ST. ROBERT, Mo. (AP) — With a population just shy of 5,000, the town of St. Robert lies just south of the heart of Missouri. It's one of the many rural towns in the state that finds alternatives to health care access through the internet.

Since the early 1990s, the telehealth network has helped connect patients to health care providers from their own homes. Increasing technology has made the service more efficient, with live audio and video sessions enhancing virtual health care.

The Columbia Missourian reports that telehealth services rely on internet access to conduct sessions, and Missouri is one of the worst states in terms of broadband access in rural areas.

Jon Moore, a physician's assistant at Mercy Clinic Family Medicine in St. Robert, relocated to the town from Fort Leonard Wood in 1998 and has been practicing dermatology with telehealth services since then. Despite believing that dermatology is underserved in the area, Moore says that telehealth services are invaluable in a small community like St. Robert. Moore said that as broadband access has improved, the health services have improved.

"We had some big problems when we were first choosing the equipment back in the early 2000s," Moore said. "A couple of times, telemedicine degenerated into telephone medicine ... I ended up describing the lesions over the telephone because we just couldn't get it going. With the evolution of broadband, it's gotten better and better."

As far as who Moore sees, patients utilizing telehealth services do so for a variety of reasons. While many may use it for convenience, others may choose virtual services to reduce the cost of health care.

"If (people) are unemployed, they may not have a car, or if they have a car, they may not be able to afford gas," Moore said.

"I've had patients that were very well insured and were just happy with the convenience of not having to get in a car and drive (to the closest specialist,) and I've had others that were just dirt poor or nursing home patients that just couldn't travel."

Sometimes uninsured or underinsured patients can't afford to consult with a specialist, he said, "so the challenge is there."

Karen Edison is the medical director of the Missouri Telehealth Network. Edison has specialized as a dermatologist for over 20 years and frequently fronts teledermatology sessions with her patients.

"I'm taking care of (patients) through video conference so I see their skin," Edison said. "They send pictures to me ahead of time and I look at all their skin photos and then I go in the room and talk to them over the computer. It's just like it is in person, it's just using technology to bridge distance."

Edison says that equipment and technology have become cheaper over the years to operate telehealth services. Today, clinics may only need to use a laptop or desktop computer to communicate with their patients and conduct sessions.

"When we first started doing telemedicine, the local rural clinics had to have some very expensive video conferencing equipment," Edison said. "Today, we use our regular computers. You don't need to have anything special besides ... broadband access to make that secure and high quality."

"We still have rural areas in Missouri that don't have high-quality broadband access and this is a problem all over the country in rural areas, but especially in the frontier areas of our country."

Rachel Mutrux is the senior program director who oversees the Missouri Telehealth Network and helps advise the state on telehealth regulations and expansion. In order for telehealth to be serviced, it can require a large amount of broadband access.

"If you're talking about live interaction video conferencing, synchronized transmissions, you would need large amounts of broadband both uploading and downloading," Mutrux said.

In the early 2000s, Mutrux says most health care organizations didn't have enough broadband to accommodate the services. The Missouri Telehealth Network would then work with telephone companies and other organizations to put new broadband into facilities. Each organization would create a special line just for telemedicine. This partnership changed when the use of electronic health records became a standard practice.

"Once they started getting electronic health records, they needed a lot more broadband anyway," she said. "So once they got a lot more broadband anyway, the telemedicine technology got a lot better and didn't need as much (extra) bandwidth as it did before."

Mutrux argues that most health care organizations have adequate bandwidth for at least some telemedicine even in rural areas of the state. She believes that where broadband is lacking would be more so in the homes of patients.

"If a telehealth appointment was happening and the video and audio was not working successfully, then that clinic and provider should have a backup means of conducting the appointment," she said. "In some cases, that would be to reschedule the appointment and in some cases, it would be to have a conversation on the telephone. It would have to be up to that provider and that clinic."

While broadband access may be getting better in rural Missouri, telehealth may continue to struggle without adequate funding.

Mirna Becevic, an assistant research professor of telemedicine at MU, says that the expansion of telehealth is not so much a concern as reimbursement and billing.

"When it comes to reimbursement for example, Medicare will only allow reimbursement if the patient is in a specifically designated rural area," Becevic said. "This really leaves out urban areas and some other areas that seem rural but do not fall into this category."

"If you think about Medicare patients, they may be in a nursing home and there are so many nursing homes in urban areas that could really benefit from a service like this, so the patient wouldn't have to leave the nursing home and miss services or meals, but this is not something that Medicare will cover, so it's a challenge."

As Missouri prepares for a new legislative session in January, state Rep. Kip Kendrick, D-Columbia, wants to focus on the expansion of telehealth in schools. Kendrick believes that would help reduce the cost of overall health care in Missouri.

"Hopefully once we pass additional statues, schools around the state should be able to implement school-based telehealth, where the nurse would facilitate the service in the office connecting with medical specialists on the other end," Kendrick said. "Children can see specialists for ongoing chronic health conditions in the nurse's office and may be pulled out of classrooms for 10 to 15 minutes.

"Telehealth is already driving down the cost of health care and it's going to become more prevalent in the future," he said. "Missouri needs to make sure we continue to modernize our statutes, but we need to make sure that people have access to care."

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Information from: Columbia Missourian, http://www.columbiamissourian.com