It costs Southeast Missouri Electric Cooperative in Sikeston about $20,000 to put in one mile of fiber-optic internet cable.

Southeast Missouri Electric, or SEMO Electric, has been working to provide fiber internet to five counties in the Missouri bootheel since 2017. One of the more recent lines the company laid cost $1.2 million. There were only 60 homes on that line.

“It’s very rural and it’s very expensive,” SEMO Electric CEO Sean Vanslyke said.

But it’s also very important, especially to Dr. Steven Douglas and especially during a pandemic.

“By in large the telemedicine … with our patients does help to get through some of the gaps with rural medicine,” he said.

Douglas is a family medicine practitioner in East Prairie, a town of about 3,000 in Mississippi County.

There are no hospitals in Mississippi County and no ICU beds. Luckily there hasn’t been a known case of COVID-19, yet either. But that doesn’t mean that Douglas doesn’t have work to do. Like all medical providers, he’s had to find a way to prepare for a pandemic and take care of his existing patients while reducing the risk of transmission.

“We’ve changed our practice from the standpoint of virtual visits,” Douglas said. “We try to do as many visits online.”

Here is where the interests of Vanslyke and Douglas intersect.

“Internet service here for much of the county stinks,” Douglas said.

SEMO Electric is slated to begin installing fiber internet in Mississippi County later this year, which could broaden Douglas’s ability to reach patients via telemedicine.

The conversations around telehealth and rural broadband aren’t new. But now, as medical practitioners are forced to find ways to meet the needs of their communities while keeping the risk of COVID-19 transmission low, doctors have become more dependent on the ability to communicate with their patients via the internet. But that internet has to be present, reliable and fast.

In many rural areas of Missouri, it’s not.

Healthcare at home

Ask any medical professional what’s changed most about their practice since in the last month, and most would probably say telehealth.

“It’s more needed than ever,” Dr. Karen Edison said.

Edison is the senior medical director of University of Missouri’s Telehealth Network. She also runs the Show Me ECHO Program, which uses telehealth to teach rural practitioners additional sub-specialty skills, like dermatology or diabetes care.

“Telehealth or telemedicine has been around for a long time,” she said “I’m a dermatologist and I’ve practiced tele-dermatology in rural Missouri for 26 years.”

Telehealth is the catch-all term for any sort of medical practice that happens virtually. A patient might talk to their provider on the phone, take pictures and video and send it to a doctor to be evaluated later or chat with their provider live via video.

Regardless of the medium, though, telehealth has long been discussed as the solution to rural-health care disparities. The Center for Disease Control estimates 15% of Americans live in rural areas where they are more likely to die of heart disease, cancer, unintentional injury, chronic lower respiratory disease or stroke.

According to the CDC, residents in rural areas tend to be older and sicker and have less access to care.

“I think in rural areas you’ve got a distance to health care facilities and sometimes time is of the essence,” Edison said. “So, if you can contact a healthcare provider, you can decrease some of those disparities.”

Telehealth can be instrumental in identifying the need to see a physician, refilling a prescription, following up on a previous appointment or just performing a yearly checkup.

“One of the buzz terms is ‘patient centered care’ and what’s more patient centered than taking care to them?” Edison said.

Yet, some practitioners and patients have been slow to incorporating telehealth into their daily practice. Not only can it be an additional time tax on busy rural providers, but some patients find it strange to discuss something as intimate as health outcomes from their sofa.

“Patients were uneasy with meeting with a physician they had never met and talking to them on a computer screen,” Douglas said.

In recent weeks patients and practitioners alike have been forced to embrace telehealth.

“I have people who drive 80, 90 miles to see me,” Douglas said. “Some of those folks have been doing telehealth for the last two weeks and it’s great.”

Most of Douglas’s patients live within 25 miles. Still, the ability to offer them care while saving them time and resources is valuable, not only during a pandemic, but possibly after.

“I think patients now will be more comfortable with telehealth visits because all of them will have experience with it,” he said.

There are no silver bullets to improve rural health disparities. However, telehealth, when combined with dedicated rural practitioners, insurance coverage for telemedicine and reliable rural broadband, could help improve health outcomes for rural residents.

Missouri expanded its Medicaid coverage for telehealth in 2018 and many private insurance providers have been extending their coverage in response to COVID-19. But while the issue of insurance coverage can be solved as quickly as a policy change, internet capabilities require an investment of both time and money.

The future is fiber

Rural broadband has been a long-time policy priority in Jefferson City. Just Friday Gov. Mike Parson announced a series of grants totaling $3.05 million for rural broadband projects.

“During a time in which many citizens have been instructed to stay home, reliable internet access is critical to meet needs for education, telemedicine, telecommuting and overall quality of life,” Department of Economic Development Director Rob Dixon said in a press release.

The broadband database Broadband Now ranks Missouri 32nd nationally in broadband access. According to the database 86% of Missourians have access to internet speeds of 25 megabits a second (mbps), but depending on the number of people and devices operating on the same connection, that might not be enough to maintain a video connection with a health care provider.

“People want to do video conferencing right now and it’s pretty hard to do that on slower speeds,” Vanslyke said.

Standard internet video services, like Zoom, require speeds of 0.6 and 1.2 mbps for an extended period of time. But the higher the internet speeds, the more people and devices can operate on one line. All of this makes fiber internet ideal for video conferencing and household use.

“It’s extremely fast,” Vanslyke said.

Vanslyke has taken out what he calls a second mortgage on SEMO Electric to pay for the project. Although SEMO Electric was one of the projects singled out to receive a portion of the governor’s $3.05 million in funds, he worries accepting the money might disqualify him from a larger federal grant program that will launch in the fall.

“We’re working through that now,” he said. “I think it’s great the state is moving forward with the ability to do broadband.”

But when it comes to laying fiber in rural areas, his coop needs all the money it can get.

“The dollars to build are so great, we need it all,” he said.

Vanslyke doesn’t want to come off greedy. He just knows how steep the investment can be to lay rural fiber. On that mile of fiber that cost $20,000 to install, there might be four houses. It’s a challenge, he said, electric cooperatives are uniquely positioned to overcome.

“The business that runs on profit, they have different goals, and that’s okay,” Vanslyke said. “But our mission is to make people’s lives better, and we make smaller margins.”

Still, the process is slow. Although the governor’s grant program signals a continued interest in rural broadband, it doesn’t necessarily solve the problem of patients trying to access health care providers now. Yet, Edison and Douglas are hopeful that the pandemic will provide evidence of the necessity of fast, reliable rural internet.

As for Vanslyke, he sees rural internet as the next frontier of rural electricity. Few people would say that electricity is a luxury, he said. So, with the increasing emphasis on telehealth to bridge rural health disparities, he’s hopeful that in the years to come high speed internet will be seen as more than a luxury, but a basic need.

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