COVID-19, Telemedicine, & the Exacerbation of Health Inequities

While the current expansion of telemedicine was born out of necessity, many healthcare institutions have recognized some of the benefits of permanently integrating this technological platform into their operations. Telemedicine offers many benefits, and perhaps, the most important being the convenience of receiving health care in the patient’s own home. This decreases travel time for patients and hopefully promotes the continuity of care. Additionally, the model of telehealth monitoring, which provides a composite of health data such as vitals, daily weights over a period of weeks to months, transmitted electronically to providers, may allow for more real time accurate and effective clinical decision-making. For example, remote patient monitoring allows providers to titrate blood pressure medications on a week’s worth of blood pressure readings as opposed to a single value in the office. Moreover, there is a potential to decrease the number of no-show visits thereby decreasing operating costs for private practitioners and healthcare institutions.

While telemedicine has promised to move healthcare towards a more patient-centered system, there are many barriers for patients in this parallel system that threaten to exacerbate the health care disparities that already exist in the American healthcare system. To start, a successful e-visit requires the patient to have a computer, laptop, or smartphone with video/audio capabilities as well as a stable internet connection. However, more than one-third of U.S. households headed by a person age 65 or older do not have a desktop or a laptop and more than half do not have a smartphone device 4. In turn, these older patients who are at increased risk of clinical decompensation and hospitalizations may not be able to participate in e-visits.  In a study reviewing the utilization of patient portals for health care communication, it was noted that elderly black patients are much less likely to use their patient portal than younger and white patients 5. Unfortunately, this is the same population more at risk for COVID-19. Furthermore, the lack of reliable broadband internet is associated with fewer telehealth visits and hampers patient online portal usage 6. This problem is most pronounced in states with a high percentage of rural residents. For example, Montana has the slowest average internet speed with roughly one-third of residents without reliable broadband coverage 7. Moreover, telemedicine also requires some basic technological skills in order to navigate the platform and connect with the provider. Even with access to a computer, 52 million Americans do not know how to use it properly 8. Those who lack digital literacy tend to be older, less educated, black or Hispanic 8. Addressing the issues faced by this vulnerable population will be essential for ensuring equitable healthcare through telemedicine. 

If telemedicine is to become an established and acceptable form of health care delivery, then it is important to ensure that the most vulnerable patient populations can benefit from this platform. The current public health emergency has given the Center for Medicare and Medicaid Services (CMS), insurance companies, medical institutions and providers a glimpse at the future of healthcare delivery: a mix of conventional in-person visits, telehealth visits, virtual check-ins, e-visits and telehealth monitoring based on patient’s needs. To continue to improve health outcomes for all patients, the deficits of telemedicine must be remedied through careful planning and federal/state investments into this platform. One potential solution could be creating public-private partnerships between CMS, health insurance companies, and healthcare practitioners in order to provide a telemedicine option to every patient. This would necessitate the addition of a HIPAA compliant online portal to health institutions/private practices that would enable providers to render outpatient services. Secondly, similar to the current VHA system model of telehealth, it is essential that CMS and health insurance companies cover the cost of webcam-enabled tablets or cell-phones, blood pressure machines, pulse oximeters and scales for patients who would not otherwise be able to purchase these items. Lastly, with the expansion of telemedicine, a one-time billable visit to instruct patients on the proper use of the aforementioned equipment should be allowed. 

During this time of public health crisis, our use of telemedicine has exponentially increased and has shown us while it is an invaluable tool to continue the fight towards health equity, if not thoughtfully executed, it has the potential to widen the healthcare gaps for vulnerable patients. Patients may face overlapping barriers to accessing telehealth including the absence of technology, digital literacy, and unreliable internet coverage. Together, these barriers constitute the digital divide, which disproportionately affects the elderly, minorities, and those with low socioeconomic status. As we undoubtedly increase our reliance on technology for delivery of healthcare, we must continue to keep the vulnerable patients at the forefront of planning.

References

1. “VA Telehealth Services.” Telehealth VA |, telehealth.va.gov/.
   
2. Lowey, Nita M. “H.R.6074 – 116th Congress (2019-2020): Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020.” Congress.gov, 6 Mar. 2020, www.congress.gov/bill/116th-congress/house-bill/6074.
3. “Fact Sheet MEDICARE TELEMEDICINE HEALTH CARE PROVIDER FACT SHEET.” CMS, www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.

4. Bureau, US Census. “Computer and Internet Use in the United States: 2015.” The United States Census Bureau, 3 Aug. 2018, www.census.gov/library/publications/2017/acs/acs-37.html.

5. Walker DM, Hefner JL, Fareed N, Huerta TR, McAlearney AS. Exploring the Digital Divide: Age and Race Disparities in Use of an Inpatient Portal. Telemed J E Health. 2020;26(5):603-613. doi:10.1089/tmj.2019.0065

6. Perzynski AT, Roach MJ, Shick S, et al. Patient portals and broadband internet inequality. J Am Med Inform Assoc. 2017;24(5):927-932. doi:10.1093/jamia/ocx020

7. Cooper, Tyler. “Report: US States With the Worst and Best Internet Coverage 2018.” Broadband Now, 9 Mar. 2020, broadbandnow.com/report/us-states-internet-coverage-speed-2018/.
   
8. Pawlowski, Saida Mamedova and Emily. “ A Description of U.S. Adults Who Are Not Digitally Literate.” National Center for Education Statistics (NCES) Home Page, a Part of the U.S. Department of Education, 29 May 2018, nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2018161.