Mobile health faces a bumpy road in rural California

Citing successes using cellphones to monitor health in remote corners of Africa and Asia, where mobile networks can be easier to come by than landlines, many people hope mobile technology can bolster the health of rural Americans. But challenges abound.

Eryn Brown reported aspects of this story while participating in the California Endowment Health Journalism Fellowships, a program of USC's Annenberg School of Journalism. Other parts to this series can be found here:

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Steering along washed-out roads in California's southern Sierra, Earl Ferguson gets excited when he sees white plastic stakes sticking up from the ground along the way.

They're markers of a new high-speed Internet line running from Barstow to Reno, which Ferguson helped to get built.

"Look, there it is," he says proudly, pointing out his windowduring a day of driving — and driving, and driving — between the remote medical facilities he works with in the region.

The Digital 395 fiber-optic network will help businesses, schools and medical facilities get better Internet access. It will also help Ferguson, a cardiologist, offer care to patients in isolated communities via two-way high-definition video systems.

There aren't many types of health technology that don't get Ferguson excited.

He's been doing telemedicine — consulting with patients over videoconference — since the mid-'90s, when he worked at NASA. He was a founder of the California Telehealth Network, which connects nearly 800 medical sites in the state. He can expound for hours on the merits and drawbacks of electronic health records. He adores his new digital stethoscope.

But there's one buzzed-about health technology innovation that Ferguson — who lives off the grid, atop a ridge two miles up a rutted dirt road, with his wife and a small menagerie of dogs, cats and burros — doesn't concern himself with much: mobile health, sometimes known as m-health.

For him, the notion of depending on cellphones and other mobile devices to educate, monitor and communicate with patients is a non-starter, for now.

"My cellphone," he points out, "works only intermittently."


Citing successes using cellphones to monitor health in remote corners of Africa and Asia, where mobile networks can be easier to come by than landlines, many people hope mobile technology can bolster the health of rural Americans.

Older adults in California's rural communities in 2007 were more likely to be overweight or obese than their counterparts in cities and suburbs, a 2011 analysis by researchers at the UCLA Center for Health Policy research found. Rural seniors also had relatively high rates of heart disease, diabetes and falls.

The disparities are complicated by difficulties many rural dwellers face accessing medical care. Physicians and other providers are rare in low-population areas. Patients in the southern Sierra might drive for hours to find a doctor who can monitor their diabetes or inspect a suspicious-looking mole.

Adopting m-health would allow doctors to reach out through mobile phones and tablet apps to conduct examinations while such patients remain at home; track exercise, blood pressure or other metrics; send reminders to take a walk or take a pill; or deliver information to help manage chronic ailments.

But spotty cellular networks in the southern Sierra create problems for people using mobile apps.

Tim Donovan, vice president of legislative affairs at the Competitive Carriers Association, said cell service in places such as the Ridgecrest outskirts was hit or miss because it is difficult for companies to make money providing mobile phone service to rural areas.

It costs just as much to build a cell tower to serve a densely populated community with thousands of people as it does to build a tower that will serve a handful of folks, said Donovan, whose Washington-based trade group represents the small wireless carriers that cater to rural markets.

Leading wireless providers have little incentive to establish roaming agreements with smaller carriers, he added, and federal subsidies to promote phone service in rural areas don't fund much wireless expansion.

He summed up the problem:

"You can't have m-health solutions without the 'm.'"


Ferguson believes that someday telemedicine systems will migrate to phones and iPad-like devices, with high-definition screens and zippy wireless links, allowing physicians to reach out directly to patients on their mobile devices.

But spend a day traversing stretches of Kern, San Bernardino and Inyo counties in his white Subaru, and it's plain why he thought getting robust m-health systems up and running wouldn't be easy in this neck of the woods.

The first stop was his home base, Ridgecrest Regional Hospital.

With 25 inpatient beds, it offers more comprehensive services than most rural critical-access hospitals, Ferguson said. In a conference room, he tried to demonstrate a tablet-based electronic health records system, but it kept freezing up—possibly, he thought, because rebar buried in the walls interfered with his Wi-Fi signal.

Even with the new Internet line in the area and upgrades within the hospital, connectivity issues are a common occurrence, he said, because most businesses and homes in the region still depend on pokey technology to link into the backbone network.

"I've had the telemedicine system go down over shared DSL because someone was watching Netflix," he said.

About half an hour east of Ridgecrest in Trona, Calif., a mining outpost of fewer than 3,000 people, Ferguson dropped by a new rural health clinic.

The place was technically open, but it was silent. There were no patients or healthcare providers there: The nurse practitioner who was scheduled to work that day had been pulled away for other business.

Ferguson wanted to check on the clinic's connection to the Digital 395 trunk.

It wasn't installed yet. He drove on.

Image removed.

Nearly 50 miles north at a lunchtime stop in desolate Panamint Springs, Ferguson gestured toward some diners, urging a reporter to ask them what they did when they needed to see a doctor.

"Of course I'd use my phone, if I was interested in that," he said. But he didn't think that was likely — the last time he sought medical care was in 1999.

"I just don't get sick," he insisted.


The last, lonely stop on Ferguson's tour was Southern Inyo Hospital, in Lone Pine.

While "Dr. Earl" met with Maniben Bhakta, a 92-year-old Lone Pine resident, hospital official Lee Barron said she thought m-health sounded great — in theory, if not in practice.

"It has to do with the type of people who live here — they're here because they don't want to be ruled by a phone and a clock and other people," said Barron, the CFO and former CEO of the hospital.

Southern Inyo is a tiny facility with a two-bed ER and a four-bed acute-care unit. Its service area extends over 8,000 square miles and includes Death Valley, California's lowest point, and Mt. Whitney, its highest. The closest medical centers, in Ridgecrest and in Bishop, are each about an hour's drive away.

As skeleton crew treats many of the 2.5 million tourists who come through the region — for altitude sickness, heat stroke, injuries suffered in auto crashes — while also trying to tend to the chronic health problems that plague many of the 5,550 residents in the southern part of the county.

The hospital offers telemedicine for cardiology, psychiatry and other types of care. Barron loved the idea of adding in a cellphone app to track a patient's diet or medication from home. But she doubted m-health would catch on with many of the region's full-timers.

From an office in Ridgecrest, Dr. Ferguson communicates with Laura Saldana, clinic manager at Southern Inyo Hospital clinic in Lone Pine, who demonstrates some uses of the technology. (Francine Orr / Los Angeles Times)

In addition to loving their isolation, many can't afford a cellphone. And those who can, including the area's volunteer EMS responders, encounter the same dead zones as Ferguson.

Hospital board member Drew Wickham, a 68-year-old retired art teacher and Ferguson patient, was more optimistic about m-health.

His cellphone didn't have many bells and whistles — "my mobile is so stupid, I just leave it in my pack," he said — but he could see how using texts or apps to monitor and communicate with patients could keep people healthier longer, and out of Southern Inyo's spare emergency ward.

"It will really improve care," he said. "I hope it happens before I'm gone."

Ferguson wouldn't offer any predictions on when m-health might become a widespread reality in the southern Sierra.

"We're working on the big things first," he said.

There was still plenty to be done to improve electronic medical records and dedicated telemedicine systems before it would make sense to move treatment to cellphones or iPads, he explained.

For now, he had to make the trek back to Ridgecrest. A patient there needed his help.

This article was originally published by the Los Angeles Times.

Photo Credit: Francine Orr / Los Angeles Times