When Hurricane Florence neared the coast in September, South Carolina watched closely as its path turned south. The governor ordered residents to evacuate. Two lanes of Interstate 26 were reversed. Gas stations ran out of fuel.

And health companies tweeted good news: Sick people who couldn’t get to the doctor’s office could talk with a doctor for free from their living rooms. One estimate stated 1,000 people ended up using the service.

There was a problem, though. In some places of the Pee Dee, where flooding from the hurricane took homes and lives, good internet connections can be sparse.

The state is expanding access to telemedicine — or, put broadly, health care done via the internet. This virtual way of seeing a doctor or managing health is seen as a solution to deteriorating health care services in rural parts of the state.

South Carolina’s government has spent $68 million in one-time commitments since 2013 on telemedicine. Health leaders are proud of their work. Every resident now lives within an hour of connecting to a stroke expert. Prisoners can “visit” with mental health experts virtually. A truck equipped for telemedicine, run by Clemson University, travels across the state bringing health care to places it can’t be found on an average day.

But it’s no secret that progress is stunted if people don’t have internet access.

Some 537,000 people in South Carolina don’t have an adequate internet connection at home — about 11 percent of the state’s population, and 26 percent of the rural population.

Even as experts hope for a future when everyone can access health care from their cellphones, those without internet may still be missing out.

State’s telemedicine story

South Carolina’s approach to telemedicine is regarded as a point of pride. Gov. Henry McMaster brought it up in his State of the State address in January, highlighting it as a path to ensuring universal health access.

An issue lies in the fact that companies lack a financial interest in extending coverage to areas where only few potential customers live. And when the internet company does offer coverage, their monopoly can make a subscription cost-prohibitive. Still, there is an infrastructure of organizations in the state working on solving the problem.

The Legislature has set aside millions of dollars for the South Carolina Telehealth Alliance, funds it can count on year-after-year. That money flows through the Medical University of South Carolina, which leads the network. Partners range from state agencies to hospitals to universities.

Among the successes they reported in late 2018: Health care providers specializing in treatment for people with opioid use disorders were able to treat 112 patients via telehealth. Mental health treatment expanded in schools. And Greenville Hospital System virtually connected its rural emergency departments with psychiatrists who work for the Department of Mental Health.

Hospitals test different approaches to improve access in rural areas of South Carolina (copy)

Medical University of South Carolina Dr. David McSwain consults with another doctor during a demonstration of one of MUSC's telemedicine carts. The technology allows providers to interact with each other in different hospitals. File/Staff

Meanwhile, MUSC’s telehealth outfit is one of only two Telehealth Centers of Excellence in the country, a designation awarded by the federal government. The award, announced in 2017, came with a $600,000 grant for the first year.

Dr. Jimmy McElligott, medical director for the Center for Telehealth at MUSC, said access to telemedicine has made incredible strides in recent years. The next step would be bringing telemedicine into people’s homes, he said.

Out-of-town doctors could remotely monitor patients with diabetes, McElligott explained. Or patients could video conference with doctors from their laptops or cellphones.

Internet access does remain a barrier, however. Still, he feels South Carolina could do it — connect the whole state.

“We still run into issues where we can’t do what we want to do,” he said. “But we’re much better off than we used to be.”

Palmetto Care Connections is an organization specifically set up to help secure broadband for health care providers, in part by helping them apply for subsidies. They recently submitted $20 million in funding requests to the federal government.

Graham Adams, who sits on the board of Palmetto Care Connections, said South Carolina has done a good job connecting providers to telehealth. But the state lags when it comes to what is considered a new frontier: Connecting patients directly to telemedicine.

South Carolina’s digital divide

The Federal Communications Commission keeps a live map showing places in the U.S. that have access to internet. Most of South Carolina is highlighted.

But the story isn’t that simple.

Eric Frederick, vice president of community affairs for Connected Nation, said internet providers can say they offer service to a whole census block even if they only connect just a single household in that area. It leads to a huge overstatement of coverage, Frederick said.

The U.S. Census Bureau also keeps a rough estimate of South Carolinians with an internet connection. As of 2017, 78 percent of South Carolina households had both a computer and an internet subscription. Compare that with rural Marlboro County, near North Carolina, and it’s 64 percent of households.

The same data shows connections in Marlboro County increased at more than twice the rate as the whole of South Carolina between 2014 and 2017. So connections are coming to rural areas quickly but still run behind in rural areas.

This is called the digital divide.

The chasm is wide when it comes to speeds available in rural areas, too, which is important if the state wants to put telehealth in people's homes.

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“The more sophisticated the application the more bandwidth you’re going to need at a faster speed,” Frederick said.

Generally speaking, 25 megabits per second of download speed and 3 megabits per second of upload speed is the benchmark. That is what would be required for a user to conference with a medical specialist in Charleston on a laptop or phone, for example.

The way to bring those speeds to rural areas depends partly on how high the infrastructure can go, said Jim Stritzinger, who has long worked to map broadband disparities in South Carolina. Stritzinger led an effort to take towers that belong to South Carolina public television and put them to work expanding internet access. Simply put, the higher the better.

"The penthouse is the most valuable spot," Stritzinger explained.

Going vertical

Stritzinger said he could hardly sleep from excitement when the civil engineering students he was working with realized something interesting: About 600 of those towers that belong to SCETV can be moved. 

That would allow Stritzinger to position the towers to be in ideal spots for internet providers, who could rent the space from the state. The towers need to be connected to fiber optic cable and set up with the correct antennas. Once they are, the towers could spread access to residents within 3 to 5 miles away, Stritzinger said. 

Clemson has been working in mobile health for decades, but it was only recently that they began to solve their internet challenges. A free mobile clinic they got through a grant in 2016 is powered by solar panels. And it has an internet connection, through a powerful mobile hotspot mounted high on the van for better reach. 

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Megan Kyle, a family nurse practitioner, works inside the Clemson mobile Health Clinic on Tuesday, Feb. 12, 2019 in Kingstree. Andrew J. Whitaker/Staff

Megan Kyle, a family nurse practitioner who treats patients on board the vehicle, said they focus on people's overall wellness. Patients might need help managing their diabetes or controlling their diet and weight. Kyle's patients — the working, rural poor — often do not have internet access, she said. If they had internet at home, Kyle said she thinks it could be a tool to improve their health. 

"Phones are an underestimated health tool," she said.

Logan McFall, a health extension agent working on the unit, explained Clemson and its partners are hoping to lay fiber optic cable at the health clinics where they often park the mobile van. Some of those clinics are still using paper charts because internet connectivity is so poor, McFall said. The high-quality fiber connection could be beamed in a 1-mile radius, he said.

All of these efforts require buy-in. And the best arguments in favor of better internet accessibility are about two things: Benefits to schools and health, Stritzinger said.

"Every community I work in, health care and education are top of mind," he said. "Those are the driving forces for bringing internet."

Reach Mary Katherine Wildeman at 843-937-5594. Follow her on Twitter @mkwildeman.