which payers over the last years have loosened their willingness to reimburse, for the so-called professional services. So the actual doctor's time taken in a telehealth application, and also to somewhat to reimburse providers who use telehealth modalities and have costs associated with that. So the business of using telehealth is getting paid for more and more, and I'd say overall that only happened after there were a lot of demonstrations about how effective this was in improving the health outcomes for people in the areas that the telehealth application address, usually rural areas. I mean that's the biggest focus for these things.


Christopher Mitchell: It seems like in your answer there is an unmet need in rural areas that there's a differential for people who are in rural areas with the care that they can get and that the entities that are in charge of figuring out how to cost effectively deliver care to them have determined that telehealth is effective. I'm assuming they're using a pretty high bar to make that decision. But then the third thing is, is are we seeing that then limited or even in some way rationed by the availability of high quality Internet access in different areas then?

Dave Kirby: Well that aspect of the problem has been what I spent a lot of my time on in the last 15 years, and the answer is yes, there's quite a distinction between the availability and the cost of broadband in rural areas as opposed to urban areas in this State. And this is repeated everywhere in the country. I'd say most of the difference is a consequence of the cost of providing wired or fiber services in thinly populated areas versus heavily populated areas. You take a city where you put in the money to bring a fiber by a building that's an apartment building that has a hundred people in it and that costs X, get that fiber from there back to a point of presence somewhere on the vendor's network. That same amount of distance in a rural area, that's only one 100th of the population density, would mean that somehow that same cost has to be born by a single connection.


Dave Kirby: And now that's an extreme to point out the effect here, but you'll find along the way that for wired connections, especially in fiber connections, this is a really important feature of the cost structure, is what it costs to bring a cable into your facility or your home, wherever that is. Wireless has made this a little bit easier for some modalities because of its ability to thread signals without having to take a wire literally down to the last inch in order to reach a person. And the good thing about that is, have been able to reach some more people in a way that's cost effective. But that's still limited in some places where you can't get either enough bandwidth on the wireless side of that connection or you can't even bring it out to some parties. And I guess we've all had experiences traveling around where there was just a dead zone, there was just no signal from any vendor you could find providing wireless services.

Dave Kirby: And that's much more common in rural areas than it is anywhere in an urban space. And again, the math of this tends to be part of having to justify putting up the cost of running, say a cell phone tower. And by the way, every cell phone tower has to have a way to move it, data that's passing through it, back up into the network. And that's usually a fiber connection of its own. Although it's a single fiber connection that carries service for a very high number of people, compared to say a suburban situation where fiber is strung between houses. So although the wireless doesn't help a good bit, it's still not gone as far in terms of cost and benefit as would be helpful for us to reach virtually everybody in the State. And this is a general countrywide problem.


Christopher Mitchell: I feel like one of the challenges has to do with the business models that have been used thus far, in that both public and private business models have tried to generally pay for themselves with the direct revenues. But I think a conversation like this, we can really try to talk about some of the value we were talking about a few minutes ago that currently is out there. Because a person in the Western part of the State who can't get to a doctor regularly, who may not be able to get even to a clinic regularly to get checked up for a chronic disease. Not only are they experiencing pain, but there's also societal costs for many people who may be on publicly supported health insurance. And so, if we can have high quality connectivity to that person, we may start saving money elsewhere. And that's one of the reasons many of us justify then spending public dollars in a variety of models to make sure everyone's connected.

Dave Kirby: I agree that part of the justification in specific cases, and going back to those, all those pilots studies I talked about a few minutes ago, they're often framed in terms of savings, in terms of dollars in the healthcare system. They're rarely framed in dollars associated with social costs elsewhere, like people who aren't healthy enough to work, not being able to participate in the work world or people who are not healthy enough to take care of their families, not being able to carry out the role of helping to raise children. Those sorts of things are rarely included as part of the cost. But I feel, and I think most people intuitively feel that, that's a serious costs in the broad sense of the term. The most important long serving, and I think the largest dollar wise program, have been the programs carried out by The Federal Communications Commission to essentially subsidize everything from telephones to nowadays broadband for the public and for healthcare providers and other social good groups like schools. Those have been going on for a long time, back since the 1934 Telecommunications Act.

Christopher Mitchell: I believe so.


Dave Kirby: Yeah. The original thesis, as I understand it, behind the '34 Act was, well America ought to be connected because without it then America isn't a country, it's two. It's those who are connected and those who aren't. And if it hadn't been for that, then connecting rural phones, initially, would not have been affordable by much of anybody because who could pay the actual underlying cost for a thinly distributed population across the amount of dollars it would have cost to put wires and enough equipment at the right intervals, and that's continued to this day. There is some limited amount of interest so far, but growing in the area of subsidizing broadband for the public, especially for health purposes. Some of the latest stuff announced just yesterday by the FCC in their connected care program and the even more emergent COVID-19 telehealth program, those are about extending dollars, subsidizing costs for methodologies that are meant to actually go out into public homes and even be mobile with people as they get through their workdays and shopping and anything else that they do in their normal lives. So I'd say there's limited, but growing interest and doing things that reach the public, but there's very well established interest in the SCCs part and carrying out the core of this congressionally mandated requirements under the Telecom Act of '96, to reach out into the healthcare community and connect public and nonprofit healthcare providers.

Christopher Mitchell: Well, in the current situation with the pandemic, we're recording this on Friday and hope to release it next week. So a lifetime could change between then, but certainly we're afraid to see a what happens next. We're hoping for the best, but it does seem like right now we're in a situation in which we would love to have the possibility that both healthy people, which is to say people who are not ill with COVID-19 would be able to do their healthcare visits from home. And that people who may have a lot of symptoms that are consistent with COVID-19 would also be able to check in from home and not travel, in that way, avoid overrunning emergency rooms until a specialist had said, "yes, you are a candidate for someone who needs to come in". And so it feels like we're just missing a tremendous amount of telehealth potential right now because we haven't connected a lot of people.


Dave Kirby: That's true, and some of that is about broadband availability. But there are other barriers too, that are coming down, and some of them are coming down very fast nowadays because of the COVID crisis. I mentioned already the reimbursement issue and although the payers have been growing over the last few years, public and private payers have been growing. And what kinds of telehealth enabled episodes of care they'll reimburse professionally for, there is still some distance to go. And I sort of, this is just my gut feel, is that this crisis will boost interest and push that quite a lot faster than it would have otherwise gone, so that by the time this is over. Let's suppose that we, I don't have any more of a crystal ball than anybody, but let's suppose we look up again a year from now, we're likely to see an awful lot of providers and payers having found new ground in which they can and feel motivated to prioritize serving patients this way.

Dave Kirby: Like any new thing, it takes some time and energy of its own just to adapt a new way of providing care to people. Doctors reasonably enough, want to know that they have a modality where they can feel assured that they're not just giving nominal access to care to people but are giving them the kind of quality care that they deserve. They also have regulatory and malpractice issues to deal with. They want to make sure they stay on the right side of those as they extend themselves remotely. And some of it's just changing habits. I'll give one example. My sister is a psychotherapist, has been a psychotherapist for 40 years and although I've been talking to her for the last decade or so about maybe doing some of her practice on telehealth based modalities, just in the last two weeks, she's essentially been forced to do that. And she's adapted and it's been a struggle, but she's there where most of her patients she's seeing remotely now and many of them are people who she feels are responding better.


Dave Kirby: She never would have gone out and done that experiment, I don't think to find out which ones would respond better. Others are responding about the same and a few, she doesn't feel are responding as well. But in this case, it's better to have some session that they don't respond to as well as they might an in person session then none at all, which would have been the alternative in this particular situation. So I think there'll be a lot of growth in this area and. I personally applaud it. I think people all over the country, regardless of almost where they live, that they ought to have access to high quality health care. But that's just me.

Christopher Mitchell: Right. So with you, it's hard for me to imagine someone who's not nodding their head right now. One of the things I'd be curious about as well as if over the over a period of weeks or months, if there's a improved ability to attend. I mean I think this is one of the things for people with recurring healthcare is if we can make it more convenient, whether it's for mental health or other forms of healthcare. We may see improved outcomes, I would assume, from just making it as convenient as possible to get help.

Dave Kirby: That's quite possible. I think people on these pilot programs that I've talked about before have tried to measure these things. And for people listening, when I think of what do they mean by convenience, they usually mean that it becomes practical for people to do things rather than just a little nicer somehow. So convenient means being able to see the therapist once a week as opposed to maybe once a month. Convenient means for most people who are also working or taking care of children or taking care of elders, not having to arrange for those things to be managed in their absence while they go off to some physician visit or some doctor visit that could have been done with a telehealth modality with just a few minutes out of both a doctor's day and the patient's day, at a time that was convenient to both of them.


Dave Kirby: And so, take somebody who's working and they have children and they have elderly parents, but the elderly parents are taking care of the children while the worker is off during the day. Well there's the grandparent has to have a doctor visit, well what happens? The worker has to go off the clock in order to take care of the children and maybe two workers. They have to take the children along with the elderly parent in the car to the doctor and then reverse the whole thing. And very many of these folks are not living in a world where they have such high discretionary income that they can say, well that's all right, I just won't make quite as many dollars this month.

Dave Kirby: Instead they have very little discretionary income. And so in effect, giving up work for a day, if nothing else, and sometimes there are other things that matter, but giving up work for a day means losing a significant income that's applied toward direct immediate needs in the household. So this convenience idea, I think, is better described in those scenarios rather than yes, well, so I can do something on my phone as opposed to having to be a salaried person who just takes an hour off and goes to a doctor visit that's five miles away. That's not the kind of situation that we'll get the big gains from. But you're right, I mean, I sort of expect surprises. I expect people to get surprised about these new modalities and I expect them to take them up and find the convenience of the ways that we've just been talking about is now possible and practical and that they'll prefer them. And that will push the healthcare community along with their own interest in providing good care and being efficient and effective.


Christopher Mitchell: I really appreciate you spelling out some of the scenarios that are encompassed by trivial, perhaps you said the word convenience. But I think that's something that, it's faced by not just millions of people, but probably tens of millions of people. And there's such hope, as we overcome all of the barriers to telehealth that you noted. The one that I focused on is broadband and I know that we can get high quality broadband to everyone and let that not be a barrier. And I don't know if anyone will write the story or do the studies to find out what a gain there is, but I think we'll find that States and the federal government save significant money as we're able to use this and all Americans are able to take full use of it.

Dave Kirby: We might save some money on healthcare, but I'd argue there's another ethical moral argument and just an argument about the culture of the country, which is making people healthy is a good in itself. It's not just making them healthy so they can work and making them healthy so they can do other things. Being healthy is a good thing for a person. Well, we've all had experience at least with being sick in minor ways and it's hard to have an enjoyable life when you're ill.

Christopher Mitchell: Yes. And as someone who's had chronic pain for 15 years, I personally, it's not a significant source of pain and there's nothing I can do about having some pretty bad arthritis. But it's frustrating to know there's people out there who are probably in more pain than me who could be treated, and as you say, live a better life, and we can solve that. So I really appreciate your time today. I think you put some of this, the telehealth discussion, into a much greater context than we normally see. So thank you very much for that.


Dave Kirby: Oh, you're welcome. I hope it's been helpful to your listeners.

Jess Del Fiacco: Thanks for tuning into this episode in our Why NC Broadband Matters Podcast series, and for listening to the Community Broadband Bits Podcast from the The Institute for Local Self-Reliance. Remember to follow Christopher on Twitter. His handle is @communitynets. And if you follow @NCHeartsGB on Twitter, you'll tap into all the NC Broadband Matters material. We want to thank Shane Ivers of for the series music, What's The Angle, licensed through Creative Commons. And we want to thank you for listening. Until next time.