Six years ago I had a stroke and telehealth saved my life. Make no mistake, I am a believer!

However, as wonderful as telehealth is, it has a serious Achilles' heel. The fate of telehealth adoption is tied to the fate of broadband adoption.

Some folks believe telehealth applications take up very little space on patients' computers, so how can broadband be an Achilles' heel? Let me count the ways.

No broadband, no telehealth

"We recently provided testimony before the Missouri legislature about the ties between digital equity and telehealth, how not having internet connections at the requisite speeds means you can't have telehealth", says McClain Bryant Macklin, director of policy and strategic initiatives at the Health Forward Foundation.

"Broadband is now revered as the super-social determinant of health because it has a direct impact on all of the other social determinants of health."

But what if there's no broadband? More than 14 million urban homes and nearly 4 million rural homes have no broadband. People of color make up 75% of the unconnected population in urban counties.

Telehealth could be particularly helpful for the many people in the United States without paid sick time or good transportation options. It could be especially valuable for patients with long-standing medical issues who don't have a primary care doctor, or are uninsured.

When good enough … isn't

Broadband in millions of additional homes isn't strong enough to drive telehealth. Redlining, politics, and adverse economics leaves low-income communities stuck with outdated, broken infrastructure.

Annually, billions in government spending to replace obsolete networks passes over big cities, and is squandered by large telecom and cable companies before broadband reaches rural homes.

The United Soybean Board surveyed farm operations nationwide in 2021, for instance, and found that nearly 60% of U.S. farmers and ranchers do not believe they have adequate Internet connectivity to run their businesses let alone meet personal and family needs.

Some of the major barriers to quality internet include slow internet speeds (21%), high costs (20%) and unreliable service (16%).

"25 Mbps download/3 Mbps upload speeds is the current definition of broadband, but nowhere is 25/3 ever good enough for homework, business office, telehealth, entertainment all in one home," said Dr. Christopher Ali, Associate Professor in the Department of Media Studies at the University of Virginia, when he spoke on my Gigabit Nation show.

"We can't keep thinking DSL and satellite are broadband. They're not! They're from the days of dialup and AOL!"

The broadband blues often stem from capacity, not speed issues

Sometimes folks use the technology term "speed" and "capacity" interchangeably when they discuss broadband. Don't! Understand the differences between broadband speed issues and capacity issues or you'll likely have an excruciatingly painful Achilles' heel.

"Speed" is how quickly data can go from Point A to B. "Capacity" refers to your data being able to move from Point A to B.

A Maserati has awesome potential for speed – but capacity to reach that speed is severely hampered on a pot-holed, winding road (obsolete infrastructure) that's carrying RVs (neighbors' data) as far as you can see.

Consider a soccer-playing kid who injures a foot and goes to the emergency room. The ER doctor sends an email note via telehealth to the parents' home and later does a Zoom session to show huge X-ray files.

Likely the email gets delivered immediately. Broadband capacity could get overloaded in that neighborhood between 4 p.m. and 10 p.m., when students have video-based homework and parents work from home late. The telehealth session could get badly garbled or delayed.

Community broadband is often great for curing capacity barriers – networks owned by cities and counties, telephone and electrical co-ops, wireless ISP (WISPs), other local ISPs and public-private partnerships. Ask around! Somebody in town might already be planning to build one. Or maybe your health community can lead the pack?

More odds and ends

A telehealth grant proposal without broadband. The FCC gave over $350 million in grants to healthcare organizations for telehealth capabilities – which was great! However, many of their underserved and low-income patients didn't have broadband to connect with grant recipients. Every telehealth grant proposal must address the issue – and money – of broadband connections between patients and the healthcare providers.

Some people need internet training wheels. You cannot give people a computer, the internet and telehealth apps and expect success unless they have a digital literacy skills! Pew Research Center found that U.S. digital literacy is lacking, with just 40% of adults correctly answering questions requiring digital skills. "What happens if there isn't PC tech support when someone has a problem with a telehealth app?" asked Peter Caplan, the managing consultant for New York-based eHealth Systems & Solutions. "Who's training patients what to do if the Internet has a glitch?" Telehealth projects should have a digital literacy support program.

Down with data caps! Big cable and telecom companies set cap limits on the amount of data customers can download for web content, audio and video streaming and applications. Companies can charge hundreds of dollars a month when customers exceed their caps. Just a few telehealth sessions and exchanging pictures or digital images can wreck a data cap. Caps were suspended in the pandemic, and should be suspended permanently.      

Redlining is alive and well in 2021. Digital redlining is the practice of creating and perpetuating inequities between already marginalized groups, specifically through severely inhibiting their access to the internet, digital technologies and digital content. By virtue of its dependence on broadband, telehealth is redlined. Currently 17 states enact some probation on public-owned broadband. Nationally and state by state, there are activists, politicians, community stakeholders fighting the good fight against both scourges. Join them! Their fight is your flight!

We've only just begun. The drive to get a majority of people online doing telehealth has just started. Many people still look at telehealth solely as video consults with healthcare professionals. Those in the community broadband and telemedicine industries would do well to help each other drive adoption through the four-legged stool that is digital inclusion: broadband/telehealth education, digital devices, digital literacy and health literacy. Let's get it done!

Saved from a stroke by telehealth, Craig Settles pays it forward by uniting community broadband teams and healthcare stakeholders through telehealth-broadband integration initiatives. Follow him on Twitter @cjsettles101.